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Resident Work Hours: The Five Stages of Grief

Barone, James E. MD; Ivy, Michael E. MD

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Dr. Barone is professor of clinical surgery, Columbia University College of Physicians and Surgeons, New York, New York, and Dr. Ivy is director of surgical education, Bridgeport Hospital, Bridgeport, Connecticut, and assistant clinical professor of surgery, Yale University School of Medicine, New Haven, Connecticut.

Correspondence should be addressed to Dr. Barone, 1544 Shippan Avenue, Stamford, CT 06902; telephone: 203–323-5194; e-mail: 〈div631@yahoo.com〉.

Reprints will not be available.

For articles on related topics, see pp. 381–383, 384–385, 394–406, 407–416, and 447–452.

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Abstract

The authors describe their reactions, as surgical educators, to the mandate of the Accreditation Council for Graduate Medical Education to reduce resident work hours. They explain these reactions in terms of Dr. Elizabeth Kübler-Ross's five stages of grief: denial, anger, bargaining, depression, and finally acceptance (“which should not be mistaken for a happy stage”). The authors describe each stage of grief and use it to make specific comments on the difficulties that the mandate imposes. They then reveal that their views about the work-hours regulations differ: Dr. Ivy now sees them as an opportunity to grow and improve, and likens the resistance to the new restrictions to that of Europeans to the printing press. But Dr. Barone (“the older of the coauthors and a known curmudgeon”) is not so sure, and shares many of the concerns described earlier in the five stages of grief, even though he has outwardly accepted the work-hours rules and insists on full compliance by his residents and faculty. In particular, he is saddened that some residents feel they have the absolute right to go home regardless of the situation on the surgery service, and this feeling is validated by the work-hours rules.

As we stand on the threshold of a new era in surgical education, we note that our reaction to the mandate of the Accreditation Council for Graduate Medical Education to reduce resident work hours resembles the five stages of grief.* Our first response to the news that resident work hours must not exceed 80 per week was denial. (“No, not me, it cannot be true.”) It must be a mistake. It's fine for internal medicine and family practice, but it can't be meant to apply to surgery.

We moved on to anger. (“When the first stage of denial cannot be maintained any longer, it is replaced by feelings of anger, … rage and resentment.”) How can we train competent surgeons under these rules? How do they expect us to cover all the patients? Continuity of care will be destroyed. There is no way this will work.

The third stage is bargaining. (“The bargaining is really an attempt to postpone.”) An 80-hour work week will be impossible to comply with. If we can show an educational rationale, may we please have an extension of the time to make it an 88-hour work week?

Next is depression. (“Anger and rage will soon be replaced with a sense of great loss.”) The most recent meeting of the Association of Program Directors in Surgery had a funereal tone. Many program directors engaged in a kind of group therapy. Condolences were exchanged. Predictions of the apocalypse were endorsed. Some said this is the ruination of the best system of medical education in the world.

Finally, ready or not, we have reached the stage of acceptance. (“Acceptance should not be mistaken for a happy stage.”) This final stage involves frantic scrambling to establish a workable system of compliance. It is marked by the grim realizations that most methods of compliance will result in the curtailing of many external rotations and disrupt even internal rotations. Conferences and schedules will need major overhauls. And, yes, things will be different. Something called “night float,” a concept never mentioned before in the same sentence as “surgery” is upon us.

Dr. Ivy, the junior author of this piece, is young and idealistic. He has rather strong feelings on this subject. He now feels that the work-hours regulations should be seen as an opportunity to grow and improve, which has been his perception of the recent experience with the Yale surgical residency program. He likens the resistance to the work-hours restrictions to that of the hunter-gatherers to farming, the reaction of the ancient Egyptians to the development of writing, or Europeans’ response to the advent of the printing press. He believes that the entirely irrational training process set up by a dysfunctional substance abuser at the beginning of the 20th century is finally in the process of being revamped by rational adults based on science.

Dr. Barone, the older of the coauthors and a known curmudgeon, is not so sure. He shares many of the concerns described in the five stages of grief. While he has outwardly accepted the work-hours rules and has rigidly insisted on full compliance by his residents and faculty, he is actually still mired deeply in phase four (depression). He worries about everything. But mostly, as he is starting to be asked if he qualifies for the senior discount at the movies, he is wondering who is going to take care of him when he needs surgery himself? He sadly notes a sense of entitlement that some residents have expressed. That is, they feel they have the absolute right to go home regardless of the situation on the service, and this feeling is validated by the work-hours rules. Will his future surgeon decide to leave the hospital at 5 p.m. and leave Dr. Barone to the cross-covering, vascular surgeon, a product of the Early Specialization Program? Indeed, what will happen to all of us?

*Our apologies to Elizabeth Kübler-Ross, MD, for the use of this term and of the quotations in parentheses, which are taken from her book On Death and Dying (New York: Simon and Schuster, 1969). Cited Here...

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