Thursday, December 16, 2004

The Future of Surgery VI....
In this month's Bulletin of the American College of Surgeons another go-round on the resident work hour limits:Residents and medical students in the 21st century:Better, worse, or just different?. A discussion following a reception for Dr. Donald Palmisano, president of the American Medical Association:
During the informal reception afterward, the discussion turned, as it often does these days, to another perceived crisis in American surgery—the move to the 80-hour workweek and the training of surgery residents in general. As one can imagine, the spectrum of views offered on this subject was diverse, ranging from rebellious to resigned, from uncaring to understanding. Most of the discussants agreed that the current crop of surgery residents is a differentbreed than we were when in training. Of course, we had heard practicing surgeons say the same of us, and, most likely, the current residents will make the same comments about their successors, if they aren’t already. Nonetheless, we bemoaned the fate of American surgery, reminiscing about surgical training during the previous millennium.
One of the authors describes his "groundbreaking" efforts at collective bargaining in 1973
In 1973, the Charity Hospital house staff placed before the administration the following eight demands:
1. A “crash cart” on every floor. At the time, there was one for the entire hospital.
2. Privacy screens for patients. All patients were, and still are, housed in barracks-style wards.
3. Some sort of cooling system for the patient wards. Not even floor fans were available.
4. Bedside commodes for patients.
5. Air conditioning in the resident call rooms. Residents would sleep on the roof of the hospital, because of the unbearable heat of the New Orleans summer.
6. A place to park.
7. Health care insurance for house staff.
8. A raise of $50 per month, for a monthly of income of $225.

The contrast between then and now is immediately illustrated:
As you may notice, four of these items were directly related to patient care, two were related to working conditions, and only the last two directly affected the residents’ pocketbooks. To discuss work hours would have been inconceivable, and to discuss lifestyle meant that one actually expected to have a life.

Does that mean that residents today are greedy or uncaring? Or have things changed?:
So what is different today, 30 years and a generation after the demands set forth in 1973? Are the physicians and surgeons of the future more self-centered, demanding to have actual lives while we were content to have jobs? Do the surgeons of the future actually dare to differentiate between having a life and a job, when we thought the two were synonymous? Is it possible that we cared more about our patients, while they care more about themselves? Are we training surgeons or shift workers? Or is it possible that patient care has changed to the point where residents no longer need to fight for patients’ rights? Are we now finally confronting the fact that one-third of a resident’s time is spent performing activities with marginal educational value, and that with better communication between physicians and nurses, residents can sleep more and be paged less? Can anyone honestly say that he or she would have preferred less sleep, fewer days off, and less time with their families while in residency, regardless of in which decade it was?
That is the unasked question. The "elders" of surgery express concern over the effects the work-week limits will have on patient care and training and are aghast that residents are expressing lifestyle concerns, when they themselves surely cannot offer an honest "yes" to the above question.
As Dylan says, "The times they are a'changin'".


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