I was in junior high school the first time I accepted a friend's invitation to join him in the Pacific Ocean. He'd been surfing since grade school, and agreed to lend me a spare bodyboard for our afternoon at the beach.
After his mom dropped us off, he wrapped a towel around his waist and shimmied into a full length wetsuit while I soaked up the awkwardness of wearing only the off-brand swimsuit I'd owned for years. It was autumn, and as we paddled out into the lineup I experienced immediate shrinkage. This post, dear reader, will spare you discussion of that type of shrinkage. Instead, I want to talk telomere shrinkage.
For the non-medical reader, telomeres are a biological equivalent of the tape at the end of your shoelace that keeps the entwined threads from unraveling. Telomeres serve that function for the DNA in your cells, shortening slightly each time a cell replicates. Once telomeres shorten to a terminal length, cells either enter a state of senescence (they no longer replicate) or apoptosis (they self-destruct). It's no surprise to learn that shortened telomere length has been associated with various age-related illnesses.
A recent article in the New York Times highlighted a study of medical trainees in which DNA obtained from saliva was sampled at the start and end of their first year of residency to determine how telomere shortening compared to the population as a whole.
Brace yourself: first year residents had telomeres that shortened at six times the rate of the population as a whole. Worse yet, those who worked over 75 hours a week (and you know who you are) had telomeres that shortened at thirty times the rate of the population as a whole.
The question becomes a matter of what one considers a favorable exchange rate. When I was medical student, a classmate submitted local legislation proposed a cap to the number of hours residents could work in San Francisco. Counterintuitively, what was hailed by the local lay press as a long overdue public safety measure was protested by the residents most likely to be affected.
Shorten my weeks and lengthen my years of training?! a different classmate aspiring to surgery complained to me, incredulous that his desired intensity of training would be regulated by anyone outside of his field. (I just googled him - he's become an academic surgeon.)
I could understand where his frustration was coming from - he'd put in the required hours, and now someone threatened to move the carrot that much further beyond his reach. He was willing to work fewer years, more intensely. Really, what's a little telomere shrinkage among friends if it gets them to the attending stage of medicine that much quicker?
This is a potentially dangerous calculus, and (not unlike debt numbness with student loans) it can be a terrible idea to let someone make decisions now that they pay for longer and later in life. It's a form of market timing - you are assuming the exchange rate you can get now (time for money, time for health) is the best deal you'll have available going forward.
Often time the sacrifice you made while young (What's a little less health? What's a little more debt?) is valued in a profoundly different manner when you reach later life (What I wouldn't give to have a little more time in the form of better health or less debt and less of a need to work!).
It reminds me of how friends in college formerly described their decision to smoke. They assumed they would live a perfectly healthy life and then die suddenly in their sleep at 80 instead of 85 for having smoked. No one envisioned a decade or more of being tethered to an oxygen canister, limited by shortness of breath with minimal exertion, unable to dance at a grandchild's wedding from COPD.
From a financial independence perspective, it has different implications. I met with a friend a decade younger than I am for coffee last week, and we talked about his current shift tolerance. He felt comfortable pulling off 14-15 shifts a month, and had built a beautiful spreadsheet that extrapolated out this workload going forward for the coming decade in planning out his financial situation. I give him credit for taking the initiative to put together a spreadsheet and map out debt repayment and other financial milestones.
He's young and hungry, and I clearly remember the feeling of invincibility that comes with that stage. Still, we discussed how it can be hard to anticipate the pulls you'll feel and the person you'll be a decade in the future. Instead of making workhorse assumptions, better to plan for a lower clinical burden (with commensurate reduced income) in the last 3-4 years of the decade, and if he's able to remain at 14-15 shifts a month, let it be a pleasant financial surprise.
My burnout was not a predictable milestone and there was no anticipating the impact it was going to have on my financial trajectory. My course corrections won't lengthen my already shortened telomeres, but with more years behind me than ahead of me, I have a vested interest in reducing my rate of shrinkage as drastically as I am able.
Comments 14
If you want to improve burnout, quality of life, patient care and reduce physician suicides limit attendings hours not (just) residents. If you specialize in Cardiology, General Surgery, Cardiothoracic surgery or any other critical care specialty that does not employ shift work 90 plus hour weeks remain commonplace until you retire. Limit ALL physicians to 55 hour work weeks (including CME, meetings, and charting from home) and you will go a long way to eliminating burnout in my opinion. Although I have sympathy for 26 year olds whose weeks are still 80 hours after being cut from 110 in the 80s it is far harder and more dangerous to do that at 60 than in your 20s. Doing this you’ll also have to limit care to emergencies only. Patients will scream. Politicians will cave and doctors will suffer. The only way to win the game of medicine long term is not to play.
Author
Just watched “War Games” with Matthew Broderick with my kids, and your final sentence reminds me of what the computer replied as it learned by modeling global thermonuclear war. The analogy is both apt and depressing.
Thanks for the post Crispydoc! I feel like I have triple threat of telomere shrinkage. Doing emergency medicine, critical care, and academics. And now the new blog as well. All adding up to be a probable recipe for disaster. But I do think of potential telomere shrinkage before accepting any new commitments in my life now. And I try to keep my total shift count 8-10 per month. That included moonlighting and critical care shifts. Anything above that and my telomeres start feeling the shrinkage. Lol. Thanks again for a wonderful post.
