“Nowadays, after I’ve fallen asleep and slid into the junction while returning home from a night shift a few times, I put on the handbrake at every traffic light,” says Dr. Uri Rosen, a resident physician in the internal medicine department at Holon's Wolfson Medical Center. That’s what happens when you do 26-hour shifts, sometimes more than once a week. “I don’t know who would be willing to get on a plane or a bus when they know that the person at the wheel has been doing this for 24 straight hours,” he says. “I’ve treated patients and done resuscitations during hour 24.”
The residents’ struggle over the length of their shifts has been on the low burner for nearly a decade, ever since a collective agreement was signed with doctors in 2011. That agreement, achieved after a lengthy battle by doctors, filled with strikes and demonstrations, promised a pilot program for shortening the length of night shifts. But there have been almost no more positions added to make this possible, so the situation remains: Residents do 26-hour shifts followed by 24 hours at home.
“A 26-hour shift feels exactly like it sounds,” says Rosen, 35. He starts at 8:00 A.M., and from 3:30 P.M., he assumes full responsibility for a department with 40 to 42 patients. “In the afternoons there’s no longer a secretary on the floor, so you’re dealing with a lot of logistics. All the coordination of external tests – X-rays, and CT – are your responsibility. By 8:00 P.M. your legs hurt, and by 10 you’re also hungry. At 3:00 A.M., during the 18th hour of the shift, in comes the ninth patient and you’re already doing bad work. You have no strength, empathy, or patience. You make a mistake and miss [giving somebody their] medication – and it’s lucky there are nurses there to fix it.”
It’s the kind of day which Dr. Reut Cohen Lasri, 34, prepares for six times a month – at least. She’s a resident in the pediatric department at Shamir Medical Center in Tel Aviv (formerly Assaf Harofeh Medical Center). “I know I’m going into 26 hours in which I won’t have time to put my head down, and I’m not sure I’ll be able eat,” she says. “If there’s time in the afternoon, you eat. But when there’s pressure, there isn’t even time for that. In principle, under the agreement a resident is entitled to two hours of rest – if that’s possible. Most of the time it doesn’t happen.”
Lasri says that studies have shown that lack of sleep can have the same effect as drinking alcohol, and she can confirm this. “You think more slowly, you finish reading a paragraph and have to read it again. You mix patients up, your tolerance for frustration drops, and you have no strength to listen to and resolve every problem that crops up. I remember falling asleep in front of someone for a few seconds and not hearing what they’ve said.”
The plague of normalcy
But something interesting happened during the coronavirus crisis. Out of a need to reduce the exposure of medical personnel to the virus, fixed groups of staff members were assigned to shifts which were shortened to only 12 hours, giving residents a taste of what their lives could look like if additional personnel were taken on, as was promised. According to the residents, the improvement in the level of professional performance, attention and treatment ability was so dramatic that what might have looked to others like a chaotic situation was to them a harbinger of normalcy.
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The transition back from the coronavirus schedule to those endless shifts has reignited their struggle for change. Now, having garnered much public acclaim for being on the front lines of the crisis, residents are hoping that they will receive what they were promised in 2011 – the employment of 1,000 more positions so that the burden is more spread out. “They added fewer than 100,” says Dr. Ray Bitton, an internal medicine resident at Assuta Medical Center in Ashdod and chairman of the Mirsham organization, which represents the residents. She noted that Israel’s population has grown in the intervening years, making the pressure on doctors that much greater.
She wants residents’ shifts to be 12 hours. “In most OECD countries residents’ shifts are up to 14 hours,” she says. “Most of the world has moved over to shorter shifts, and Israel is one of the last of the dinosaurs.”
The country’s 7,500 residents bear the primary burden of hospital care in Israel. They are two-thirds of the physicians in an average hospital department, and are also solely in charge around two-thirds of the time. From 4:00 P.M., when most senior doctors finish their day at the hospital, until 8:00 A.M. the next morning, as well as on weekends, they are in charge of the wards. There is one resident per department, backed up by a senior specialist on call at home who can be called in to the hospital in the case of an emergency.
This schedule continues for between four and seven years, depending on the doctor’s specialty. While very difficult, at least it eventually ends with the doctor earning the status of a specialist. But the punishing schedule isn’t always good for the patients, either, as anyone who has ever come to an emergency room or has been admitted to a ward in the middle of the night can testify. It’s hard to miss the lack of patience and attention, the apathy, the reluctance to explain anything and the drooping eyelids of the sole doctor in the department who has been on the job for 18 hours and has eight more to go.
Bitton complains that the residents don’t always get much support from more seasoned doctors. “There are plenty of arrogant responses from senior physicians, who sit around and talk about how they did 32-hour shifts and that’s what made them the excellent doctors they are today,” she says. Although as time passes, she says, there’s less of that. “More and more specialists, including department and hospital directors, say that the fact they worked like that doesn’t make it good.”