SDN Article: The Career Costs of Setting Boundaries in Residency

[Dr. David Lenihan, Ph.D., J.D., FRSM]

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In a New York Times article titled “On ‘The Pitt’, She Clocked Out on Time. In Real Life, It Started a Debate” (paywall), author Alisha Haridasani Gupta examined how a short yet pivotal scene in “The Pitt”, the popular HBO Max Original from Warner Bros. Television, has raised eyebrows and generated penetrating discussions among doctors, both new and established.

“Joy Kwon, a third-year medical student trainee with a photographic memory and a scathing eye roll, clocks out at the end of her 12-hour shift,” Gupta’s story says. “Before she steps away, one of her supervisors, Dr. Frank Langdon, tries to pressure her to stay. But she doubles down, reminding him that she has finished her shift and that she isn’t being paid.”

Before she leaves, Kwon tells Langdon, “Maybe all you lunatics need to learn how to set some boundaries.”

As the father of two doctors and given my former roles as President and CEO of a medical school whose graduates have been matched to residencies at America’s premier hospitals, I understand the overwhelming physical and mental pressures that students and new doctors face. While frequently invigorating, medical training and residencies can also be exhausting, soul-crushing, and relentless. The decision that Joy Kwon made to put a discrete end to her shift at Pittsburgh Trauma Medical Center made sense.

However, while Joy prioritized her physical and mental wellness by adhering to the end time of her schedule, she potentially impacted her career trajectory, both short-term and long-term.

Short-Term Cost: Diminished Team Trust​

Midway through the latest season of “The Pitt”, the hospital’s computer infrastructure went down due to a massive ransomware cyberattack. This caused the entire hospital to immediately switch to paper charts and work without access to digital patient histories or records.

Prior to the attack, Kwon, thanks to her innate gift, memorized the hundreds of specific details on the ER’s digital patient screen and then reproduced them on a whiteboard with a Sharpie after everything went offline.

Once the hack was resolved, the fatigued staff realized they needed to devote extra off-the-clock hours to updating their previously offline digital patient records, which were now back online. None of the doctors or residents were happy about this, and the drain on everyone’s brains and bodies was immense.

Kwon had the same grueling grunt work to finish as her fellow doctors, but when the hours of her shift came to a close, she was out the door, likely leaving the extra tasks of transferring her patient records to someone on the remaining day shift or incoming night shift to handle.

If this is how the action played out, it isn’t hard to imagine the annoyance and sense of betrayal that the residents and physicians felt toward her for exiting when everyone else was putting in extra (and unpaid) hours to repair the damage of the cyberattack, in addition to migrating the handwritten information of her patients’ paper records to the hospital’s computer system. I imagine that the ill will would have been massive.

Kwon’s actions, while understandable given her desire for a healthy work-life balance, prevented a memorable and enduring bonding experience with her suffering co-workers. It also potentially created simmering mistrust among them at being left to complete her tasks. Such resentment, especially among a tight team in a period of crisis, is not easily forgotten or forgiven.

The Long-Term Cost: Setting Boundaries in Residency Narrows Your Specialty Options​

If you are interested in being an ER doctor or pursuing another high-acuity specialty, boundary-setting of this kind is not realistic or achievable. As shown in “The Pitt”, ER docs must function and focus in situations of extreme chaos. In fact, some – like Dr. Jack Abbot, a character on the show who’s also a U.S. Army veteran and volunteers as a TEMS provider for the Pittsburgh SWAT team in his off-duty hours – seem to crave the mayhem.

Kwon is intent on maintaining professional-personal equilibrium in her life, and explicitly said on the show that she is not interested in an ER residency. She has chosen accordingly, deciding to pursue pathology by the end of the season. Other non-urgent, lifestyle-friendly areas include dermatology and psychiatry, though both of those commonly require ER rotations during internship year.

For students who aspire to work in internal medicine, family medicine, pediatrics, or general surgery, ER rotations are non-negotiable. You’ll either need to adjust your work-life balance ambitions to fit the needs of your patients and fellow doctors or accept that upward mobility is limited: any aspirations to become a Chief Attending Physician (Dr. Robby’s title) or a similarly higher-ranking supervisory position within the ER department would be unattainable.

Professionals in all industries dream of finding improved steadiness between the demands of their day jobs and the pleasures of their personal lives. Finding that symmetry keeps us sane, well-rounded, and fulfilled. But doing so at the expense of your patients and co-workers (fellow ER staff) will impede your success in your work journey.

Conflict of interest disclosure​

The author is a medical school executive and has held senior leadership roles at institutions that train students entering residency. He reports no financial interest in the subject matter of this article.

AI use​

No AI use was disclosed by the author.

