Over the Thanksgiving holiday I came across this article detailing the fallacy that the University of Washington's Emergency/Safe Ride Home Program has become. It made me thankful...to longer be in residency.
The ACGME, which accredits residency programs, created a common program requirement for fatigue mitigation processes:
It is expected that programs adopt fatigue mitigation processes and ensure that there are no negative consequences and/or stigma for using fatigue mitigation strategies.
As part of its response to the requirement, the University created the Emergency/Safe Ride Home Program and touted the program to residents during orientation week. A common sense program providing safe transportation after night shifts or call shifts rendered residents unsafe to drive home? It sounded incredibly progressive...until residents tried availing themselves of the service.
A third year medicine resident submitted receipts totaling under $40 for Uber rides requesting reimbursement under the policy. She was denied reimbursement, and in the email reply (which was cc'd to her program director) the Assistant Dean overseeing the program wrote:
"If you are experiencing significant fatigue this early in the year, I encourage you to speak with your program about scheduling and to consider connecting with our Wellness Service."
Message to the resident:
- You are weak.
- Consider mental health support to address your weakness.
- As Assistant Dean I'm going to use my position of power to stigmatize you in the eyes of your immediate superior.
- Think twice before writing me again.
Cheap resident labor permits academic medical centers to run. UW residents have no contract at present, and have even taken to a symbolic walkout to protest their working conditions.
I'm guessing a number of readers trained under conditions worse than those of the current generation of UW residents, and that sympathy may be limited by the, "In my day..." line of reasoning. Or as a favorite book from when my children were younger put it, "You get what you get and you don't get upset."
Medicine Exalts Martyrs As Role Models
I was a medical student rotating on general surgery at San Francisco General Hospital in the late 1990s. You can accurately date the period in internet epochs because SFGH had not yet been renamed Zuckerberg-SFGH.
Surgery at UCSF was grueling, and the surgical residents who chose the program knew up front that it had a reputation for brutal hours. It was a self-selecting group that prided itself on toughness; the expectation was exhaustion.
During that rotation there was an attending physician, Dr. X, who commanded exceptional reverence from the surgical house staff. Dr. X had trained under the legendary Dr. DeBakey at Methodist Hospital in Houston.
During his training, it was rumored a nurse was tasked with taking Dr. X and each of his cohort of surgical residents up to the roof once a day for 20 minutes at a time to prevent them from developing vitamin D deficiency. They were so committed to medicine they did not leave the OR to seek sunlight unless it was absolutely required.
When I think back to that medical legend now, it seems about as believable as the urban legends of waking up in a bathtub full of ice with a missing kidney. Yet at the time, the story served to reinforce a sense of pride in perseverance while perpetuating a shared history of superhuman endurance in medicine.
With age, I have come to regards this and related myths as greater cause for pity than admiration.
Does UW Really Need to Pinch Pennies Here?
It's a bit absurd to think that saving a few bucks on Uber rides for exhausted residents is going to be the margin that puts the University in or out of the red.
Scared they will all abuse the privilege? Designate each resident a capped allotment to use toward reimbursable rides on the tough rotations where they are likely to need them, and let the resident decide when and if they are necessary.
To residents at UW and elsewhere, thank you for what you do in spite of the outrageous treatment you sometimes receive.
Your existence right now is much like Yossarian in Catch-22 by Joseph Heller. The fact that you recognize being a part of the system is crazy is evidence of your sanity.
There's a better than good chance you'll make it across the divide to a financially secure place in the future.
Until then, don't let administrators bully or otherwise make you feel less than.
Comments 5
Interesting post. Instead of shaming the resident, UW should be ashamed. We care about you..not! Looks like other training programs offer rides w/ much less restrictions. In this day and age, martyrdom is not aspirational. Residents need to practice self-care. Thanks for spotlighting this CD.
Author
It gets dispiriting after a while, MD. Not kinder, not gentler, just more duplicitous.
I don’t know how to feel about this. July 3, 1983 I was starting my surgery rotation, my first clinical rotation and I was on call. My gig was the burn unit and my resident was a guy who was board certified in internal medicine and had just completed 4 years as a flight surgeon in the AF and now wanted to be a surgeon. Very competent guy. About 10 am, SB was choppered in from Joliet IL. Her “boyfriend” threw a can of gas on her and lit her up and burned off 85% of her skin. I’m sure they were both drunk and stoned. SB was poorly arousable but not consciousless. We gave her some Narcan prior to intubation to provocatively test her mental function and she sat bolt upright in the bed and said WTF!!!! Last thing ol’ SB ever said. I think we worked on SB all day and half the night. I got to start my first IV! It was an 8.5Fr subclavian. I painted the chest and shoulder, donned my gloves and found blood without dropping a lung! Damn those named veins are just where the anatomy books say they are. Bad disease requiring a bathtub full of resuscitation fluid means big IV’s.
The point is SB needed a Dr. Someone to keep her alive. Her injury dictated our reality, not some dumb assed committee. There were no “shifts” there was only the relentless reality of the full court press of resuscitation, non stop, while we tried to save her life. We won that day, but she died of sepsis 4 months later after countless parry’s and thrusts during that 4 months fighting with her disease.
It’s kind of hard to get worked up over some dweeb bitchin about being butt hurt over an Uber ride when I think about SB. Is being a physician sometimes brutal? Why yes, yes it is. Thing is eventually I got to go home and regroup, kiss my wife and eat a pizza. SB got 24/7 of hell, hyper-al instead of pizza and then a pine box. Nobody from Joliet ever came to visit SB. It was only about an hour away.
Author
Heartbreaking story – I can’t imagine a first IV being a subclavian. I don’t doubt you had amazing training and it tested you constantly.
I also don’t doubt UW residents are committed to their patients and get the job done that needs to be done.
I re-watch favorite films from my youth and some of the blatant stereotypes would never pass muster today. The standard has changed.
Similarly, I think medicine is redefining what constitutes an acceptable loss rate. We no longer sweep dust under the rug after physician suicide and resume our business as if nothing had happened. We no longer laugh about single vehicle car accidents residents have following sleepless night shifts – what used to be a punchline is now an institutional embarrassment.
My disappointment is over a program that purports to support the new standard while punishing residents who try to hold them to that standard. If the program simply announced, “We could care less about your safety after a night” I’d have no problem with it – they’d set honest expectations.
Even if you take a “Kids are soft today” angle, I don’t think it lessens a valid critique of hypocrisy by the powerful against the vulnerable.
True enough the system sucks. I did it for 35 years. I never read a study though that showed Uber rides make a difference to the rate of resident death or physician death with a P < .05. Virtue signaling is not a solution. It's not even "a start". Pretending to solve a problem is not a solution