An interview with Sir William Osler on resident work hours and physician responsibility in the 21st century

Abstract

Since 2003, duty hour regulations (DHRs) imposed by the Accreditation Council on Graduate Medical Education (ACGME) have been a controversial issue in the medical community. The conflict touches upon the ethical principles of beneficence, nonmaleficence, justice, and the activities of every physician. However, the controversy concerning DHR presents opportunities for reevaluating a physician’s roles, responsibilities, and work-life balance in the 21st century. In this article, the DHR controversy is discussed through the thoughts and ideas of Sir William Osler using an interview format. An internal medicine residency program director adds comments to this discussion based on his understanding of current ACGME regulations.

Residency training is a major milestone for every physician, during which the rigors and challenges of medicine are faced every day. These challenges have increased physician burnout from the demands and the long hours that residents and attending physicians endure while on duty. Patients eventually began to experience fallout from these conditions through prolonged hospital stays or harmful medical errors.^1,2 In response, duty hour regulations (DHRs) were imposed by the Accreditation Council on Graduate Medical Education (ACGME) to alleviate the public’s concerns about physician burnout and hospital errors.³ However, these regulations remain controversial and require physicians to re-evaluate their roles, responsibilities, and work-life balance in the 21st century. With such high stakes, this discussion should include the insights of one of modern medicine’s founding fathers, Sir William Osler. This article discusses the DHR controversy using an interview format with Osler—using direct quotations from his works—and Michael Phy, the program director for the internal medicine residency at Texas Tech University Health Sciences Center in Lubbock, Texas.

RESIDENT WORK HOURS AND ETHICAL OBLIGATIONS

Interviewer: In response to concerns about patient safety, DHRs imposed by the ACGME were implemented to reduce physician work hours in 2003.³ The regulations were a result of several studies showing a link between fatigue in residents and physicians and medical errors, motor vehicle crashes, and occupational injuries.^1,2 Many residency program directors, however, have argued that current DHR guidelines reduce continuity of care and fail to prevent resident fatigue.⁴ Dr. Osler, what guidance would you provide physicians in approaching resident work hours and training?

Osler: The hardest conviction to get into the mind of a beginner is that the education upon which he is engaged is not a college course, not a medical course, but a life course, for which the work of a few years under teachers is but a preparation.⁵ The physician’s challenge is the curing of disease, educating the people in the laws of health, and preventing the spread of plagues and pestilences.⁶

Interviewer: Absolutely! And given the growing demands on physicians, it seems apparent that the question of regulating the working hours of physicians and residents cannot be answered without referring to the fundamental ethical principles dating back to Hippocrates. Do you think this is accurate, Dr. Osler?

Osler: The education of the heart—the moral side of man—must keep pace with the education of the head. Our fellow creatures cannot be dealt with as man deals in corn and coal. The physician needs a clear head and a kind heart; his work is arduous and complex, requiring the exercise of the very highest faculties of the mind, while constantly appealing to the emotions and finer feelings.⁵

Michael Phy: The guidance I provide young physicians or medical students with is that being a physician is not a job where limitations to duties and responsibilities can easily be applied. Work shifts will not always start and end at predictable times; daily workloads may be comparable over time, but there will be extreme variations. There are limitations on the number of hours worked in a day and a week, the number of patients that can be admitted, and the number of days off a month. More so, there is a deep lack of patient ownership as patients are handed off frequently within a given shift. These limitations temporarily provide some “protection” from what can be, at times, an unlimited amount of work. In the best of circumstances, programs would be able to gradually increase duties and responsibilities to trainees as they move through the program (all the while staying within the DHR guidelines) so that they are as prepared as they can be when they complete training. The stark reality of DHRs is that they cease to exist in any widespread fashion the moment you are done training.

DUTY HOUR REGULATIONS AND COMMUNITY OBLIGATIONS

Interviewer: I certainly agree with your sentiment, Dr. Osler, and what you mentioned may lie at the heart of this very issue. In my experience, many physicians feel tension between the commitment involved in their chosen vocation and their personal life, particularly on residency work hour regulations. What are your thoughts on this struggle, Dr. Osler?

Osler: The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.⁵ The way of life that I preach is a habit to be acquired gradually by long and steady repetition. It is the practice of living for the day only, and for the day’s work, Life in day-tight compartments.⁷

Phy: Osler and I have some similar thoughts about what the practice of medicine is and how it connects to commitments to duty and personal life. In my opinion, medicine is both a profession and “service” industry. I have never witnessed a time where a physician started his or her day by saying, “Okay, what is everyone doing for me today?” No. Rather, the day starts by saying, “Who needs to be seen first? Who is the sickest? Can we add another to the schedule?” and so on. On most days, the needs of others will come before yours. Yet, there is a lot of joy and satisfaction in delivering that service. But you must be careful. Service, especially medical service, is an animal that needs to be fed constantly, and it is never full. There must be a balance or “sweet spot” somewhere to avoid burnout and dereliction of other (personal) duties.

Interviewer: But with current work hour restrictions, Dr. Osler, physicians worry that continuity in their training and patient care will be compromised. Based on your many years of treating patients, how important is developing the physician-patient relationship and maintaining continuity of care?

Osler: One element must always be taken into account in prognosis and that is the personal equation of the patient. No two cases of the same disease are ever alike; the constitution of the person, his individuality, stamps each case with certain peculiarities.⁸ Care more particularly for the individual patient than for the special features of the disease.⁹

Phy: The physician-patient relationship is obviously important. Before DHRs we might have believed that spending more time with the patient always equated to a better physician-patient relationship. To me, the key is communication. If you are not a skilled communicator, then maybe spending more time with the patient eventually allows you to overcome some obstacles and develop a healthy relationship with the patient. Presently, it is true that DHRs have limited time for trainees to spend time with patients or even being present for other educational endeavors. Patient care can become compartmentalized or fractionated with limited time with patients. But we should be aware that there are many other factors that now compete for time with the patient and jeopardize the physician-patient relationship. The electronic health record is a system that inherently requires the physician to pay an inordinate amount of attention to it—even while the physician is in the same room with the patient. Physicians who can master this can still have very meaningful relationships with their patients and still be economical with their time.

