Everyone Is Working Hard: Why Shift Work Shouldn't Be Celebrated

February 7, 2020

Danielle B. Cross, MD, MS, a neurology resident in training, shares her thoughts on why glorifying exhaustion is unhealthy.

Danielle B. Cross, MD, MS

There’s a phenomenon, or more like a belief, in medical training that “more suffering makes for better doctors.” As a result, we tend to compare ourselves to each other in the worst possible ways. Per this belief system, suffering is character-building, so who wouldn’t want to demonstrate that they excel in this area?

A friend of mine still tells a story from when I was a medical student on a sub-internship, back when I considered becoming a surgeon. We all understood the purpose of the rotation to be an opportunity to prove yourself. It’s hilarious that it could ever be interpreted to amount to more than that, especially given the increasingly bumper-rail environment created for medical students. As a student in surgery, you legitimately can only slow down the people you admire and work with. From that perspective, I remember everyone who ever mentored me in a clinical setting in an increasingly fond and appreciative way. During that rotation I was set on being tough as nails, or at least coming off that way.

As a sub-intern, there are no set limits on on-duty hours. I think that’s largely because you aren’t contributing much. Too few hours or too many…it doesn’t help or hurt any patients, which was ostensibly the goal of work-hour restrictions at the outset. As a student, you hope the experience provides insight into your future life as a resident. At some point, I was scheduled for a 24-hour shift. The first 20 hours passed pretty uneventfully. Morning rounds came and went the next day as expected. Then my real adventure began. After walk rounds with the team, a senior resident looked in my direction and commented that “there’s a cool case starting now, you should check it out.” Understanding what I know now, there were infinitely fewer people tracking my sleep than I initially thought. It seems unlikely that this resident had any awareness at all of what my recent schedule had been. That being said, lots of people just get ignored so I was grateful for someone to be thinking of me and suggesting anything.

Understanding that you pretty much never say “no thanks” during one of these rotations, I eagerly made my way to the OR. At the time, the trip to the operating room still held a magical appeal to me. Wearing scrubs even today, by regulation, is still enough to keep me in good spirits through almost any experience. I mean when else do you get to wear functional pajamas to work? Walking to the OR, alone or as part of a group, only added to the highs as compared to the lows of the rotation. Knowing where to go, knowing what to do, knowing who to talk to are all things that no one can know prior to their clinical rotations. Like anatomy lab, it’s an experience that feels quintessentially doctor-ish, so I cherished the feeling of being part of the club.

I made my way to the OR for a case that ended up lasting several hours. By that time, I had made friends of the scrub nurses and managed to avoid any major screw-ups, so my time in the OR was more or less enjoyable rather than arduous. My story really starts after that. Once the morning case wrapped up and I was washing my hands outside the proper OR suite, a senior resident approached me and casually suggested that I report to the other, different hospital for an early afternoon case. That kind of suggestion wasn’t within the course of a normal day so it was clearly in the realm of a challenge. After all, I could leave. I could go home. No one would dare question that choice. After all, I had just been pretending to be a doctor for approximately 30 hours.

What followed was a test of will and attention. Cloaked from thyroid to ovaries in protective lead, I observed, and contributed nothing, to a spinal case with a 5-inch field. The lead was shockingly warm--like heavy insulation in the otherwise chilled room. A warm, heavy blanket reminiscent of something I would curl up under on a coId night. To add to the drama, as I am quite short, I was perched on top of a medical-grade stool so I could theoretically see what was happening a few inches down into the five-inch sterile opening. I remember pinching myself on the arm to stay awake. And when that didn’t work, fear of falling into the field held me upright.

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Several hours later I was outside washing my hands again, impressively lucid and able to participate in the conversation. I was approaching hour 37 of being in the hospital when one of the chief residents who had participated in the case looked at me and with sincere curiosity asked, “How are you awake?” I shrugged, unable to answer how my brain did what I recognize now as flipping the lights on inside my head upon independently recognizing that the sun was up so it was time to continue on with the new day. He sent me home shortly after.

