Thursday, March 19, 2020

The origins of sleep-deprived residency

All of us know that nurses and doctors work long, consecutive hours, and none more so than doctors during their resident training years. Few people, however, know why. Why did we ever force doctors to learn their profession in this exhausting, sleepless way?

The answer originates with the esteemed physician William Stewart Halsted, MD, who was also a helpless drug addict.

Halsted founded the surgical training program at Johns Hopkins Hospital in Baltimore, Maryland, in May 1889. As chief of the Department of Surgery, his influence was considerable, and his beliefs about how young doctors must apply themselves to medicine, formidable. There was to be a six-year residency, quite literally.

The term “residency” came from Halsted’s belief that doctors must live in the hospital for much of their training, allowing them to be truly committed in their learning of surgical skills and medical knowledge. Fledgling residents had to suffer long, consecutive work shifts, day and night.

To Halsted, sleep was a dispensable luxury that detracted from the ability to work and learn. Halsted’s mentality was difficult to argue with, since he himself practiced what he preached, being renowned for a seemingly superhuman ability to stay awake for apparently days on end without any fatigue.

But Halsted had a dirty secret that only came to light years after his death, and helped explain both the maniacal structure of his residency program and his ability to forgo sleep.

Halsted was a cocaine addict.

It was a sad and apparently accidental habit, one that started years before his arrival at Johns Hopkins.

Early in his career, Halsted was conducting research on the nerve-blocking abilities of drugs that could be used as anesthetics to dull pain in surgical procedures. One of those drugs was cocaine, which prevents electrical impulse waves from shooting down the length of the nerves in the body, including those that transmit pain.

Addicts of the drug know this all too well, as their nose, and often their entire face, will become numb after snorting several lines of the substance, almost like having been injected with too much anesthetic by an overly enthusiastic dentist.

Working with cocaine in the laboratory, it didn’t take long before Halsted was experimenting on himself, after which the drug gripped him in a ceaseless addiction.

If you read Halsted’s academic report of his research findings in the New York Medical Journal from September 12, 1885, you’d be hard pressed to comprehend it. Several medical historians have suggested that the writing is so discombobulated and frenetic that he undoubtedly wrote the piece when high on cocaine.

Colleagues noticed Halsted’s odd and disturbing behaviors in the years before and after his arrival at Johns Hopkins. This included excusing himself from the operating theater while he was supervising residents during surgical procedures, leaving the young doctors to complete the operation on their own. At other times, Halsted was not able to operate himself because his hands were shaking so much, the cause of which he tried to pass off as a cigarette addiction.

Halsted was now in dire need of help. Ashamed and nervous that his colleagues would discover the truth, he entered a rehabilitation clinic under his first and middle name, rather than using his surname. It was the first of many unsuccessful attempts at kicking his habit.

For one stay at Butler Psychiatric Hospital in Providence, Rhode Island, Halsted was given a rehabilitation program of exercise, a healthy diet, fresh air, and, to help with the pain and discomfort of cocaine withdrawal, morphine.

Halsted subsequently emerged from the “rehabilitation” program with both a cocaine addiction and a morphine addiction. There were even stories that Halsted would inexplicably send his shirts to be laundered in Paris, and they would return in a parcel containing more than just pure-white shirts.

Halsted inserted his cocaine-infused wakefulness into the heart of Johns Hopkins’s surgical program, imposing a similarly unrealistic mentality of sleeplessness upon his residents for the duration of their training.

The exhausting residency program, which persists in one form or another throughout all US medical schools to this day, has left countless patients hurt or dead in its wake—and likely residents, too.

That may sound like an unfair charge to level considering the wonderful, lifesaving work our committed and caring young doctors and medical staff perform, but it is a provable one.
Source: Why We Sleep by Matthew Walker

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