DUTY HOUR RESTRICTIONS AND WORK-LIFE BALANCE

Interviewer: Many physicians make enormous sacrifices to understand the complexity seen from individual to individual, as you’ve stated. But, Dr. Osler, how much should physicians be willing to sacrifice in service of their communities and their profession?

Osler: The art of medicine is very apt to outrun or override the science and play the master where the true role is that of the servant.¹⁰ You have of course entered the Profession of Medicine with a view of obtaining a livelihood; but in dealing with your patients let this always be secondary consideration.¹¹ In a well-arranged community a citizen should feel that he can at any time command the services of a man who has received a fair training in the science and art of medicine, into whose hands he may commit with safety the lives of those near and dear to him.¹²

Phy: As I mentioned before, we are servants. How much we are willing to serve others and sacrifice is as unique as our own genetic codes. As physicians, we have some control over how much we will serve or give when we see patients. Think about the time and energy required to maintain records, attend continuing medical education, participate in physician advocacy groups, perform scholarly activity, and fulfill administrative and educational roles. And then consider random life circumstances such as growing a family, losing family, personal illness, and career changes. All of these can affect what level of professional service and sacrifice you can give. I feel that the medical community is becoming more aware and accepting of limitations in training, although the public perception is a bit behind on this. There is still a strong expectation that when someone is sick, their doctor will always be there to see them or take their call.

Interviewer: Very well said, Dr. Osler. But shouldn’t the wellness and satisfaction of physicians be an important part of patient care? The implementation of DHRs was directed to address this very issue. Surely you’ve strived to maintain your own health and satisfaction!

Osler: In no relationship is the physician more often derelict than in his duty to himself.¹³ Self-satisfaction, a frame of mind widely diffused, is manifest often in greatest intensity where it should be least encouraged, and in individuals and communities is sometimes so active on such slender grounds that the condition is comparable to the delusions of grandeur in the insane.⁵ Hilarity and good humour, a breezy cheerfulness, a nature “sloping toward the southern side,” as Lowell has it, help enormously both in the study and in the practice of medicine.⁵

Phy: Actually, the DHRs were first designed as a paradigm shift to improve patient safety. They were not created in the name of improving wellness, satisfaction, and decreasing burnout in training physicians. Although adjustments in DHRs have been around for a while, there is no known correlation that it has translated into increased patient safety. But the notion of resident wellness and satisfaction has gained quite a bit of traction in graduate medical education. In July 2018, the common program requirements for all resident training programs mandate that wellness policies be instituted into graduate medical education so residents can “retain joy in medicine while managing their own real life stresses.”¹⁴

Interviewer: Perhaps maintaining the interest and wonder in medicine is something that is often overlooked in residency training, particularly regarding important and complex questions currently facing the medical community. But though these issues remain unsolved, many residents feel at the mercy of a system beyond their control, particularly on DHRs. But in the end, Dr. Osler, who has the final say in the work-life balance of the resident and physician?

Osler: Physicians, as a rule, have less appreciation of the value of organization than the members of other professions. No physician has a right to consider himself as belonging to himself; but all ought to regard themselves as belonging to the profession, inasmuch as each is a part of the profession; and care for the part naturally looks to care for the whole.¹⁵

DUTY HOUR RESTRICTIONS AND PROFESSIONALISM

Interviewer: Very well said, Dr. Osler. I have one last question before we part. Given the stress and long hours faced by residents and physicians, how important is professionalism in maintaining the image and confidence of patients with their physicians? How can this be maintained?

Osler: I would rather tell you of a profession honored above all others; on which, while calling forth the highest power of the mind, bring you into such warm personal contact with your fellowmen that the heart and sympathies of the coldest nature must needs be enlarged.¹⁶ Much has been done, much remains to do; a way has opened, and to the possibilities in the scientific development of medicine there seems to be no limit.⁵ The master of self, conscientious devotion to duty, deep human interest in human beings—these best of all lessons you must learn now or never.¹⁷

Phy: There are many things that residents can do to be more in control of their work-life balance. Overall, the profession dictates a never-ending amount of work. It is our own personal duty to learn healthy coping skills and ways to safely navigate the rough seas that often come with our overloaded work lives. If residents have wisely chosen the specialty that fits them best and programs that provide support and work with colleagues who are inclined to help each other, then an unhealthy work-life balance is less of an issue.

CONCLUSION

DHRs in residency training have become an embedded and accepted part of postgraduate medical education. Whether or not DHRs have positively impacted patient safety remains unknown, but most physicians agree that the new regulations have shifted the traditional concept of physician work-life balance. Further complicating the debate, medical professionals trained before and after DHRs took effect may have differing opinions and ideas about physician professionalism, work-life balance, and duties. Despite the controversy, DHR will remain an integral part of medical training and will create more discussion on related issues, particularly physician burnout. Even before Sir William Osler, the medical profession constantly challenged the dedication and resolve of physicians in their pursuit of understanding, managing, and ultimately treating complex pathologies across all stages of life. With each generation, new challenges and policies require physicians to revisit previous traditions and adjust accordingly to tackle the challenges facing their patients and communities.

Acknowledgments

We thank Dr. Kenneth Nugent at Texas Tech University Health Sciences Center for his advice and support writing this article.