
Physician Training Stress and Accelerated Cellular Aging - yhoneycomb
https://www.biologicalpsychiatryjournal.com/article/S0006-3223(19)31329-0/fulltext
======
lenticular
Residents don't sleep much, so this doesn't surprise me at all.

Related, the residency process needs to be massively reformed. The flimsy
justification for making people responsible for human lives work 80 hours a
week is usually that the long hours help them learn faster. But that's really
BS. The brain has an incredibly hard time forming new memories when sleep
deprived.

I know a couple of nurses who often talk about how spaced-out residents are at
night. They'll page them to consult on something, usually waking them up. The
residents will usually just blearily agree with whatever the nurse was
planning on doing, so they aren't getting in meaningful physician supervision.

~~~
synaesthesisx
The pioneers of the modern residency system were fueled by copious amounts of
cocaine & other stimulants. Perhaps we need to reevaluate the requirements &
expectations we place on medical residents today. It's essentially a form of
professional hazing, and I personally know many surgical residents that are
literally operating on people today while absurdly sleep deprived (by no fault
of their own, just the insane hours of their program).

That said, if whoever's operating on me is running on 3 hours of sleep I'd
rather they be hopped up on stimulants than not...

[https://en.wikipedia.org/wiki/William_Stewart_Halsted](https://en.wikipedia.org/wiki/William_Stewart_Halsted)

~~~
sarcasmOrTears
One time I met with the head of an union and he told me many tough jobs
(mining mainly) were perfomed while on drugs, which aren't available anymore
causing all kinds of issues for the workers. I wonder if there was truth in
that statement and maybe some formal research on this.

~~~
killjoywashere
As I recall, the CIA did do a fair amount of this research on this, up to and
including implanted cortical stimulators, which created some serious backlash.

Getting prescribed "on/off" switches in pill form is a well-known thing in the
military. You just can't do combat air patrol over remote areas of Asia
without some uppers. This quickly went from the pilots (mid-grade officers)
and other fight crew, to being adopted by folks who have to go halfway around
the world routinely (flag officers).

It's an active topic of conversation, some do, some don't. As a military
physician who was a line officer and has been through 5 years of graduate
medical education (internship + residency), and now occasionally has to do
those round-the-world trips, it's not clear to me that there's an obvious
right answer in policy or per-person. We (leaders and followers alike) expect
leaders to function at the outer limits of human capacity, and have for a long
time. I can tell you this: it doesn't get easier with age: a fairly common
definition of success as a leader is proving your ability to take on more
responsibility, so the more you do, the harder it gets. So avoid starting
early.

------
chriselles
I’ve worked on a human performance assessment program for nearly 10 years.

We induce stressors cross the spectrum to better inoculate volunteer
candidates from stress and enhance their resiliency.

They are often suffering from sleep deprivation/deficit.

We have very robust safety procedures in place.

After observing hundreds of volunteer candidates in depth over nearly a
decade, I would say that sleep deprivation/deficit is an exceptionally and
deceptively dangerous problem.

Akin to carbon monoxide poisoning in a way.

Members of the military and first responders may need to operate for extended
periods with little to no sleep/rest. And that includes physicians in training
for things like mass casualty scenarios.

So it IS worthwhile to possess “reference points” of personal adversity to
manage decision making while stressed.

But to LIVE a sleep deprived life of a physician resident is nothing short of
madness and a recipe for failure.

I’ve been under Assessment. And it certainly feels like it ages you
prematurely. And anecdotally, it appears to do so to many of our candidates.
Temporarily.

I’ve had my telomeres measured a few times.

Fortunately, active effort to target 7+ hours of daily consistent sleep,
fitness, nutrition, and other choices seem to play a factor in outlier
telomere length.

Or I’m just lucky.

Just because we have always done it this way with residents, doesn’t mean we
should.

~~~
Havoc
>We induce stressors cross the spectrum to better inoculate volunteer
candidates from stress and enhance their resiliency.

Oh god. That gives me flashbacks to university. They gave us this super messed
up exam schedule - writing majority of waking hours & not knowing what
class/course/topic you're walking into. Asked the profs WTF is up with the
cruel exam plan and that was that exact answer: The professional exam
(country's CPA equivalent) is structured like this so yeah we structured your
exams to intentionally & artificially create stress. Dry run for that level of
unreasonable pressure. Never occurred to me that my uni profs might be out to
intentionally stress me before that comment.

