The necessity is the mother of all inventionsthey say.
Every so often, one wonders why resident doctors work marathon hours. The Legal Statute of Medical Personnel in our country points to the “non-existence of a maximum annual working day”, which is something that goes against article 40.2 of the Spanish Constitution and that enables this group, unlike the vast majority of sectors, do not have a de facto right to rest that limits the duration of the working day.
Although in the last decades some limitations have been contemplated, such as the exclusion, as far as possible from the resources of the center, of doctors over 55 years of age, that is what makes us see hospital doctors work the famous guards of 24 or more hours. Some are lucky and can rest for a while at midnight, but that rest is not guaranteed and will depend on the urgencies of the moment. What, then, is this labor anomaly due to? Why are doctors governed by codes that seem more typical of the 19th century? It seems that, in part, out of the personal interest of those who invented the system.
The drug addict who operated slow (and improved surgical practice)
This is what two researchers told a couple of years ago in the newspaper Discussions of surgery, talking about the American case. The American guard system drew on German and Austrian doctors, especially in Vienna in the late 19th century. The New York surgeon William Stewart Halsted studied its ins and outs and adopted it to the possibilities of the newly opened hospital of the Johns Hopkins University in Baltimore. He, along with William Osler (medicine), Howard Atwood Kelly (gynecology), and William H. Welch (pathology) constituted the four great founding professors of Johns Hopkins Hospital, whose model would later greatly influence the rest of world medicine. They were not the pioneers, but they were the most influential.
The fact is that Halsted not only took the learning of the residence system from Europe, also brought a cocaine addiction, whose effects he would try to alleviate years later getting addicted to morphine. Thus, and as reported in the scientific journal, many aspects of Halsted’s program were carefully designed to help him hide his addiction and simultaneously optimize the care of his patients.
An example of these effects is your change in the way the surgery works. In his time hectic work was very fashionableAnd it was believed that the faster you operated on a patient, the more likely they were to survive. That speed was the best weapon of surgeons.
The drug wreaked havoc and, as it did not have the skill of yesteryear, began to operate slowly and meticulously, to such an extent that those who witnessed his public operations mockingly said things like that “I had never seen an operation wound on the upper part of a subject whose lower part was already healing.”
Ironically, that lack of reflexes disabling him to go faster made him more conservative, with a more contemplative style, trying to preserve as much tissue and blood as possible from patients. In the long run, this operating style was shown to be much more efficient, thereby gaining prestige, which it was not short of.
The better the less you see me: or the proto resident system
Another consequence, the one that matters to us, is the establishment of the labor model. Halsted decided that instead of a fee-for-service, young doctors would be paid under a regime of full-time geographic pay or GFT. This consisted in being paid a minimum amount of salary (just enough to support their families, travel to acquire new knowledge, and just leisure and peace) for their full availability. During those formative years, they were also expected to make scientific contributions from their free time.
East training did not have a specific duration or defined objectives, so progress to the next level was uncertain. It was about one rigid pyramidal structure, highly hierarchical, autarkic and with a division of iron functions where the most stubborn are promoted, which fostered a maximum competitiveness between applicants. If you didn’t advance, you stayed in an internship. If you were successful, perhaps you were applying for a position as a resident, a position already of enormous reputation. The residents then went on to direct clinical services and supervise training programs. There was only one direct on the show: William Stewart Halsted. Thanks to that pyramidal structure, the chief surgeon hardly had to deal with any intern other than his most trusted circle of apprentices. This extreme delegation had one goal: that no one bothered to contact him for practically nothing, and that he could dedicate himself to dealing with his addiction out of the sight of all.
This hypothesis is confirmed by testimonies and recordings of the time: it is known, for example, that their absences sometimes occupied periods of five to six months, something intolerable for practically no professional. It is also known that his subjects came to cover his absences and to do his work, with the intuited desire to ingratiate him and thus occupy his position.
After his death, it is known that its residents, who became the American surgical leaders of the first half of the 20th century, they branded their residency system as their greatest achievement. We are talking about a guy who imposed the use of gloves in the operating room or who invented the radical mastectomy, among other great advances of the time. The men who said this had invested between 12 and 14 years of their lives in training, much of it working for free or almost free.
George J. Heuer, a thirteenth disciple, is known to have modified Halsted’s model by adding some compensation guarantees to workers to make it work outside of the Hopkins environment, but kept it intact in virtually everything else. He implemented it in many other schools and thus this model essentially became the North American standard that survives to this day, and whose practice is not very different from that of Europe.
“I haven’t slept for 32 hours, should I operate on you?”
So, thanks to his legacy, we have newly graduated overexploited doctors doing the bulk of the daily work and with minimal promotion possibilities. If you manage to survive, your desire will be to maintain the status quo so that you too can enjoy the privileges of being at the top.
This made the educational level of the residents, as well as their clinical expertise, enormous, but this trend was highly selfish for Halsted, and it also had repercussions on the doctors’ own quality of life: “I am at the moment a resident surgeon and the conditions are inhumane, “says a Reddit member in a post about it. “We work between 80 and 100 hours a week every week. We are assigned 28-hour shifts every three days and we are responsible for the care of between 40 to 50 patients while we work under sleep deprivation ”. He and his colleagues can’t quit, they say, because if they didn’t do those hours, their pay would be so low that they couldn’t guarantee their livelihood.
“I don’t know how many times I have fallen asleep at the wheel”Says another who identifies himself as a neurosurgeon. “Many times I have stopped and slept on the shoulder because I could not take it anymore. Apparently, I have also been talking in my sleep to patients in the operating room, according to the nurses, who say that they see me very stressed all the time.
The same type of complaints are made by the doctors here, who assure that the guards suppose “half a salary” and feel “fed up” with being reproached that if they protest it is because they don’t feel the “calling”. As we know, this situation is not good for patients either: sleep deprivation for 24 hours or more produces health effects similar to having 0.1% or more alcohol in the blood, and residents who worked 24-hour shifts in ICUs commit 36% more serious medical errors compared to residents with 16-hour shifts. “I have not slept for 32 hours, am I operating on you?” Some professionals tired of their situation tell their patients in protest. One of the causes that veterans allude to is that the medical union “is by definition individualistic and disintegrated.” There is no consciousness.