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Not the Last Word: Remember the Sabbath Day to Keep it Social

2020; Lippincott Williams & Wilkins; Volume: 478; Issue: 4 Linguagem: Inglês

10.1097/corr.0000000000001182

1528-1132

Joseph Bernstein,

Sleep and Work-Related Fatigue

Taking call every other night during internship was hard, but scheduling my social life was easy. If friends were to suggest meeting at a concert or ballgame (even months ahead), I knew right away that I’d have to decline. On any given date, I was either on call, running around the hospital, or post-call, recovering as I best could from all that running around. In the face of this, senior surgeons would try to convince us younger doctors that we were coasting. They’d regale us with Tales of the Giants—sagas of medical heroes, battling the dragons of death and disease for 168 hours or more each week Table 1.: Competitive hyperbole captured in Monty Python’s “Four Yorkshiremen” [4] routine, excerpted.(Table 1). I detested these Tales almost as much as I hated taking call every other night. I vowed then that if I were ever appointed to the attending staff, I would never subject my residents to demeaning comments about their “cushy” lifestyle. That promise was put to the test shortly after the implementation of the 80-hour work week. Initially, when the 80-hour duty restrictions were announced, I was happy. The change arrived too late to help me, but vicarious relief was enough. For some reason, however, the new rules did little to quiet residents’ grousing about overwork. It was a struggle to remain silent. In time, some reasons for the residents’ unhappiness became clear. At certain hospitals, for instance, you will be shocked—shocked!—to hear that the rules were not respected. Other programs might, on the surface, seem compliant, but only by demanding a lot of off-the-clock work at home. The new rules also begat circadian-rhythm-disrupting scheduling grids, haphazard alternation of day and night shifts that produce jet lag without the benefits of travel. Moreover, even when the letter and the spirit of the work restriction rules are honored, residents will still feel pinched by the demands of their job. This goes beyond the commonplace observation that 80 hours makes for a pretty long week. An 80-hour work week almost inevitably violates the sanctity of the weekend. Especially when violations of “sanctity” are invoked, you might think the problem with weekend work is that it deprives the residents of their deserved Sabbath day of rest. That’s not it. Programs are currently required to ensure that the resident has “one day in seven free from patient care and educational obligations” [1]. The problem is that this “free” day is not necessarily on Saturday or Sunday and thus does not enhance social contact. Social contact demands coordination. Just as my kids think Instagram is the best app for keeping in touch because all of their friends think Instagram is best, people want to take off on Saturday and Sunday because everybody else is off then too. It is on the weekend one can most easily meet family or friends at secular temples such as the baseball stadium or concert arena, to say nothing of meeting them at sacred temples as well. I can anticipate a response: Some weekend work is inevitable. People get sick at any hour, any day. There is a lot to learn. Operating rooms that are empty on the weekend scream out to be used (in a pitch that hospital executives are singularly attuned to). And I can take that further: Some weekend work is desirable. The sacrifice of a weekend, for one thing, teaches residents to subordinate their needs to those of the patients. But just as the dose makes the poison, the current scheduling requirements take this too far and places residents at risk of becoming what Sabbath scholar Judith Shulevitz [12] termed “atomized, isolated souls” [13]. Fixing this will require a change in the rules, guaranteeing at least one Friday-to-Monday weekend off each month (but two would be better). Saying to residents, “Unlock more time in your day for rest and relaxation—That's an order!” as John Kelly MD does in his latest Your Best Life column [6] is not enough, even if that order is issued with loving kindness. Unlocking that time requires first finding that time, and that is why at least one free weekend must be assured. (Without that, Dr. Kelly’s order would be too similar to the advice I got from my high school basketball coach, who said to me with great sincerity and great insight into my deficiencies: “Be taller!”) In his sequel to The House of God [11], Samuel Shem pointed out, correctly, “Isolation is deadly, connection heals.” Connection is needed for the residents' well-being, to be sure, but connection is also needed for the well-being of the patients they treat. It’s harmful for patients to receive care from socially deprived physicians, just as its harmful to receive care from sleep-deprived physicians. We therefore need to further revisit the duty hour restrictions and guarantee weekend time off. Residents must be allowed to remember a Sabbath day, to keep it social. Colleen M. Farrell MD Resident Physician in Internal Medicine Bellevue Hospital and NYU Langone Health I applaud Dr. Bernstein’s concern for the social connectedness of resident physicians. As a third-year resident (in internal medicine, not orthopaedic surgery) I can attest that not all 24-hour periods off in a given week are created equal. Early in my internship, I had a 2-week rotation as “night float,” providing overnight care to the patients of several day teams. In accordance with Accreditation Council for Graduate Medical Education requirements, I was given one night off each week. On that night off, I felt I needed to keep my nocturnal schedule so I could return to my job rested and alert. That meant that I was wide awake while my husband, a new law student, was fast asleep. We had just relocated to New York City, and so my night off seemed an ideal time to explore the city that never sleeps. I craved company and connection, which naturally led me to Times Square. If any part of the city would be awake, it would be this famously bustling intersection. Yet once I arrived at Times Square, standing amongst the flashing ads, selfie-taking tourists, and Mickey Mouse performers, I felt isolated and alone. Aside from time to rest, what I wanted most of all for my day off was a chance to connect with the people I know and love. I think of resident physician wellness in terms of the hierarchy of needs theorized by psychologist Abraham Maslow in 1943. Maslow argued that human beings are first driven by physiologic needs like hunger, exhaustion, and safety. But once these fundamentals are satisfied, “then