Author
Ah, to be young and invincible once again…that’s quite a commitment, Vi. As Gasem noted, one can work intensely and, provided there is meaning and satisfaction in the work, it might mitigate the telomere hit somewhat. I’m glad you are limiting further commitments and being assertive about your shift limit.
Interested to see how la vida loca goes for you as it seems you are enjoying much of it on your terms!
CD
Excellent post CD. That is absolutely frightening results about telomere shrinkage during residency. Wow. It does make sense because working that hard/intense for that long a period puts such a stressor on both mind and body.
Add to it that doctors are typically the worst patients (don’t seek help until way late) and its a recipe for a shortened lifespan indeed.
Being able to practice medicine involves quite a large sacrifice and unfortunately most of the general public will never understand the extent of that sacrifice and instead get inundated with media blasting how doctors are overpaid.
Author
Guilty as charged, Xrayvsn. Perhaps we are paid to compensate for the months our lives are commensurately shortened?
Not sure what to make of that study. The presumption is telomere shortening is related to a years worth of “stress”. People in medicine don’t start stressing in their internship but maybe a decade before. It could be we are all nascent Rocket men burning out our fuses over decades. The real stress happens later than residency, when you get a wife, a life, debt, kids etc. I worked hard in residency, but not as hard as when I became a private practice attending , group/business owner and contract negotiator. That’s when the chips are really on the table.
It might be interesting to use telomere shortening as a sub-cellular bio-metric to longitudinally measure positive (or negative) lifestyle change. I’m not convinced much of what we “do” like shortening residency work loads really combats the injury. I always was much happier working every other in a 40 bed post op hearts ICU than working some sleepy service like endocrinology. The ICU was very busy but once you learned how to manage it wasn’t particularly stressful. Nothing o do except get an A1c once in while would have me thinking about a bullet. Something objective like telomere’s might give actual insight into the physiology and strategies to fix it.
Author
Sounds like a K grant waiting to be funded, Gasem! Sounds like you found your place of flow, and there were certainly high intensity workplaces and rotations that could be conducive to flow and contentment. Perhaps, as you suggest, a lack of meaning may shorten telomeres as much as an abundance of responsibility and stress.
I’d also agree that it was not necessarily internship per se; perhaps internship is a proxy for transition and uncertainty. My imagined greatest rate of telomere shortening was when burnout, a first lawsuit and a second child converged with bidding on our home.
Interesting article made better by the Seinfeldian reference. Perhaps in a future post you can tell us which domain you’ve mastered.
Author
In the ED we are generalists by definition, GasFIRE, so to answer your question, I’m a jack of all trades and master of none.
I’m going to answer your question plain and simple: Yes, your career in medicine does cause you shrinkage (telomere shrinkage). In fact, everything in life causes telomere shrinkage. The key is to decrease the rate of the shrinkage.
The main things that decrease this rate include:
– Eat a healthy diet filled with whole vegetables and fruits and include some legumes. Avoid sugar, refined carbs, and processed foods. Limit or avoid meat (especially processed and red meat) and dairy.
– Manage stress. Some stress is good. Excess stress is not. Find a balance. If you work too much, cut back.
– Get moderate exercise. Enough to get your blood pumping. Don’t be a weekend warrior and overdo it.
– Get enough sleep. This one is huge and a vast majority of folks do not get enough of it.
– Drink clean water, breathe clean air, avoid environmental toxins (chemicals, radiation, pollutants, pesticides) as much as possible.
Funny. I read this after a swim in a Northern Ontario lake. So, it resonated..
I actually read a book on the telomere effects a couple of years ago. It was no surprise what shortened them. Stress, poor sleep, poor diet, lack of exercise. The initial length is largely inherited. However, there was also the message that like many parts of our bodies, the telomeres are in constant flux. Constantly breaking down and being built with the balance of those two determining length. With that, they can shrink but also re-lengthen. So, I guess the question is how much does shrinking them in early career allow you the freedom to regrow them later and before permanent significant damage. The answer heavily depends on how soon you achieve an optimal life balance. Some recognition of the issue and deliberate decisions about how to spend your time and money along the way seems key.
-LD
Author
LD,
Your comment fits right in with our latest parenting challenge – we are encouraging our kids to build up rather than tear down during their interactions with siblings, something that regrettably does not happen as often as we’d like.
I wonder if failure to achieve homeostasis early enough (I’ll be generous and say by your 40s since it’s in my interest to use this arbitrary cutoff) is akin to the ubiquitous financial blogger case of the 20 year old who invests for a decade and then adds nothing to the nest egg vs. the 30 year old who begins investing at 30 and contributes annually thereafter, the latter never catching up to the former due to the early benefits of compounding.
Fondly,
CD
P.S. Since you are one of my ribald adolescent confidantes, allow me to share something totally unrelated: A colleague taught me a medical pearl today as my son and I peered over the railing from several floors up…apparently a variant of the cremasteric reflex causes testicular retraction when gazing down from a height. Did not know that one, nor did I check if it was occurring in real time, but it makes intuitive sense.
This is a great blog post—wish it was required reading for first year med students! Thanks for writing it.