Summary

INTERVIEW Robert Lipsyte: help me if I go to a hospital? Robert Klitzman It's an interesting question. I think what it would do is have doctors available who have had a chance to sleep I think that they will be therefore think less uncomfortable as they perform their work. There'll be less fatigued I think they'll be less angry at times that those odd moments but I think that residents and interns find it frustrating being up all night. Robert Lipsyte Does that anger and irritation affect the way that you that that residents treat their patients or make diagnoses or make decisions? Robert Klitzman One would hope not I think doctors and interns like anyone else are human beings. And in speaking to doctors, particularly after my book came out a number of interns and residents spoke to me about their experiences. And what I found is people would report to me how they had felt quite depressed during their internship quite anxious. quite angry at times residents who've been several years out of their internship would even say to me, they feel they've never quite gotten over internship this several years afterwards. So I think that Robert Lipsyte and maybe some of the, the the anger and bitterness that we face in older doctors may still have to do with that period of internship. Marilyn do you think that there's too much responsibility given to interns and residents? Our life in the tape? The the young intern said we don't really make life and death decisions. Is that true? Marilyn Agin No, I don't agree. I found when I was an intern that especially at night, when you're on call, there's usually a skeleton staff. I was I was the intern, there was a second year there was a third year. And I remember times where I was all alone taking care of some very, some very sick children. Some of them had cancer, we're on chemotherapeutic drugs, we're on IV drips went into fluid in balance, I had to make decisions. Because often the senior was in the emergency room. The second year was in the delivery room, there was an emergency delivery. And although I could call for help, there were times I had to make certainly spontaneous decisions. And as an intern, you don't even really know all the time when there's an emergency. In terms of you know, electrolyte imbalances, these are things that you learn in the course of the year, Robert Lipsyte have you ever did you ever make mistakes? Marilyn Agin Well, no, not real. I'm sure I've made mistakes, nothing that was, you know, irrevocable. And I do remember though, being up all night, and kind of in pediatrics, it's very important to know your dosages. Because it's not like an adult where their standard doses you have to base it on weight. I remember kind of calculating, rechecking myself dividing it again, to make sure I was giving the right amount Robert Lipsyte to it and making those mathematical calculations tired and yeah, yeah, Joe, you're involved with the committee. One of the things that Sidney Zion said a couple of minutes ago, was that it's not such a big deal to restructure the work practices of interns and residents. Does that make sense to you? Joseph Sachter Absolutely. I think it's been our experience that when different departments try to show some flexibility and innovation, you can substantially comply with many of these regulations, recommendations and regulations. Now, simply by rearranging the schedule of doctors, the doctors work. One example I can give you as a metropolitan hospital where the Department of Medicine has taken positive and excellent steps and in in regulating hours, I think they mentioned on the piece here, that New York hospital voluntarily moved down to an 80 hour limitation. I think that 80 hours is key, because I think what we've been discussing here and what people tend to seize on is this idea of person up to 32 hours, 36 hours and the effects that has, and that's important, but I think what's left behind is what happens chronically, what happens to a doctor when they are working 110 120 hours a week, for weeks on end, three, four or five years. And it's that chronic fatigue, that really exerts a very insidious but very predictable effect on all patients. It's not just the isolated patient, which some mistake could have been made Robert Lipsyte What would be an example of that kind of, Joseph Sachter it's it's the chronic fatigue, that I'll give you a specific example. It could be when you're, if you've somehow managed to get bed at three, four in the morning, and the four hours that was quoted on by the stock to your hospital, seems optimistic to me, I never had four hours of sleep when I was an intern. So now it's four o'clock in the morning, the beeper goes off, the nurse calls, Mr. Smith, down, the hall can't fall asleep. Okay. Maybe the reason Mr. Smith can fall asleep is because someone else told him that he has an inoperable tumor, I wouldn't be able to fall asleep either. But it's four o'clock in the morning, you haven't gotten any sleep at all. And the response instead of trying to go to Mr. Smith, and see what's going on, is to just let her sleeping pill. And that's that's the effect of the chronic fatigue. It's treating patients like a collection of symptoms and not human beings. I think that's important, I think it's going giving an order over the phone not seeing the patient, which can often have tragic consequences, as we saw earlier. And I think it's in the part responsible for the kinds of things when patients come back and we can complain about doctors being arrogant, insensitive of not taking the time, all those are traced back to the same things. So I think it's really to the credit of the ad hoc committee of Dr. Bell, Dr. Axelrod, that they addressed this not just in terms of limiting 24 hours. In fact, the initial grand jury recommendation was 16 hours but said 24 Yes, but 80 as well. Now, 80 seems like a lot. But I think in terms of the way medicine is practiced today, it's certainly a step in the right direction. Robert Lipsyte And beyond even that, the idea that so often the least experienced doctors, were also tired, are being asked to make your phrase was spontaneous decisions. Why in this system Aren't you know, as we've just synchronized doctors, our age, coming back one night, a week, one night a month doing this? Does that would that make sense? Would that have helped you when you weren't intern? Would that have helped those children who needed their doses? modulated Marilyn Agin Yeah, I think it would have helped to have more backup. I'm not sure if I would have needed to call a senior attending at three in the morning for something like that. But I just think if there was more staff available, it could even be more senior residents. And as you know, as we just saying, I wasn't so chronically tired. I could possibly deal with this better too Robert Lipsyte Robert, you talked about so many doctors who have never gotten over that kind of psychic trauma. Do you think that besides affecting interns and residents care immediately that it will affect care for the rest of that physicians life in their attitude towards patients? Which other doctors? Robert Klitzman Well I think to a degree, it may, I think that the internship year in many ways needs to be seen in part as a rite of passage. And I think it's important to realize this importantly, is the context for the bell Commission's findings, as it become instituted. And specifically, I think the rite of passage involves a personal transformation that medical students undergo during the internship and making them into doctors, that has a lot of effects, both positive and have some downside as well. For instance, I think two important ones. I think that people want physicians who are compassionate, but I think that we also want physicians who are familiar with disease with people who are dying, so that when someone dies, and a family is in an acute emotional crisis, that someone in that crisis will be level headed, will be rational, be calm will know what to do. And we look at physicians to do that. I think that that kind of adjustment, that kind of coming to see oneself differently happens during internship. The downside, though, I think, is that interns developing this sense of becoming familiar with disease and with dying, can become perhaps hardened or numb to and I think that's the danger that needs to be sort of talked about more, I think, I think that interns and residents need to have a context in which to view their experiences. And I think the other thing that internship does, though, in terms of being a personal transformation, is that it empowers doctors we give in society, society gives doctors tremendous power. In this country, doctors determine what kind of foods we should eat, they determine what kind of sex we should have, what kind of exercise we should do. And similar when someone goes into a hospital patient, an intern, we let intern come and put needles in us put tubes in various parts of our bodies, wake us up at all hours. And the kind of confidence that's involved in the kind of empowering that goes on, I think happens during internship. I think that the internship years in many ways, a kind of personal transformation, which ones comes to see oneself differently, on which one goes through a kind of trauma coming out, in some ways a different person Robert Lipsyte but we have to find some way to keep the humanity within that year, doctors, thank you very much for being with us.