Speaking of residents - that's a key thing that gets me through all that
stuff. Reminding myself that I'm not a surgeon...nobody dies if I screw up. I
can do crazy stress, long hours, little sleep like a boss but 99% sure I could
not emotionally do that if my steady hand determines whether someone lives.
The people that can - happy concede that they are a better man than I am.

~~~
saulrh
> The professional exam (country's CPA equivalent) is structured like this so
> yeah we structured your exams to intentionally & artificially create stress.

Even on second and third thought this seems insane. I can understand doing it
on something that turns out to be relatively inconsequential as a learning
experience, but doing it for people's PEs and final exams? That sounds like a
great way to overwhelm every possible feature related to engineering quality
in favor of "how well do they survive an unrealistically horrible stress-
test". Because, like you said, _nobody dies if you screw up_. Being able to
handle acute stress is not that useful for a civil engineer or similar.
Teaching people to handle chronic stress? Maybe, but the research I see says
that there _is_ no way to deal with chronic stress and even attempting it
damages you, potentially permanently. Acute stress, nope.

~~~
Havoc
>this seems insane

A little bit. Big part of the issue was that the professional exam results
were published by originating university.

So there was this really perverse incentive for universities to send only the
most battle hardened candidates into the process to kept the very public stats
on the uni's performance on these independent professional exams high.

And if you think that's wild - it gets better. This being HN: Some
enterprising genius looked at this entire process and decided he's going to
set up a recruitment company that does nothing other than exporting survivors
of above process. Literally park them anywhere globally - nothing really
matters & nobody cares where cause clearly these guys can cope and collecting
a juicy placement fee is easy money. One of the best/safest business models
I've ever seen - leverages a beautifully subtle anomaly in the global labour
market that isn't immediately obvious to outsiders.

>Being able to handle acute stress is not that useful for a civil engineer or
similar.

Alas in my particular world (Accounting/auditing) it is. 3 months of soul
crushing stress and rest of year is more relaxed. Rinse & repeat.

>Teaching people to handle chronic stress?

That's one saving grace I guess. I find that 3 months of intense stress is
bearable. Or rather it's about the limit of my endurance.

Certainly not healthy - talking about this purely practically.

~~~
saulrh
> Alas in my particular world (Accounting/auditing) it is. 3 months of soul
> crushing stress and rest of year is more relaxed. Rinse & repeat.

Cripes.

And I bet that the soul-crushing stress even after you've gotten the license
is probably because you don't have enough people licensed to do the work,
which in turn is because the universities try to keep their stats high which
artificially restricts the supply. And there's probably a feedback loop going
on where the industry considers the stress "normal" and adds it to the PE
because "that's how the industry is and you need to be able to handle it",
normalizing the deviance and inducing evaporative cooling [1].

No offense, and thank you for being able to handle your job because auditing
is one of those things that's certainly necessary for the smooth functioning
of civilization and it really sounds to me like the supply of that capability
is dangerously restricted, but... yet again I am thankful that my interests
guided me to a career in software engineering.

1\.
[https://www.lesswrong.com/posts/ZQG9cwKbct2LtmL3p/evaporativ...](https://www.lesswrong.com/posts/ZQG9cwKbct2LtmL3p/evaporative-
cooling-of-group-beliefs)

~~~
Havoc
Yeah sometimes I wonder about that career choice of mine. Software or actual
engineering would have been cool.

>it really sounds to me like the supply of that capability is dangerously
restricted

In some countries yes quite restricted, don't think dangerously so. Way more
scared of them rubberstamping poor candidates. Plus auditing isn't
particularly difficult to be honest.

>one of those things that's certainly necessary for the smooth functioning of
civilization

Maybe. I'm not 100% convinced. I'll definitely take the job security though.

------
i_am_proteus
A decade or two back, the US Navy used the recruiting slogan "Accelerate Your
Life."

On submarines, it wasn't uncommon to see men who looked unusually old: full
head of grey hair before age 40, perhaps.

I have never been a medical resident, but submarine service can be pretty damn
stressful; we jokingly called the service "the life accelerator" because of
how fast people seemed to age.

I always chalked it up to natural deviation, but maybe it'll turn out to be a
genuine effect of sustained stress.

~~~
nradov
Are submarines more stressful than surface ships? I was never in the Navy but
I've heard surface warfare officers complain that they were constantly sleep
deprived. Between standing watches, training, maintenance, and managing
subordinates they barely got a few hours of poor quality sleep per day.

~~~
davemp
Subs keep their air at significantly lower oxygen concentrations for fire
safety reasons which may contribute to the stress. I had a teacher tell
stories about sailors putting bags over whatever emitted the oxygen and then
breathing it directly.

~~~
nradov
The average PPO₂ on submarines appears to be no lower than the air in Aspen
CO. People living in Aspen don't age faster than normal. Since higher oxygen
levels cause oxidative stress in the body it's even possible that lower oxygen
might protect against some aging symptoms.

~~~
shrimp_emoji
Isn't the new meta that aging isn't due to oxidization but to an impairment to
the body's anti-oxidization mechanism _due to under-oxidization_? Because, if
that's the case, more oxygen would slow your aging by putting your anti-
oxidization system to work.