My friend tells this story to other people all the time. She’s genuinely proud that she saw me later that evening, around hour 40 of being awake, for a brief dinner. I didn’t say much other than to make excuses for being a bad dinner partner. In the course of explaining that I’d been awake since the prior pre-dawn hours, what she heard was a war story; something that inspired pride and was meant to be shared. Something other people, herself included, thought she could never do.

Knowing myself and how I came to be awake that long, I knew it wasn’t true. There was nothing special about keeping your eyes open. Under the right stress, anyone could and would do it. If anything it probably just said more about the level of stress I was able to achieve. Ironically, my friends who fell asleep in the same situation were the ones who went on to become surgeons.

Now, I always cringe a bit when my friend tells this story. There’s no need to compare ourselves to each other by focusing on the inhumane parts of the job. It does and always has felt like a race to the bottom. Who benefits from competing to win the competition for most sleep-deprived, the most abused, the most miserable? I’m happy to say that I can recognize that I am not, and don’t aspire to be, any of those things.

However, when I started residency, I was a big part of this culture. It’s all I really knew and was the only way I knew how to connect with people around me going through the same thing. I stopped piling on when I realized how it affected my views of my colleagues from other specialties. You see, the mindset of those inclined to be miserable engenders contempt and narcissism; the kind of absurd thoughts that everyone else isn’t working hard or worse, is just lazy.

The idea that everyone around you is working to capacity may at first seem depressing, but there’s actually a lot of camaraderie lurking just below the surface in the hospital.

In reality, we never know what’s going on in other people’s lives or what their job demands of them. Like anything, my contribution to this culture was easier to hear when the same beliefs were spouted from the mouths of other people around me. I realized how ridiculous it was to assume that any other trainee wasn’t also being stretched to their limit. Then I realized it wasn’t just the residents; other hospital staff and ancillary workers were all in the same boat.

Once I opened my eyes, I saw the challenges the nurses deal with without ever bringing it to our doorstep. I also saw the miracles that our social worker seemingly conjured from thin air. Simply put, I became more appreciative of everyone around me.

A little empathy, a little benefit of the doubt. That’s all I needed. When I learned that about myself, I started loving everything about being a doctor. After all, it’s kind of amazing to be surrounded by so many people that are so dedicated to their work.

I don’t often see the world through rose-colored glasses, so this change in mentality surprised even me. I found it metastasized to other areas of my life without effort. I could see that my patients, like everyone I worked with, were also just trying to get by while doing their best. Kind of like when you first see your teacher in regular clothes at the grocery store--an 'aha' moment that seems juvenile and obvious in retrospect.

This discussion will eventually lead to a discussion about resilience and why it’s such a toxic idea. But before we get to that, I think we have to first address the false idea that so many of us have or still hold about the merit of suffering. Not only should we not have to suffer, but we shouldn’t impose the expectation of trial and tribulation on others either.

I can’t pretend that I don’t enjoy pride, whether it originates in me or my friends and family. I just disagree with what should be a source of pride. I would argue that viewing adversity for the individual as likely positive in the long run is a set up for the inevitable misery of the many. I can say that because I distinguish between hard work and what feels like pointless hardship. In this story, I would feel differently about the same set of facts if I had contributed something during all of my legendary 40-hour shift (an exaggeration that my friend has maintained over the years attributed to creative license). As a resident, I’ve had plenty of 30-plus hour days that brought some real fulfillment entirely because of what I did during those hours--not just due to the number of hours.

This blog has been reposted with permission from amillenialmd.com.

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Danielle B. Cross. MD, MS, is a neurology resident in training with interests in vascular neurology, technology, diversity and inclusion, and education. She has previously taken time away from medical education to work in a small medical startup where she became a believer in work-life balance. She looks forward to fellowship and plans to continue contributing to her blog, amillennialmd.com, and podcast Call Room with A Millennial MD. Follow her on Twitter @amillennialmd.