Are you on the ROAD?
I’ve been thinking about the duty hours issue over the weekend. I also read this morning, via Dr. John M’s blog, a poignant article by Dr. Ed Marsh in the Wall Street Journal. http://online.wsj.com/article/SB10001424127887324789504578380382204116270.html. Dr. Marsh is a retired pediatrician who writes about the old ways vs. the new ways. It occurs to me that the conversation about duty hours for residents is emblematic of the ways in which medicine has changed since Dr. Marsh started out.
The classic understanding of the doctor as committed to the practice of medicine and the care of his patients (because the were largely “he’s”) to exclusion of all else is gone, as has been pointed out exhaustively in the media. Gone are the days when your doctor was on-call 24/7, you could always get him on the phone, he took care of you in the hospital, he took care of your mother and your child, he lived in the community and understood it’s social structure and participated in the greater good. I know this picture is idealistic, Norman Rockwell-ian, nostalgic, and probably mythical. I think we all like to imagine this utopian past because we miss the sense of intimacy, timelessness, and trust that existed between doctor and patient before technology and regulation came between us.
At least that’s what I’ve been told. I’m not old enough to remember those days. Many, but not all, of today’s medical students wouldn’t dream of taking a job that required call 24/7, even if such an arrangement still existed. They wouldn’t want the lifestyle. Lifestyle is key now. There’s a saying in med school among students that there is a ROAD to happiness: radiology, opthalmology, anesthesiology, and dermatology. Why these? Less call, fewer emergencies, good pay, no pesky long-term patient continuity issues. Dr. Marsh says “…most of us who came into the profession in the early 1960s had modest financial aspirations and substantial social commitment.” No longer. Lifestyle is key. I would never say this is true of all doctors or medical students, but it is certainly the case for many. This desire for a good lifestyle extends to residency as well. While duty hours restrictions have been implemented for “patient safety reasons”, it undeniably gives residents a better way of life. It also results in a less immersive training experience and a less intense sense of medicine as a calling.
I have changed my mind about the duty hours thing in the last year or so. Residents have a lot of debt from medical school, they’re getting to the point where they want to start families, and they still don’t make any money while their business school friends are well on their way to their first million. They don’t want to work 120 hrs/wk. Medicine is a career or a job, not a lifetime social commitment. I get it. You only live once. You want to go to Paris once in a while. When I was a resident I too resented the amount of time required of me. Why it didn’t occur to me that medicine was a job where you worked nights and weekends is a mystery to this day. I applauded the duty hours restrictions because it meant less work for me. Selfish? Yes. Lazy? Maybe. Understandable? I think so.
But what I realize now is that the hours and commitment are part of the job. It’s what you sign up for. It’s part of the deal. You can’t sign up to be a doctor and resent the time your patients require. It’s what makes doctor’s jobs unique. We, myself included, have lost the realization that to care for others is a privilege. Why have we lost it? Are medical students lazier than they used to be? Not really. Are the wrong people in medicine? People go into medicine for all sorts of reasons, maybe sometimes not the ideal ones. But the real reason we have forgotten that medicine is a privilege is all the things that get between doctors and patients: money, insurance, regulations, computers, lawyers. These things are here to stay. Lifestyle is too.