Resident wellness is often compared to sending canaries into a coal mine. Last week, rather than continuing to hold her breath, Naomi Osaka left the mine. As part of the French Open, she was required to participate in press conferences. However, to protect her mental health, she declined. The organization responded by fining her $15,000 and publicly threatening to remove her from the tournament. Instead, Naomi said no. The highest-paid female athlete in history left the tournament of her own accord, making a statement that moved the organization to revisit its untenable contract.
Working for an organization does not mean it automatically gains control of your mental health and privacy. Yet so many institutions operate as if they do, and I can't help but think of the parallels in graduate medical education.
The foundations of health are sleep, exercise, and nutrition. Yet, as a resident, some of my attendings would humblebrag how they lacked all three during their training. Their 120-plus–hour work weeks were tough but made them better trained than I would ever be with my mere 80-hour work weeks. Similar to stories of pulling all-nighters before an exam or surviving on energy drinks, I was not impressed. Why was martyrdom part of residency? And why does it continue?
It is undeniably clear that sleep deprivation is harmful. According to the CDC, "being awake for at least 24 hours is equal to having a blood alcohol content of 0.10%. This is higher than the legal limit (0.08% BAC) in all states." Yet, 28-hour shifts continue to be the norm. As a medicine consult attending, when I call surgery residents to give them recommendations, I worry. In the 24 hours since I last gave them recommendations, they've neither slept nor showered. I often repeat the recommendations and reassure them that they are also written in my notes in case they are having trouble focusing.
A 2019 study found that the sleep deprivation of an intern year ages a young doctor's DNA 6 times faster than the average person by shortening telomeres, the terminal regions of DNA that protect it from degradation and subsequently disease. This news was met on MedEd Twitter by some feeling validated in their fatigue and others mortified by the harm we are causing. Why wasn't this study alone enough to change the system?
I've been given many reasons why 28-hour shifts continue in internal medicine residencies. Some program directors cite the difficulty of knowing when patients will most reliably present for admission. As a former engineer, I know that industrial engineers on your campus or at nearby institutions would love to solve this problem for you. Some attendings say they went through worse, and looking back, don't remember it as being so bad. I would argue that "not so bad" is still not good and ask them to reflect on how those years have affected their health today.
Many others recall the immense learning that happened in the hospital overnight. Seeing how patients evolved and were stabilized was invaluable. To that I say that hospital medicine has significantly changed. A plethora of literature on sepsis, acute and critical care, emergency department decision-making, and quality improvement, along with more advanced diagnostics, means that we are better at triaging to the right intensity of care, and that our current understanding of disease allows us to stabilize a patient sooner after admission. Moreover, this is not how hospital medicine is practiced today. The median hospitalist shift length is 11 hours. This means that it is critical to know how to safely hand over patients whose pictures are evolving and to triage care of the patients we receive. These are the skills that are now relevant.
Above all, neither logistics, fond memories, nor a lack of inertia to revisit an old problem should trump the health and well-being of a person. Graduate medical education should take a lesson from Ms Osaka (and the many other female athletes who have called out their sponsors) and say no. An organization intended to support learning should do just that: create an environment where residents are rested and primed to learn while retaining the habits of sleep and self-care that will sustain them though their lives. We should be like Naomi.
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Cite this: Shobha W. Stack. Be Like Naomi: Protect Your Residents' Mental Health - Medscape - Jun 15, 2021.