legislation that currently regulates resident work hours as a condition of a hospital’s Medicare participation is a result of advocates from OSHA, the American Medical Student Asso- ciation and the Committee of Interns and Residents who were concerned about these trends. Currently, resident work hours are limited to 80 per week, there must be at least one twenty- four hour off-duty period per week, and shifts are curtailed to a maximum of 24 hours.
For those who question the wisdom of these regulations, per- haps even seek to circumvent them, I invite reflection on the work of Jerald Winakur, M.D., internist, geriatrician, and au- thor, that Dr. Jones uses in the “Physician, Heal Thyself” sec- tion of her Medical Humanities course, “On Becoming a Doc- tor” for 4th year medical students. The following is an excerpt from his poem, “To the Medical Student Who Jumped From the Roof of the Hospital.” First do no harm Hippocrates said to those who chose to follow his path. But I have always been on my own—the nights on the wards merging into the next day and the next. I watched the lights of the city ignite, then fade until the sky bled morning… Maybe once I thought: I knew it all…an arrogant illu- sion that soaks into the skin like formaldehyde… At the bedside, in the end there is only one’s self to blame…Hippocrates always looks away when another pair of lids is closed. 5
Referring to this poem in his short story, “Wake-Up Call”, Joel Winakur concludes, “It is time to open doors. It is time Hip- pocrates ceases to glare and begins to look benevolently upon his own. And it begins with each of us.”5
This beginning of benevolence includes both caring for self and caring for colleagues. Physician-ethicist Joel Frader criti- cizes a system-wide problem that he calls “the routinization of looking the other way,” a pattern of denial and suppression reinforced in professional training that says one is not sup- posed to complain or acknowledge needs and shortcomings. In his research on doctors suffering from addiction, Dr. Vergh- ese notes in his research that even when doctors are suffering from addiction, there is a common feature -- “exquisite denial that allowed them to believe they could still care for patients perfectly well.”4 There is a pervasive hesitancy for doctors to show the same humanity to themselves that they show to patients. Tess Jones emphasizes that the move from denial to isolation is key. Intuitively or empathically there is a need to break through the isolation of the suffering for healing to occur. Today’s residents assert that they are educated and will avail themselves of counseling and employee support systems if necessary. Is this a cultural shift that transcends this denial and reflects a new self-awareness and self-nurturing? Or is it part of the tradition where doctors have difficulty seeing them- selves as patients, deny their vulnerability –even to the point of failing to have primary care doctors themselves? 6
Michael Crookston, the psychiatrist that handles the Utah Re- covery Assistance Program, (URAP) emphasizes that we have a long history of not taking care of each other. He warns us not to stand idly by until there is a disaster when you could save a
career and a life. Impairment in work is the last place doctors will let it fall apart, losing their health and relationships first. Each physician is responsible for reporting suspected impair- ment of a physician to superiors--to the Chief Resident or Program Director—not to peers or anyone who might be implicated in a libel suit. If informed by concerned colleagues, the chief resident can serve as an advocate for a person, not a punisher or punitive force, but as a centralized person to keep track of concerns throughout various rotations. Chief residents are in positions to discern when an isolated situational depres- sion, performance lapse, or other problem has been resolved, or when it has developed into a patterned behavior that needs intervention. If the Chief Resident or Program Director decides that intervention is called for, in Utah there is an impaired physician program that is structured to be helpful and accessi- ble. URAP is contractual, confrontational, monitored and confidential, a program in which if one remains clean and sober one can finish residency. Once completed successfully the case is sealed—as though it never happened.
How does one define whether a problem exists and strategize how to proceed? Residents at our LDSH Resident Conference suggested the following signals and strategies. Initially, look for acute causes: is this a change, not a personality disorder? Is there burn-out, grief, perhaps some explanatory isolated incident, or possible psychiatric difficulties: schizophrenia, d e p r e s s i o n , b i - p o l a r i t y ? R e a l i z e t h a t s i t u a t i o n a l d e p r e s s i o n c a n trigger more chronic conditions. Secondly, reflect on what
your relationship is with the person. Generally, people would prefer to talk with peers, then chief residents, then the attend- ing. Friends may ask, “How is it going?” or if an incident has occurred, “What happened? Tess Jones stresses that medicine is about decoding stories, interpreting them, healing through bearing witness. It is a move from chaos to coherence, from
suffering to healing, mitigating isolation.
inappropriate responses in a colleague arouse a question of impairment, doctors become like patients, with a need to tell their stories. Friends listen. Medicine interprets. If one is not in a friendship relationship with the person, one might create vulnerability by showing concern, supportively and sympa- thetically, saying something like, “Residency is really tough for me sometimes—how is it for you?” Thirdly, be observant and get the facts. Sleep deprivation signals are vague things to look for. Is there a primary care doctor helping? Know that a red flag is self-medication, to be avoided at all times, due to its slippery slope nature. In this complex maze of humanity, voic- ing your concerns may save a life.
Linda S. Carr-Lee Research Associate
1 2 Verghese, Abraham. The Tennis Partner. HarperPerennial. 1998. See Reuben, David B., MD, Noble, Sarah. House Officer Responses to Impaired Physicians. JAMA 2-16-90 263:7, and Gastfriend, David R. MD, Physician Sub- stance Abuse and Recovery. JAMA 3-23/30 05 293:12. Crookston, Michael MD. VAMC Resident’s Conference: Impaired Physicians.12- 14-05. Verghese, Abraham, MD. Physicians and Addiction. NEJM. 5-16-02 346:20 Winakur, Jerald, M.D. Wake Up Call. The New Physician. October 1999. pp.9- 10. 6Frader, Joel. In “ Physician, Heal Thyself”: Addiction, Depression, Professional- ism.” On Becoming a Doctor, MS IV Capstone Course, Spring 2005, Therese Jones, PhD. Center for Medical Humanities and Ethics. University of Texas Health Science Center, San Antonio. 3 4 5