Reforms of training probably should begin by stopping the overwork of residents:
***** 08th July 2000
Young doctors
Tired
NEW YORK
AMERICA'S 400 teaching hospitals may not immediately resemble "Tom Brown's Schooldays"; but for young resident doctors, life at a 19th-century English public school might seem familiar. As new boys (and girls), young trainee doctors are expected to work until they drop, often completing 100-hour weeks. Once they have qualified, the Flashmans then go on to inflict the same dire regime on the next generation of young doctors, telling them that, yes, it will be good for them too.
Being one of America's 100,000 medical interns or residents is certainly a hard life. Lack of sleep is the most common complaint. But there are others. A survey published in the Journal of the American Medical Association in 1998 found that 93% of trainee doctors experienced at least one incident of mistreatment by a teacher, and more than half reported episodes of being belittled or humiliated by more senior physicians. Around 70% of the trainees reported seeing colleagues working in an impaired condition, most often caused by lack of sleep. Young surgeons seem particularly exposed to overwork and harassment.
Last year, the National Labour Relations Board overturned an earlier ruling that prevented American trainee doctors at private hospitals from joining trade unions. (Residents have been allowed to join unions at public hospitals for some time, but more than 90% of them learn their trade at private hospitals.) The original ruling, handed down in 1976, officially classified medical residents as "students" rather than "employees". Now they are free to organise themselves.
The Association of American Medical Colleges, which opposed the NLRB decision, worries that the threat of strikes or binding arbitration will undermine the educational mission of hospitals. Jordan Cohen, the AAMC's president, calls binding arbitration an "abhorrent idea" that would violate the trust between student and teacher. Some studies, such as one conducted in 1988 by surgeons at the Medical College of Wisconsin, have come up with the implausible conclusion that sleep loss had no apparent effect on their trainees' cognitive performance. Perhaps no one should be surprised. Surgeons, the most brutal taskmasters by most measures, are predisposed against finding fault with the system.
The medical establishment still holds most of the trump cards. Senior physicians have enormous power over a trainee's future career. But pressure for change may be mounting. Medical residents are complaining that a longstanding New York state law limiting their hours to a mere 80 hours a week has been ineffective, and the state health department has repeatedly fined hospitals for violations. Around 400 residents at two private New York hospitals recently voted to join the Committee of Interns and Residents, a union affiliated with the Service Employees International Union which already represents 10,000 people (mostly from public hospitals).
According to Michael Phelan, CIR's organising director, the response of residents in the private sector to the NLRB decision has been "phenomenal." The union has gained nearly 1,000 new members since the NLRB ruling, and the number of inquiries received by the union from interested doctors has tripled. All this could lead to increased leverage for the union movement in America's teaching hospitals.
Patients might gain if unionisation occurs. At a public forum last year, hundreds of New York medical residents confessed that fatigue had led to close calls. A Veterans Affairs Medical Centre study back in 1991 found that changing work schedules to give doctors more rest resulted in 29% fewer errors to do with medication. Naturally, staff costs for hospitals would rise if trainees worked shorter hours. But the Veterans study also showed that gentler schedules could cut the amount of time patients spend in hospital.
Recently, a small chink opened up in the medical establishment's armour. The Accreditation Council for Graduate Medical Education, which oversees the training of American doctors, cited nearly one in three of the programmes it reviews for violating existing standards for working hours. Surgical programmes came in for a particular pasting, with more than half the pediatric surgery programmes exceeding the maximum allowable hours on duty. The CIR smells a rat: it thinks the new enforcement efforts might be a Flashmanlike ploy to reduce the appeal of unions. But most young doctors will be grateful for respite of any sort.
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Yoshie