When It Rains…

One of the central tenets in medicine is: the more you see, the more you know. Put another way by an old Hopkins surgeon: “If you’re on call every other night, you miss half the cases.”

In the beginning of internship I worked roughly 100 hours a week, despite the new rules limiting resident workweeks to 80 hours. There’s no question my weeks were made longer by my own inefficiency. Despite four years of medical school, internship was a new phase of training with added responsibilities and every day brought unique challenges, from diagnosing aortic dissections to dosing medications. It was also my style: every night before leaving I made a final set of rounds, visiting my patients to make sure that they were o.k.

Inevitably, one of them wasn’t. Mr. Jones’ blood pressure was elevated, Mrs. Smith was having chest pain, or Mr. Brown was suddenly seizing. Each time I stayed until the problem was solved and the patient was safe. As the nights grew longer, I often encountered the on-call team of residents admitting patients. One time, one of them turned to me sympathetically, saying: “You know, you can’t save everyone. The longer you stay in the hospital, the longer you stay…”

As the year stretched on, I could leap most of the hurdles that internship threw me, but one thing remained constant: every fourth night I got another bolus of seven patients. They arrived in varying states of health. Some were admitted with simple heart attacks, pneumonias, or bad cases of dehydration. Others arrived literally dying, bleeding out from an aneurysm, bottoming out their blood pressures, or herniating from a large mass in their brain. We took whatever patients came to us, did our best to care for them, and discharged them as quickly as we could because we knew that in a few days seven more were coming.

I often hear patients complain that they are being forced to leave the hospital before they are ready, and a few times this year I have wondered if they are right. I worried I might be discharging a patient too hastily in my effort to make space for the next one coming in. There are policies designed to discourage premature discharges: if a patient “bounces back,” or is readmitted to the hospital within 48 hours, the team who had him before resumes his care. “Bounce backs” bring a certain embarrassment to the team, and extra scrutiny to ensure that the patient is better before they are discharged the next time, but despite these protections, I still worry.

In my darkest hours, I fear that our assembly line style of admissions pits our interests against our patients’. Under the tremendous pressures of volume, we prize speed over healing, and place more weight on testing than talking. As interns, we are protected by rules limiting the number of patients we can care for—in our program, no intern can have more than 15 patients, and no team can take care of more than 25 patients in total. But caring for 15 patients sounds easier than it actually is; if any are sick, the others can easily become neglected.

As physicians, we could learn a lot from the airlines and the nurses. Our new work hour regulations reflect the growing evidence that sleep deprivation impairs decision-making, but it is interesting to compare how the airline and medical industries have addressed this problem. Airlines mandate that their pilots cannot work more than 100 hours a month, or 18 hours consecutively, while the ACGME stipulates that residents should not work more than 80 hours a week, or 30 hours a shift. There’s a certain hubris we display believing we can work two to four times as long as pilots, and still offer the same level of safety. It’s the same arrogance that let an old Hopkins surgeon work every other night and still complain about missing half of the cases. Some traditions die hard.

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