‘Almost inhumane’: Treating the complex problem of physician fatigue

TVO.org speaks with physician and author Jillian Horton about why doctors sometimes work dangerously long hours — and how we can change the system
By Daniel Kitts - Published on Mar 12, 2021
Physician and author Jillian Horton says doctor training can sometimes be "soul-destroying."

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Even before the pandemic highlighted the on-the-job pressures medical professionals face, physician Jillian Horton spent a lot of time thinking about the physical, mental, and emotional strains doctors routinely experience.

On Thursday, she appeared on The Agenda to discuss We Are All Perfectly Fine, a memoir in which she chronicles her own struggles with burnout and argues that the health-care system is pushing doctors to the breaking point — putting both them and their patients at risk.

After watching her conversation with Steve Paikin, I wanted to look deeper into one issue she touched on: the mind-bogglingly long hours doctors sometimes work.

When doctors start their careers as residents, their hospital shift can last between 24 and 26 hours, according to guidelines in several provinces.

So why does the medical community put hospital patients in the care of rookie doctors suffering from sleep deprivation? I spoke with Horton about her own experience with long shifts, why the practice persists, and whether it will ever change.

TVO.org: What's the longest shift you ever worked as a doctor?

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Horton: When I was an intern, our days would typically start in the hospital with rounds and teaching at eight in the morning. And then, very commonly, we would not leave until 12 o'clock the next day. So that is 28 hours.  

TVO.org: I’ve heard doctors can catch some sleep during these long shifts. How often does that happen?

Horton: In major teaching hospitals, on the main rotations where people are providing a ton of patient care to a high volume of people, you don't. If you're really lucky, you get 60 minutes at some point between 3 and 4 a.m. — maybe. But much more commonly than not, you were awake virtually the entire time. There's certainly nothing built into the system that allows you to go and have a rest break. It is one of the reasons that those shifts, and those kinds of hours, are just so punishing — and almost inhumane.

TVO.org: When we talk about long shifts, we're talking mostly about interns and residents — people just starting out their careers. Do more established doctors ever work extremely long shifts?

lot of Horton: As time goes on, the majority of us who continue to work in acute-care-type settings no longer sleep in the hospital overnight when we're on call. Although, certainly, as you look at the surgical specialties and acute-care medicine, a lot of doctors on those services [e.g., trauma calls] end up sleeping in the hospital overnight — when they're able to sleep. I have colleagues now during COVID, who do the same kind of work I do, who have gone back to an overnight, in-house model.

TVO.org: Why does the medical community continue with this practice, given that young doctors might make life-and-death mistakes because of fatigue?

Horton: It's hard to change a culture. A culture takes hundreds of years to form. The second thing is, sometimes when we go through really horrendous experiences — and some parts of residency are really horrendous and soul-destroying and damaging — we have to try to find a way to live with them. I think one of the ways that a lot of physicians try to find a way to live with that experiences is they say, “It built my character. And it was good for me. Yes, I suffered. But I was taught something important.”

And some people are very bitter about it. They think, “I suffered; I went through all that. I don't see why the next generation of doctors would have it any easier.” And where those comments come from? I think they come from a tremendous place of hurt.

It's been a slow process to get our profession to a point where we recognize that we have some problems that are actually destroying us.

TVO.org: You talked about doctors rationalizing that the experience of residency and working those long hours taught them something. Have you ever felt that your time in residency prepared you for those moments when physicians are forced make very difficult decisions and deal with multiple patients at once?

Horton: Absolutely — although I think the majority of that, I could have learned during the day. I don't think I had to learn it at 3 a.m. [after already having worked 19 hours]. I often question what kind of learning actually happens in the 17th, 18th, 19th, 20th hour of being awake and performing in a high-stress job.

You are so tired, so unable to think clearly, so reduced in your capacity to function that you miss things. People say things, and you think, “I don't even remember hearing that. I don't even remember seeing that EKG. I completely forgot to check on this, because I was so sleep-deprived.”

TVO.org: In 2016, the then-president of the Royal College of Physicians and Surgeons told CBC News that shortening shifts can cause two problems. First, it can force young doctors to do more in less time. Second, it increases the number of times a patient's case gets handed over to another doctor. Both these situations can lead to errors. How do you respond to that argument?

Horton: There's absolute truth in it. Anyone who treats this as a simple problem with a simple solution does not understand the depth of the problem. There are problems with every potential solution that we look at for this. I just don't accept the idea that this in any way is the best that we can do, that this is the way that medicine has to be practised. Culture change is hard work, but this moment really calls us to do that for the future of our profession.

TVO.org: What, if anything, is being done by the medical community to transition away from long shifts?

Horton: There's been a lot of work all over North America and around the world. Some programs now limit the consecutive number of hours that a trainee is allowed to work, such as capping shifts at 16 hours. The system where I work in the last few years has restructured some of people's most difficult rotations to involve shorter work hours.

There is a lot of discussion about it, and there's a lot of resistance to it in certain quarters. It is harder to enact in certain specialties than in others. But to me, difficulty and complexity certainly doesn't mean that we don't try.

This interview has been condensed and edited for length and clarity.

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