Friday, October 29, 2004

On internship and sleep

How to respond to "news" that sleep-deprived interns make more errors? Just as Eskimos have multiple words for "snow," doctors can hold forth about multiple forms of fatigue: the tiredness that accompanies one hour of sleep, or two, or three, or none. The tiredness of disrupted sleep - one crisis, or two crises, and so on. The tiredness of being on call every other night, or however many nights per week. The anxious, irritable tiredness when everyone is crashing at 0300 and nothing is going well. The happy tiredness near the end of call. The numb fatigue post-call, while roaming through a parking lot, trying to figure out where on earth you parked....

Somehow, during those endless, agonizing shifts, generations of doctors were transformed. Sleepless, helpless, acutely ill patients journeyed through night after night with sleepless interns. Seeing illness up close, so intimately, so directly, and so intensely, changes something in the intern. There are social and cultural aspects - bonding with other interns who share your burdens; becoming one of the tribe, through hazing. And there are psychological aspects: "Now I am the doctor." Doctoring becomes second nature, bypassing the daytime brain. The experience contributes to a gulf between doctors and non-doctors, which persists throughout our working life and beyond. One only has to read a few entries at intueri to get a small glimpse of the experience...even now, after legislation to reduce intern work hours.

My opinion of those call schedules? The gain is not worth the pain. The hours are abusive. They destroy relationships. A well-rested intern can make grievous errors; why take more chances with a tired one? Still, I never thought I would see the old system change. Is change finally occurring? Perhaps the financial incentive of cheap intern labor is finally outweighed by the risks of their sleepy errors.

As Dr. Centor notes, in bringing down these old systems, we change care delivery. Imagine being desperately ill, and seeing a longer parade of young interns come and go. Who's the captain of this ship? Who knows the big picture? (If patients think that care is impersonal now, just wait...) It's also a change in the experience of becoming a doctor, and of being a doctor. We will be team players, with all the opportunities for discord and dysfunction that one can imagine. Will there be a corresponding change in our attitudes, our "lone ranger" tendencies, our entitlement? Will the gulf between doctors and the rest of the world become smaller?

Tonight, as an attending on call, not much has changed for me. Familiar forms of tiredness will settle over me, and inhabit my brain, as they did during training. The ER is calling again...I don't expect to get much sleep tonight.

And no one had better wake me up to ask me for a sleeping pill!

(to clarify - there are no interns or residents at our medical center; on-call duty belongs to attendings who take turns.)

Update: excellent commentary on this topic at A Chance To Cut Is A Chance To Cure.

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