Video: Principle of Patient Welfare | Commentaries

A Medical Student Perspective

As a medical student, my quality of life depends on finding balance between work responsibilities and personal needs. However, my professional standing seems to depend on my work ethic and the sacrifices I'm willing to make for my training.

What might be the negative repercussions of a student choosing to leave her shift when she feels too tired or stressed out? Students often know the most about a patient's social and emotional state, so leaving without adequately signing out psychosocial issues could compromise patient care. Some patients may prefer to have a student present for support during procedures or in family meetings. The student's absence may affect the patients' perception of their care. Less time spent with patients could also result in missed learning opportunities. The grueling environment of clinical rotations may be a requisite "initiation" for the life-or-death decisions that will come in the years ahead.

When faced with a difficult decision on the wards, perhaps the most salient consequence for students is a poor evaluation. Medical students confronting ethical dilemmas often make decisions based on how their residents will evaluate them.¹ Most strive to be a "team-player" and are reluctant to speak up about moral conflicts fearing it will reflect poorly on performance.² Even when work obligations are complete, leaving a shift without offering additional help risks being perceived as uncommitted and lazy. Nevertheless, students making every effort to be a "team-player" may find themselves compelled to doing things they feel are unethical and counter-productive to their learning.¹ The first time a student is asked to do a difficult procedure can result in failed attempts and suffering for the patient.¹ Working extra hours while sleep deprived can compromise learning and health. Sleep loss from a night on-call has been shown to impair cognitive performance³, increase risk for motor vehicle accidents⁴, and may be contributing to the high rates of depression and anxiety among medical students.⁵ Psychological distress can lead to poor academic performance and decreased empathy towards patients.⁵ Sleep loss and subsequent poor quality of life, therefore, can interfere with the very reason we train to be doctors -- to provide the best possible care for our patients.

Perhaps finding the courage to address the dilemmas we face is a step in the right direction? The fear of being poorly judged for simple decisions, like eating lunch or asking to leave, is real. However, the assumption that drives that fear is often irrational. Most of my residents and attendings are reasonable people who understand my need to eat and sleep. One of my greatest epiphanies was realizing this obvious fact: the only way my resident can know that I'm done with my work and ready to leave is to tell them! So, when I'm exhausted on post-call days, I have found what often works is simply asking my resident if there's anything else I can do before I leave. This can be an effective and sensitive approach to finding balance between supporting my team and advocating for my personal health.

References:

1. Christakis DA, Feudtner C. Ethics in a short white coat: the ethical dilemmas that medical students confront. Academic Medicine 1993;68:249-54.
   
   
2. Caldicott CV, Faber-Langendoen K. Deception, discrimination, and fear of reprisal: lessons in ethics from third-year medical students. Academic Medicine, 2005;80:866-73.
   
   
3. Halbach, MM, Spann, CO, Egan, G. Effect of sleep deprivation on medical resident and student cognitive function: A prospective study. American Journal of Obstetrics & Gynecology 2003;188:1198-1201.
   
   
4. Barger, LK, Cade, BE, Ayas, NT, Cronin, JW, Rosner, B, Speizer, FE, Czeisler CA; Harvard Work Hours, Health, and Safety Group. Extended work shifts and the risk of motor vehicle crashes among interns. New England Journal of Medicine, 2005;352:125–134.
   
   
5. Dyrbye, LN, Thomas, MR, Shanafelt, TD. Systematic Review of Depression, Anxiety, and Other Indicators of Psychological Distress Among U.S. and
   
   
6. Canadian Medical Students. Academic Medicine, 2006,81:354-373.

Meghan Gould
4th year medical student
University of California, San Francisco