Image: Photograph by Warrick Page/HBO Max

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[Wistfulness]

L-take. The TV character in question is a third-year medical student, not a resident. She had completed her 12-hour shift. Which to sane people, is more than a full day's work. This article seems to be promoting some pretty toxic attitudes about work ethic.

Kwon had the same grueling grunt work to finish as her fellow doctors, but when the hours of her shift came to a close, she was out the door, likely leaving the extra tasks of transferring her patient records to someone on the remaining day shift or incoming night shift to handle.

This is how shift work... works? Patient care wasn't compromised. Transferring documentation from a paper chart to a computerized chart... a task that could be completed by anyone capable of using a mouse and keyboard. Why do we need a medical student who has been at the hospital for 12-straight hours to do it. You literally call it grunt work!

If this is how the action played out, it isn’t hard to imagine the annoyance and sense of betrayal that the residents and physicians felt toward her for exiting when everyone else was putting in extra (and unpaid) hours to repair the damage of the cyberattack, in addition to migrating the handwritten information of her patients’ paper records to the hospital’s computer system. I imagine that the ill will would have been massive.

It's actually very difficult for me to imagine getting mad at someone for going home after a particularly difficult 12-hour shift.

If you are interested in being an ER doctor or pursuing another high-acuity specialty, boundary-setting of this kind is not realistic or achievable. As shown in “The Pitt”, ER docs must function and focus in situations of extreme chaos. In fact, some – like Dr. Jack Abbot, a character on the show who’s also a U.S. Army veteran and volunteers as a TEMS provider for the Pittsburgh SWAT team in his off-duty hours – seem to crave the mayhem.

Maybe we shouldn't be glorifying the guy that stresses himself to the point of wanting to jump off the hospital building in the final episode of the season.


The take-away from this article seems to be sacrifice your mental health and physical health to fill gaps created by poor leadership and administration.

 

[Tenk]

As an attending physician in an academic ED, I can tell you that I would never in a million years give a damn if a medical student left when their shift ended nor would I notice if they left an hour early or late unless they explicitly told me. Even if they did, I would forget it happened in less than 30 seconds when I received 7 pop up chats in Epic.

 

[Doctor-S]

As an attending physician in an academic ED, I can tell you that I would never in a million years give a damn if a medical student left when their shift ended nor would I notice if they left an hour early or late unless they explicitly told me. Even if they did, I would forget it happened in less than 30 seconds when I received 7 pop up chats in Epic.

Same here from PhD-MD with AMC Level 1. Agree with @Tenk ... although it would probably take me 60-seconds to forget it happened!

 

[NontradICUdoc]

As an intensivist, I can tell you that when my shift is over I am gone. Unless a massive train wreck comes in and I am working to stabilize the patient, when my shift is over it is over. And if there is a very unstable patient and I stay post shift, I leave when they are stable enough for me to do so. But I am also the attending. In addition, As an academic intensivist, when I have students I have no expectation that they stay longer than they need to. In fact, it is my resident that tells them to leave not me. I disagree with this article in that there is no work-life balance here.

“However, while Joy prioritized her physical and mental wellness by adhering to the end time of her schedule, she potentially impacted her career trajectory, both short-term and long-term.” I very much disagree with this sentence. As a TYR program director and director of Osteopathic Education I look at all of the applications for not only my program, but all of the DO applicants for the IM program. And we have never had any faculty ask. “Has this student ever prioritized physical or mental wellness and leave on time or were they dedicated and stayed longer?” In fact, this may be a problem because of the 80-hour work rule. The ACGME will give some leeway to patient care, but if this is a constant thing then they will surely come in for an inspection.

One issue in medicine today is burnout which can leave to, in extreme circumstances, suicide. We are at a crisis here, especially since we are going to have a worsening shortage of physicians for an ever aging population. And telling students that they will sacrifice their future if they put their wellness first is shooting ourselves in the foot on top of getting is smashed by all the regulations, politics, and administrative responsibilities that affect our reimbursement and take us away from our patients.

I encourage all of my residents to leave on time, and as soon as they sign out set their EPIC chat to offline until they are back on shift. I encourage them to NOT look at any charts and if by chance they are texted or called about a patient and they are off to tell the caller they are not on call and call someone else. I would encourage every student and resident to 100% focus on their physical and mental wellbeing. Leave their shift on time, hit the gym, catch a game, go bowling, meditate, yoga, cook, draw, hit a movie, etc. But do not, under any circumstances, stay longer than you need. That is why it is SHIFT work. Give a good signout and live

 

[Tenk]

Same here from PhD-MD with AMC Level 1. Agree with @Tenk ... although it would probably take me 60-seconds to forget it happened!

Dang, either your memory is good or you don’t get enough pop ups.