S P E C I A L T H E M E A R T I C L E
Resident Work Hours: The Five Stages of Grief
James E. Barone, MD, and Michael E. Ivy, MD
ABSTRACT
The authors describe their reactions, as surgical educators, to that of Europeans to the printing press. But Dr. Barone
to the mandate of the Accreditation Council for Graduate ( the older of the coauthors and a known curmudgeon ) is
Medical Education to reduce resident work hours. They
not so sure, and shares many of the concerns described
explain these reactions in terms of Dr. Elizabeth Kübler-
earlier in the five stages of grief, even though he has
Ross s five stages of grief: denial, anger, bargaining, de-
outwardly accepted the work-hours rules and insists on
pression, and finally acceptance ( which should not be
full compliance by his residents and faculty. In particular,
mistaken for a happy stage ). The authors describe each
he is saddened that some residents feel they have the
stage of grief and use it to make specific comments on the
absolute right to go home regardless of the situation on
difficulties that the mandate imposes. They then reveal
the surgery service, and this feeling is validated by the
that their views about the work-hours regulations differ:
work-hours rules.
Dr. Ivy now sees them as an opportunity to grow and
Acad Med. 2004;79:379 380.
improve, and likens the resistance to the new restrictions
s we stand on the threshold of a new era in The third stage is bargaining. ( The bargaining is really an
surgical education, we note that our reaction to attempt to postpone. ) An 80-hour work week will be im-
the mandate of the Accreditation Council for possible to comply with. If we can show an educational
AGraduate Medical Education to reduce resident rationale, may we please have an extension of the time to
work hours resembles the five stages of grief.* Our first response make it an 88-hour work week?
to the news that resident work hours must not exceed 80 per Next is depression. ( Anger and rage will soon be replaced
week was denial. ( No, not me, it cannot be true. ) It must with a sense of great loss. ) The most recent meeting of the
Association of Program Directors in Surgery had a funereal
be a mistake. It s fine for internal medicine and family
tone. Many program directors engaged in a kind of group
practice, but it can t be meant to apply to surgery.
therapy. Condolences were exchanged. Predictions of the
We moved on to anger. ( When the first stage of denial
apocalypse were endorsed. Some said this is the ruination of
cannot be maintained any longer, it is replaced by feelings of
anger, . . . rage and resentment. ) How can we train compe- the best system of medical education in the world.
Finally, ready or not, we have reached the stage of accep-
tent surgeons under these rules? How do they expect us to
tance. ( Acceptance should not be mistaken for a happy
cover all the patients? Continuity of care will be destroyed.
stage. ) This final stage involves frantic scrambling to estab-
There is no way this will work.
lish a workable system of compliance. It is marked by the
grim realizations that most methods of compliance will result
in the curtailing of many external rotations and disrupt even
Dr. Barone is professor of clinical surgery, Columbia University College of
internal rotations. Conferences and schedules will need ma-
Physicians and Surgeons, New York, New York, and Dr. Ivy is director of
jor overhauls. And, yes, things will be different. Something
surgical education, Bridgeport Hospital, Bridgeport, Connecticut, and assis-
called  night float, a concept never mentioned before in the
tant clinical professor of surgery, Yale University School of Medicine, New
same sentence as  surgery is upon us.
Haven, Connecticut.
Correspondence should be addressed to Dr. Barone, 1544 Shippan Avenue,
Stamford, CT 06902; telephone: 203 323-5194; e-mail: [e-mail] .
Reprints will not be available.
Our apologies to Elizabeth Kübler-Ross, MD, for the use of this term and
of the quotations in parentheses, which are taken from her book On Death
For articles on related topics, see pp. 381 383, 384  385, 394 406,
407 416, and 447 452. and Dying (New York: Simon and Schuster, 1969).
A CADEMI C M EDI CI NE, V OL. 79, NO . 5 / M AY 2004 379
F I VE S TAGES OF G RI EF, CONTI NUED
Dr. Ivy, the junior author of this piece, is young and described in the five stages of grief. While he has outwardly
idealistic. He has rather strong feelings on this subject. He accepted the work-hours rules and has rigidly insisted on full
now feels that the work-hours regulations should be seen as compliance by his residents and faculty, he is actually still
an opportunity to grow and improve, which has been his mired deeply in phase four (depression). He worries about
perception of the recent experience with the Yale surgical everything. But mostly, as he is starting to be asked if he
residency program. He likens the resistance to the work- qualifies for the senior discount at the movies, he is wonder-
hours restrictions to that of the hunter-gatherers to farming, ing who is going to take care of him when he needs surgery
the reaction of the ancient Egyptians to the development of himself? He sadly notes a sense of entitlement that some
writing, or Europeans response to the advent of the printing residents have expressed. That is, they feel they have the
press. He believes that the entirely irrational training process absolute right to go home regardless of the situation on the
set up by a dysfunctional substance abuser at the beginning of service, and this feeling is validated by the work-hours rules.
the 20th century is finally in the process of being revamped Will his future surgeon decide to leave the hospital at 5 p.m.
by rational adults based on science. and leave Dr. Barone to the cross-covering, vascular surgeon,
Dr. Barone, the older of the coauthors and a known a product of the Early Specialization Program? Indeed, what
curmudgeon, is not so sure. He shares many of the concerns will happen to all of us?
From the Archives
TEACHING OF GRADUATE SURGERY
1933
It is generally recognized that the four years of undergraduate medical work does not prepare the student to practice
surgery. It is granted that some form of graduate instruction is necessary in order properly to equip students to practice
surgery, and it is agreed that the initiation and conduct of forms of graduate teaching is the responsibility of medical
schools. There seems to be no doubt in the minds of those concerned with medical education that additional
advantages would accrue to surgical teaching and surgical practice were graduate teaching included in the educational
program of more of our medical schools.
. . . In my opinion, the medical schools should attempt to develop the highest type of surgeons men fitted to
continue the teaching of surgery in medical schools and to assume the leadership in the practice of surgery in the
various communities of the country. I have my own idea what, from an educational viewpoint, these men should be.
They are men who have had a rather broad fundamental training in the sciences related to medicine, and a specialized
training after their graduation in medicine in surgical pathology, surgical diagnosis, preoperative and postoperative
treatment, and in operative surgery. Their training in general surgery has included specialties in urology, orthopedic
surgery and gynecology. Their operative experience has been large, and acquired by assisting their seniors, by the
performance of major surgical operations under their direction, and by the independent performance of major surgical
operations. In addition to this clinical training, they have acquired experience in and become imbued with the desire
to pursue research, and they have acquired experience in teaching and in departmental organization. More and more
I am realizing that all this in not enough; that the men I would seek to develop shall have acquired a spiritual
experience as rich as their surgical experience, which enables them to follow only the highest ideals of medicine.
GEORGE J. HEUR
Cornell University Medical College
 Teaching of Graduate Surgery. Journal of the Association of American Medical Colleges. 1933;8:205 13.
380 A CADEMI C M EDI CI NE, V OL. 79, NO . 5 / M AY 2004