The first piece of advice I received about managing family life alongside a medical career: “Marry a cactus.”
It was my first year of medical school; the speaker was a surgeon on a panel the school had organized for new students to discuss work-life balance in medicine. My husband, I figured, could survive pretty well without watering. But then I glanced down at my pregnant belly: The baby, I thought, was not going to be a cactus.
Fortunately for me, policies enacted years before my time made it easier for me to juggle being both a doctor and a mother. In 2003, the Accreditation Council for Graduate Medical Education (ACGME) enacted the first nationwide restrictions on duty hours for medical residents. In 2011, they were updated to their current form: workweeks capped at 80 hours, with a mandatory eight hours of rest between shifts.
But ever since the new restrictions were put in place, they’ve been the subject of heated debate within the medical community. Proponents argue that they prevent exhausted, overworked physicians from making dangerous errors in judgment. Critics claim that the profession now coddles new doctors, and that patient care has suffered as cases are more frequently passed from one doctor to another when shifts end.
Last month, researchers published the long-awaited results of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) in the New England Journal of Medicine. The study followed surgical residents at several top-tier teaching hospitals, divided into two groups. In the “standard policy” group, residents had to abide by the current work-hour restrictions. In the “flexible policy” group, residents were still limited to 80 hours per week, but they could go beyond the maximum 28 hours per shift, and were not guaranteed a rest period in between each one.
The study authors found no significant difference in patient deaths and serious complications between that the hospitals assigned to the “flexible policy” arm and the “standard policy” group. Looking at self-reported measures of resident well-being, they found that even though residents in the flexible-policy groups were more likely to “perceive negative effects of duty-hour policies” on “time with family and friends,” rest, and health, they did not report lower job satisfaction or morale. “Flexible, less-restrictive duty-hour policies,” the authors concluded, are “non-inferior” to the standard policies. Meanwhile, a second study, iCOMPARE, led by researchers from the University of Pennsylvania, Johns Hopkins University, and Harvard Medical School, is currently underway, focusing on duty-hour restrictions for internal-medicine residency programs.
But there’s an important point that these studies—and the national conversation about resident work hour restrictions as a whole— are missing. A return to less restrictive duty hours would represent a big backwards step for the medical system as a whole. Eliminating these policies would lead to a system that disproportionately discriminates against women and parents—particularly mothers, who are more likely to take on primary parenting roles. Women are still vastly underrepresented in most surgical specialties and in healthcare leadership, and “weeding out” parents by removing any hope for family time won’t help things.
I was 25 when I found out I was pregnant with my first daughter. Three maternity leaves later, I am lucky to be at a program that’s helped me achieve difficult task of balancing a career as a pediatrician with a meaningful family life. But I’ve faced my own share of tacit judgment from others in the program, and, at times, a nagging sense of shame that I am somehow breaking the rules. There are plenty of residents with children, but most that I know—of both genders—have a partner who does not work, or whose career has taken a significant and often irreversible back seat.
No one would dispute that medical training ought to be rigorous. Staying at the bedside of a critically ill patient for hours; seeing a lengthy operation through to completion; learning to make decisions while fatigued and triage under pressure: These are valid aspects of medical training that at times must trump arbitrary work hour restrictions. Because of this, some argue that residents should avoid having children during training, to maintain more control over their schedules. Others argue that residency ought to be grueling to prepare doctors for the “real world” as an attending physician, where no one counts how many hours you’ve worked or how much sleep you got. But how many capable doctors have been driven out of the profession, or deterred from even considering it in the first place, by schedules that make family life impossible?
Some of the proposed changes to the duty hour policies may seem benign. However, having protected time off between shifts may mean the difference between getting to tuck your child into bed and not seeing them awake for days on end. Lifting restrictions on shift lengths (or turning to the so-called “flexible” duty hours) would mean further strengthening a culture of medicine in which doctors are rewarded for disavowing all personal and emotional needs. As the medical community continues to question the usefulness of duty-hour restriction, it risks pushing qualified people out of the field entirely.