None of this is oversimplified and stupid.

------
yingw787
Not surprised at all. I have friends still in med school. Apparently there’s
an exam called the Step 1 where you can only take it once, and if you pass but
don’t do well enough then you get shipped to somewhere not great to do your
residency. I thought the hardest part was the MCAT but I was totally wrong :(

~~~
assblaster
Step 1 can be retaken, along with all the other exams of the USMLE.

~~~
yingw787
You’re right; you can retake the Step 1 up to six times. However, you can
retake it if you fail, you can’t retake if you pass. AFAIR that’s what my
friends were worried about; you can retake if you fail but if you were
planning on failing why retake it. It’s the pass with a low score that sends
you to a bad place.

~~~
arkades
Correct.

------
outlace
Just graduated from medical school. Started out with 0 gray hairs. Now I have
salt and pepper hair on the sides. Not worth it.

------
needlesurgeon
North American Neurosurgeon here. My opinions are based on my personal
experience and my understanding of the literature. I am not an expert in
residency well-being or work-hour restrictions.

First: the literature is unequivocal about the effects of chronic sleep
deprivation. This cellular aging article fits within what is known already.
Sleep deprived humans are dumber, more stressed, and now age faster that non-
sleep deprived humans.

The tacit assumption for work-hour restrictions is that sleep deprived
physicians result in inferior medical care for patients. It turns out that the
literature does not support the tacit assumption. When researchers looked at
complications/mortality pre- and post- work-hour restriction, there was no
difference. This result is somewhat counter-intuitive, and has been reproduced
in various contexts. The one mortality benefit that has been for physicians
themselves: less physicians get into car accidents after their call shifts.
It's worth noting that there is literature to suggest that less ICU errors are
made by sleepy residents, however, this also didn't translate into mortality
differences.

So what's happening? There are a few interpretations of these results. The
first is that resident physicians really aren't important for patient care,
and that the majority of care provided comes from attending physicians. For
anyone who has been admitted to an academic institution, this interpretation
is silly and is unsatisfying.

The second is that there are sufficient checks and balances. When a sleepy
physician makes a silly mistake, nurses can catch errors "this patient has an
infection; are you _sure_ you don't want to start antibiotics?" and
pharmacists can catch errors "You ordered a hundred times the lethal dose.
I'll correct that for you." When the day-team comes by and hears about the
patient, they can quickly fix the errors made. Having made some silly errors
myself, this certainly plays at least part of what happens.

The third is that most of medicine is rote. Frankly, after a few years of
doing the same thing over and over again, you don't really need that much
brain power to do a lot of medicine. I have admitted hundreds of people with
brain tumors over the years, and the immediate workup and management for the
majority for patients is identical. I can do this in a sleep-deprived state. I
am not saying that some cases are more complicated than others. As a HN
analogy: consider how much sleep you need to print "Hello World!" in your
favorite language.

The fourth is that the ability to capture complications / mortality is
increasing at the same rate as residency work hour restrictions are resulting
in better patient care. In other words, we're searching and finding problems
we wouldn't have caught otherwise. It's hard to counter this argument, but I
don't know of any data for or against this position.

There are certainly more reasons, but I think the point is made. It's not
obvious, it's multifactorial, but it's definitely robust.

OK, so the obvious question is this: Why do resident physicians need to work
so hard?

First, let's look at the statistics. Suppose you're providing neurosurgical
care for a catchment area of a million people. Brain tumors, as a category,
affect 1:10,000 people. This means you'll be admitting 100 new brain tumors a
year. However, not all brain tumors are the same (in fact, depending on how
you want to slice the pie and what you consider a tumor, there are on the
order of 200 different tumor diagnoses). Some tumors are common (e.g.
metastatic lung tumors) and some are literally a one in a million diagnosis.
In order to see the gamut of tumors in your training, you simply need the time
in hospital. In my estimation, brain tumor surgery has a mean of 3.5 hours,
with 95% of the cases being between 90 minutes and 24 hours. This means that
the average academic center is doing at most two tumors per day. The argument
here is that you need the hours to see the cases. There's no doubt that
sleepier doctors learn worse than non-sleepy doctors. But I can tell you that
I have participated in very rare operations in sleep deprived states, and I
remember the approaches much better than common operations I've seen in non-
sleep deprived states.

Suppose we are interested in maximizing physician well-being, regardless of
the literature supporting patient outcomes. The simple solution is to simply
restrict work hours. So, who runs the hospitals? One approach is to hire more
residents. Well, residents eventually need jobs. Suffice it to say, swamping
the medical profession with more doctors who have less training is not an
intuitively satisfying solution to the problem. Moreover, more doctors means
more handovers. Increasing handovers has been shown to result in order more
unnecessary tests for patients, and to result in inferior patient care.

Restricting work hours means that surgeons may have to train longer. Well, at
minimum in the US, becoming a neurosurgeon is 4 + 4 + 7 years of post-
secondary education (undergraduate, medical school, residency -- residency
used to be 6 years). Many residents choose to become subspecialists, adding
another year or two (or possibly 3 or 4). Further work hour restrictions could
turn the 15-year training process into a 16 or 17 year process. Fair enough,
this could solve the problem. But really? From a purely economic perspective,
this is silly. Think of the opportunity cost of educating yourself for 20
years (i.e. 20 years of debt) to work for 25 more before being asked to
retire.

Suffice it to say, it's a tough problem. In recognition of this last point,
many specialties are moving towards competency based training. That is,
graduating surgeons when they meet a competency rather than having spent
sufficient time in hospital. This is a no brainer in other fields (e.g. flying
planes, building bridges). While this is in fact reflecting the times (greater
emphasis on patient safety than in the past), there's no doubt in my mind that
this is being implemented because those in power feel that they are graduating
surgeons less competent than the generation before them.

This last point, is in my opinion, the important question to ask. If anyone
knows of any literature about this last point, I'd be grateful.

