In my self-righteous youth, I bristled at the thought of physicians unionizing. Certain our collective altruism and professionalism would prevail. Unions were for oppressed laborers, not well-regarded, well-paid professionals. Reading the recent paper in JAMA and 30-plus years in the field have caused me to think again. That, and recently having provided support to a young physician couple with a newborn. There is nothing quite as messy, all-consuming, and awe-inspiring as becoming a new parent. Unless you think about being a resident or fellow. In each case, few breaks and endless rapid learning make support teams and rest essential. These new parents are organized. Almost everything went as planned. They have insurance, financial resources, and family support. Yet the enormity of the emotional and physical demands still surprised them. As a physician couple, they proactively planned all that was possible to plan. They timed their parental leaves in order to optimize each parent’s time with the baby. One, an attending, took a partially paid several months absence with the support and “benign neglect” of their boss. The other, a fellow in a very high stakes specialty, opted for a split leave — taking some early time to bond with the newborn — some when the other parent returned to work to ease the transition for all. The fellows’ experience caused me to question whether anyone is caring for the fellows. Although ACGME program requirements include attention to physician wellness and fatigue mitigation in theory, there was little evidence in practice in this case. There is nothing to cause me to believe this is an isolated case. The attending parent had little more than routine communication and congratulations from the workplace. In contrast, the fellow was called directly by their program director while on leave shortly after the birth. The call was not one of congratulations. Rather it was a request to come in and take a shift because “we are shorthanded.” Despite being sufficiently boundaried to decline this request, the fellow spent considerable time fretting about how the choice not to come in during leave may impact future evaluations or lead to retaliation upon returning to work. This would have been true regardless of whether it was parental leave or vacation. The fellow sought to contact the “wellness person” for guidance about this concern, only to find that the wellness person and the program director making the request were one and the same. Meaning that the wellness person created this no-win choice. There is a fundamental conflict of interest when the person theoretically attending to the trainees’ wellness is also looking for warm bodies to fill the schedule. The lack of “warm bodies” to fill vacancies without burdening colleagues brings back to relevance the paper by Linzer, which calls for adequate staffing to cover predictable life events — such as illness, parental leaves, etc. He suggests the possibility of “physician float pools” to compensate for the understaffing caused by these events. The discussion about whether parental leaves discriminate against non-parents is one for another day. However, the argument for having extra FTE to cover inevitable events is an old one that still holds true. I have personally not called in sick when I should have for fear of overburdening my already overworked colleagues. Asking trainees — the bottom rung of the power hierarchy — to choose between pleasing the director and taking the scheduled vacation/leave/mental health day is not fair. Certainly, a solution like having a roster of attendings or trainees willing and able to be pulled in for extra duty (and extra pay?) when needed could be found. A group email request to the roster would not put any one trainee on the spot. Fortunately, there was no retaliation upon returning to work. Unfortunately, the “make-up” calls for those missed during leave were stacked tightly. Of course, extra time and calls are expected to be repaid — but must they be repaid at a rate that is deleterious to the well-being of the fellow? This fellow’s makeup schedule contained three 24-hour shifts in seven days. Seven 24-hour shifts in three weeks with a total of two non-post call days off. The ACGME recommendation directly states, “a culture which encourages covering for colleagues after an illness without the expectation of reciprocity reflects the ideal of professionalism… Well-being includes having time away from work to engage with family and friends, as well as to attend to personal needs and to one’s own health, including adequate rest, healthy diet and regular exercise.” Whether or not the calls are to be made up, the schedule should be humane. The fellows’ schedule of about 100 hours worked (of the total 168 hours in a week) left time for no such thing. Again, from the ACGME, “psychological, emotional, and physical well-being are critical in the development of the competent, caring and resilient physician and require proactive attention to life inside and outside of medicine.” I could not agree more. However, this fellow’s program, in practice, demonstrated evidence of neither. Ironically, during a support call with the couple, they received notification from an airline that staff shortages may impact flights since it is unsafe. Therefore flight crews are not allowed to work more than 12-16 consecutive hours. Is the work of a fellow any less likely to be impacted (or less important) than that of a flight attendant or pilot? Even fast food workers in NYC are more protected by the Fair Workweek Law, which mandates at least 11 hours off between consecutive shifts unless the worker consents (in which case they receive extra pay.) Few tasks are more vital than caring for patients unless it is caring for those providing that care. Fellows, demographically, are often juggling parenthood and fellowship simultaneously. Someone must look after their well-being. If the programs, even when mandated by the ACGME, won’t do it (for example, by scheduling with back-up plans for predictable absences, avoiding roles with conflicting interests, scheduler, and wellness person, and treating work hours as a safety concern, to begin with) then maybe the time for unions has truly arrived. Source
