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The "Rest" of the Story

Dr. George Bartley

Dear Readers:

Becoming a doctor traditionally has required many years of long days and short nights. Not only is the length of the process considerable (four years of college, four years of medical school, and specialty training that varies from three to seven years or more), but the work schedules for interns, residents and fellows often have exceeded 100 hours or more per week. One reason for such a demanding path is to ensure that physicians and surgeons can perform under conditions of extreme stress, allowing correct decision-making to become second nature.

A couple of years ago, in response to intuition — and evidence — that physicians are likely to make more mistakes when fatigued, the Accreditation Council for Graduate Medical Education (ACGME) placed limits on the number of hours that interns and residents can be on duty. The ACGME ruled that, on average, such physicians should not work more than 24 to 30 hours at a stretch or more than 80 hours in a week.

As you might imagine, the decree caused a lot of controversy within medicine. I was among the many physicians who deplored the ruling as a major erosion of the commitment required to put the needs of patients before all other considerations. Working extreme hours "builds character," we said. And although less frequently stated overtly, I agreed with those who believe that "if I sacrificed my personal life during my 20s to become a doctor, then so should these young pups."

Before taking pen in hand to editorialize against this ill-conceived mandate, I reviewed a considerable body of written commentary on this issue dating back to the 1980s. The arguments convinced me that patients are ultimately best served by caregivers who are well-rested and not unduly stressed. As an example, I imagined myself settling into a seat on a trans-Atlantic flight. The pilot comes over the intercom and says, "Good evening, folks. Some of you commented while you were boarding that I looked a little haggard. Well, I have been up for about 36 hours. But don't worry, I feel great, and I've done this route many times. So sit back, relax, and enjoy the flight." My guess is that most of us would want to get off that plane, even if we had great faith in the airline and its flight crews.

The leadership of Mayo Clinic has strongly endorsed the ACGME guidelines. The long-term results of this sea change in medical education are unknown, however. For instance, given the continuously expanding body of knowledge that a practitioner needs to master, will training programs need to be lengthened even more? And if so, will this deter talented people from a career in medicine? Will physicians-in-training use their off-duty hours for rest, time with family, or study? Or will they moonlight to help pay off their college and medical school debts, which for many residents exceed $100,000? Will the next generation of neurosurgeons, transplant surgeons, heart surgeons, and others whose training historically has been extremely grueling be sufficiently "battle-hardened" for the demands of their work? We'll see. But without doubt, the future of medicine will always require committed people whose primary concern is the needs of the patient.

Sincerely,

George B. Bartley, M.D.
Chair, Board of Governors
Mayo Clinic Jacksonville