~~~
skybrian
It sounds like the strategy is put in a lot of hours doing routine cases
(where little learning happens) in order to experience the rare cases. This
seems inefficient? Couldn't residents be called in to look at the rare cases?

I guess they would need to be close by when it happens, but that doesn't seem
to justify sleep deprivation?

Or maybe there are other ways to increase the odds of seeing a rare case?

~~~
riahi
This is the difference between coding the solution to a tough technical
problem yourself versus watching someone else code it.

There can only be so many assistants.

~~~
needlesurgeon
I'm told by my anesthesia friends that it take about 6 weeks to train someone
to be technically proficient at putting someone to sleep and waking them back
up again.

The five years of training are needed to understand why you're doing it, and
to see enough disasters to know how to get yourself out of the disaster
situations.

While I don't fly planes, I would imagine flying a plane would be similar.

I also drive a car. While I was technically proficient while I got my license,
it took years to get to the point of predicting the behavior of other drivers
on the road, and to not panic when unexpected events happened (hydroplaning,
odd pedestrian behavior, etc.).

~~~
riahi
It's a similar telescoping training problem in Radiology. We can train someone
to have basic proficiency in interpreting a specific imaging examination in a
relatively short period of time, but building the knowledge base, following up
ambiguous diagnoses with pathology correlation, and seeing sufficient volume
requires 5 years after internship. This doesn't even include all the knowledge
we have to know for image acquisition, artifacts, and protocol design/QA.
After all, you don't see what you don't know.

Yes you can look at case books and question banks and sample teaching cases,
but until you are dictating the case primarily and have to decide whether to
call a diagnosis which will have profound downstream treatment implications,
it's a very different experience. While most specialists are comfortable with
their area of imaging, I'm talking Radiologists remote reading cases for a
rural location, where their report will determine if the patient is
transferred and to where, with significant costs to the system and the patient
if they are wrong.

I'm not sure how to "fix" it other than adopt a variant of the "commonwealth"
competency-based system in Australia, where residencies have "usual" terms but
if someone is competent and willing to sit the board certification exam early,
they can try.

------
hinkley
Do intense residencies make better doctors or is this one of those self
destructive cost saving measures?

Sort of reminds me of the concussion situation in football. Some coaches, I
believe especially college level, are looking at subbing in other training
methods to reduce on field practice time and thus chance for injury. Maybe
walking the hospital floor 12 hours a day isn’t the best training.

~~~
cycrutchfield
I think a lot of it is just hazing. Attendings probably feel like just because
they were given a hard time during residency they need to do the same to the
newcomers.

------
assblaster
Procedural specialities will always need an extreme amount of hours spent
honing their skills. Considering that your experience is the basis for a good
outcome for your future patients when you are solely responsible, you know
that the more you work the better off you'll be.

The procedural specialities operate on a hierarchy that emphasizes underlings
doing most of the grunt work while senior residents can be all day in the
operating room. There's likely a better way to do it, but this is how it has
been done for decades and just won't change.

~~~
percutaneous
Perhaps working 50 hour weeks and being well rested would result in faster and
more efficient learning than working 80 hours. Yes - you have to do your time,
but humans don't learn well sleep deprived.

You could try and force them to work 100, or 160 hours per week and I suspect
you'd rapidly find quality of work and learning nosedive.

I think it's worth considering 80 hours is already on the wrong side of that
curve.

------
Ericson2314
Is the medical profession finally looking in the mirror?!?

