Valor and Fear in Surgeons

Recently a Boston hospital was cited for “hours violations” by the Accreditation Committee for Graduate Medical Education (one of 227 violators this year), and was told it would jeopardize its accreditation as a surgery training program if it did not correct the problems — which it acknowledged “is not easy.” After the Libby Zion case in New York City, when a young woman died as a result of resident fatigue in 1984, an 80-hour-week limit was placed on doctors in training.

Why isn’t it easy to enforce?

Thirty years ago, I was a medical intern at a Boston hospital. In my novel “The House of God,” I describe how doctor fatigue often harms the patient. The Zion reforms are in the best interests of both.

There have been reports of frequent violations of time restrictions, residents working more than 80 hours a week, or being off duty for less than the specified 10 hours at a time. While this may seem masochistic, doctors justify it by the necessity of “continuity of care” of patients and being on call long enough to “see a large variety of cases.” Unstated is the need to join the long, mythic tradition of doctors who, with a little superhuman effort, rescue the sick and dying.

Surgeons have a special place in the pantheon of medicine. With astonishing skills, determination, and judgment — and, yes, valor, for they will sometimes endanger their own lives to save others, as in a blood-spattering gunshot surgery on an AIDS patient — they actually reach into the body and heal. The valor sometimes gets out of hand.

Surgical programs are still heavily male, and the macho image still rules, colored by aphorism: “the only problem with being on call every other night is that you only get to handle half the patients,” or “the only way to heal is with cold steel,” or “a chance to cut is a chance to cure,” or even, when things go wrong, “you can’t become a good doctor without killing a few patients.”

In terms of valor and hours worked, these brave residents have a point, wanting to do more surgery and post-op follow-up rather than stop at a specific time. It gets hard to stay away from the hospital for 10 hours at a stretch. But anyone who has done it knows the debilitating effect on both doctors and their loved ones of working in a hospital for 36 hours, getting six hours sleep, and going back in for another 36 — every other night on call.

In addition to valor, the issue is fear — a word surgeons might deny. The source of fear is not personal, but fear instilled by the system. An unspoken reason that residents secretly work over the legal limit is that, in the pecking order of the wards, they fear the implicit power of the hospital hierarchy, the attitude of “we had to go through hell, and so do you.”

Oversight of limits is difficult, and in that vacuum the fear of not being tough enough, skillful enough, or resourceful enough to stay up (sometimes aided by drugs) can affect behavior.

When a senior doctor at the top of the surgical pyramid gives the impression that the limits on hours are not all that useful at the moment a horrific new case comes in, the fear of standing up against that pressure is almost palpable. In a power-over system, there’s always someone with more power than you.

But all the valor in the world can’t make up for a fuzzy mind and fingers that feel strangely distant. In terms of the best care of the patient, the real valor is to turn it over to the fresh surgeon just coming in after a good night’s rest.

In these last gasps of the pathetic Bush era, the fear culture pervades all of our lives, and it takes regulation (by a group like the accreditation committee) and advocacy by a union (the Committee of Interns and Residents) to get all members of the hospital community to embrace and prioritize the humane training of residents, and the human-to-human goal of good medical care.-

Stephen Bergman is also Samuel Shem, whose fourth novel, “The Spirit of the Place,” has just been released.

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