there will emerge the love and affection and belongingness needs” [8]. Social connection is not a luxury, but rather integral to health. A growing body of research points to an association between social isolation and worse cardiovascular and mental health outcomes [7]. Former Surgeon General Vivek Murthy was so concerned about loneliness he made it a priority of his tenure [9]. For these reasons, I heartily support Dr. Bernstein’s proposal to prioritize opportunities for social connection in designing resident physician work schedules. Where I would differ slightly is in the specific prescription. While for some residents a full weekend off is ideal, others may actually prefer a day off during the week—perhaps to coordinate with a partner’s schedule, care for a child, or have available time when businesses (including physician, dentist, and psychotherapist offices) are open. I would urge residency program directors to not only prioritize time for social connection in resident schedules, but to design an approach to scheduling in which residents’ individual priorities and preferences are taken into consideration. That said, given the option, I predict many residents would enthusiastically elect to have a monthly weekend outside the hospital. I suspect this change would have positive ripple effects within the hospital. From my own experience, when I feel connected with my friends and loved ones, I am able to be more present with and forge deeper connections with my colleagues and, most importantly, my patients. Mohammad Diab MD Chief of Pediatric Orthopedics UCSF Benioff Children's Hospital I recall a conversation years ago with my college chum, Dr. José A. Bowen, former President of Gaucher College and Dean of Humanities at SMU, and author of Teaching Naked [3]. José pointed out that the traditional three R’s of education (reading, writing and arithmetic) have been supplanted by a new three R’s: Resilience, reflection, and relationships. Resilience now is a topic of study in orthopaedic journals [2, 10, 14], and we all now look for “grit” in our trainees. Reflection is programmed into medical school curricula, from small groups to smartphone applications. Dr. Bernstein is appealing to relationships—not just professional, but to family, friends, society—which arguably are the most essential and certainly are the most gratifying. Experience is a pillar of medicine, inculcated in the first Hippocratic Aphorism [5]. Some studies indicate that experience is even more important to surgeons than medicine docs. For instance, if one is ill, one hopes for an older surgeon (for the experience) but a younger internist (who is likely more up to date on treating various diseases). Temporal restrictions on training are artificial. Older surgeons like myself believe there should be no limit, because experience is vital to a good surgeon. But even Dr. Bernstein and I have come to grips with the fact that certain time restrictions are an immutable reality. What we need is to manage the hours better: Stay late when a case goes long, leave early when there is nothing constructive to do, and take care of your relationships. Judith Shulevitz Author of The Sabbath World: Glimpses of a Different Order of Time [12] I know nothing about medical residencies, or even medicine, so let me see if I’ve got this straight: The new 80-hour workweek seemed good at first, but now it seems bad, because the times off are less predictable than they were during the old 100-plus-hour workweek, when a resident simply alternated between work and catatonia. Eighty hours vs. 100 hours? Unpredictable hours versus total sleep deprivation? What’s wrong with you doctors? Sometimes I think you’ve decided to torture trainees just to raise the barrier to entry to your profession. To be serious, I don’t understand why extreme and unpredictable work hours are essential to the education of doctors. My main objection to these kinds of schedules is that they discriminate against women, or, to be less gender-specific about it, families. They require individuals or couples to postpone childrearing in a way they may not want to do, because the United States doesn’t have the requisite child-care infrastructure for these couples, and even if it did, it’s bad for children to have their parents workdays be so variable and long. Children need set schedules, and they need their parents. The culture of overwork in the medical profession is rooted in an age when doctors were men whose wives who stayed home with the children. Times have changed. Residencies should change with them. But you focus more on the desynchronization of work than on overwork, so I’ll home in on that. In his column, Dr. Bernstein cites my essay [13], in which I tell the story of how the Soviet Union eliminated the weekend. In the late 1920s, the Central Committee wanted to keep factories running all the time, so they abolished Saturday and Sunday. Then they divided the workforce into five groups and gave each group a different day off. Lenin’s wife was delighted, because she thought the weekend was overly associated with church and family, two bourgeois institutions the Communists didn’t care for much. Not surprisingly, the experiment failed. Workers were not free to object, so machines started breaking. Also, party machers got upset because they could no longer gather workers for their weekly indoctrination sessions. Two years after the implementation of the 5-day week, Stalin had to get rid of it. But during that time, one worker did have the temerity to express his opinion in Pravda: “What are we to do at home if the wife is in the factory, the children in school, and no one can come to see us? What is left but to go to the public tea room?” [13] (I’m assuming that tea rooms served harder stuff than just tea.) I suspect that a lot of residents would identify with that worker. But this is a society-wide problem, not just a problem for the medical profession. Due to just-in-time scheduling (for low-income workers), the cult of being “on” all the time for the boss (for professionals), and the gig economy (for everyone else), the preponderance of the American workforce puts in either irregular hours or extremely long hours or both. These people—that is, we—are denied the intangible good that come from a) hanging out with family and friends without weeks spent laboriously organizing the get-together and b) participating in religious, political, civic, and sports activities. Needless to say, society suffers, too. Churches and synagogues and school boards and Indivisible groups need set times if they’re going to survive. Destroy our institutions and you destroy civil society; destroy civil society, and our democracy will be in greater trouble than it already is.