What does it feel like to work 28 straight hours in a high-pressure environment with people's lives at stake? Not that great. But for some, apparently, it's an environment that pushes them to thrive. The number of consecutive hours doctors-in-training should work is one of the most controversial issues in medicine. Critics of longer shifts argue that it's dangerous for sleep-deprived and subsequently mistake-prone doctors to care for patients. Advocates counter that greater continuity of care—taking care of a patient over time—is invaluable, and that fewer handoffs between doctors improves patient safety. While those who train to be physicians have worked crazy hours since the beginning of time, debate has heated up more recently in light of evidence of the alarming rates of burnout and depression among medical trainees, as well as recently proposed scheduling changes to allow first-year residents to work 28-hour shifts (up from 16 hours). Research on whether or not longer shifts are good or bad is mixed, and decisions about resident work hours are generally made by medical educators and policymakers for whom residency is a distant memory. In the public domain, the debate is usually set up as a comparison between a bleary-eyed doctor who can barely think straight versus one who just started a shift, but is fumbling through notes to figure out who you are. The reality is far more complex. I asked residents to describe the experience of being on call in their own words. "I think it's a necessary evil. As an intern, I saw juniors [second-year residents] doing 30-hour call. I thought that was crazy. I can't see how anyone could do that. Then you do it as a junior and you see it's valuable in its own way. I guess in some ways it's unsafe because I'm physically exhausted. But it's also helpful because I rounded on my patients in the morning, saw them in the afternoon, and cared for them overnight. I know those patients backwards and forward. If patients did well, they did well because of me. If they did badly, they did badly because of me. There are no excuses." -Internal medicine resident, Second Year "People make it seem like doctors are pretty much drunk on the job at the end of 30 hours. That's not the case. The big thing I want patients to know is that your doctor is not going to be comatose. Staying awake for 30 hours is not that hard. I thought it was insane, but you do it and you notice that if you're working, you'll be able to stay awake and focused." -Internal medicine resident, Second Year "You don't really understand unless you've done it. There are few other professions in which people are expected to perform at a really high level for that long. To a lot of people it just seems crazy. But despite all the negatives, there are real benefits. You can't learn just by reading. Experience is critical." -Surgery resident, Second Year "My brain doesn't function after 24 hours. I notice myself making a lot of mistakes. On morning rounds, I'm so tired. I come off unprofessional. It's like I drank a glass of wine. When I have to sit down, I literally can't keep my eyes open. When someone asks me a question on rounds, I can't remember stuff I just read." -Internal medicine resident, Second Year "I know I've made bad decisions at the end of a long call. I remember one time a patient's blood pressure was already low and I ordered a medication that would have lowered it more. I just wasn't thinking clearly. Ultimately the patient did okay. But it's that kind of thing that makes me wonder whether this whole 30-hour call thing is worth it." -Internal medicine resident, Second year "Mistakes happen, but they're usually caught before they harm anyone. I feel okay doing procedures because the adrenaline rush will wake me up no matter how sleepy I am. But I struggle with more nuanced clinical decisions." -Internal medicine resident, Third year "I had a case in ICU with this guy who was initially doing really well, and then started to feel worse and I totally misjudged the way he was going to go. I think because I was so tired I kind of put him in a box of someone who was doing well. But he completely tanked and ended up dying. I'm not sure I could have prevented his death even if I was fresh. He was probably going to die regardless. But I do think I might have been able to prolong his life. At the very least I could have called his family earlier so they could come see him." -Internal medicine resident, Second year "There's a huge educational value in seeing a patient's clinical course evolve over 24 hours. That can't be replicated in any other way. But the lectures at the end of a shift are completely useless. If I go—which I usually don't—I'm always falling asleep. It's a bad scene." -Internal medicine resident, Third year "There have definitely been some dangerous drives post-call. I was completely exhausted this one time. I was falling asleep on rounds. That day I was driving home and had to remind myself over and over: Okay, just focus. Be careful. I knew that if I didn't devote 110 percent of my attention to driving, things could be bad." -Surgical resident, Second year "I don't do anything post-call. I don't drive. I don't eat breakfast. I don't shower. My personal hygiene suffers. But whatever. You try showering when you can't stand up." -Internal medicine resident, Third year Source
