'Clocking Out:' Residents as Shift Workers

8:30 AM IN the CCU.

The attending is chewing out the cardiology fellow, who came on duty just a half hour ago, for something that is not his fault. He—the attending—had asked the overnight fellow to place a pulmonary artery catheter in a patient, only to return in the morning to find that it has not been done.

"That's the problem with you guys these days," he complains. "Everything is just shift work for you—if you don't feel like doing something, you dump it on the people coming on after you."

This attending, though not of the House of God generation, was still old enough to have trained in the days before duty hour restrictions, before terms like "work-life balance" and "wellness" had worked their way into the vernacular, when residency was your life and everything else would have to wait. If he had been the fellow asked to place a line, you'd better believe he would've done it before leaving the hospital.

Today's residents think differently

than their predecessors about

both responsibility and sacrifice.

His grievance is a common one, but his target—the fellow—is wrongheaded. What he's really protesting is a system and set of values that has created a generation of medical shift workers. It is true that today's residents think differently than their predecessors about both responsibility and sacrifice: In general, we are less willing (or authorized) to commit ourselves to the hospital and patients at the expense of our own well being. Whether this results in better or worse patient care is a topic of ongoing inquiry.

Whatever the case, the shift work that is now inherent to residency does not seem to be going away, despite the ACGME's recent proposal to loosen the restrictions. At this point it's built into the training—work hour compliance and safe patient handoffs are stressed early and often. Residency programs live in fear of running afoul of the ACGME and losing their accreditation. What's more, shift work is increasingly becoming the norm for many doctors in practice, particularly in emergency and hospital medicine, so this type of training has utility beyond the structured confines of residency.

Residents are the inheritors of this state of affairs, not the creators. We are in the midst of a great experiment that is changing the way medicine is taught, as well as physicians' attitudes toward their profession. I've heard older doctors say that for them, medicine was always considered a sacred vocation, whereas for the younger generation it is "just a job." While this argument is mostly semantic, I disagree with the underlying sentiment. Residents today are no less hard working, dedicated or loyal. We are simply taking part in the transformation of a system that those before us deemed to be dysfunctional. The experiment has neither succeeded nor failed. It just needs more time.

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