Musings on a 40 hour week

Curled up on the couch with a massive cup of coffee, I am wrapping up one of the most horrific weeks since starting work. Having to deal with between 30 and 40 newly admitted patients daily, my pager going off every 5 minutes (god, I hate that sound), I’m on call tonight (please please please do not call me to rechart meds at 2am) and not having seen sunlight since last weekend makes me count the days (14…) till my trip to the US to AHS12.

The tension in the hospital is almost palpable by the end of the week. The conversations are shorter, comments are snarkier and the only smiles you see is when there is the obligatory Friday junk food fest is involved. Somebody is leaving floor 1 for floor 2 so we all have to subject our bodies to a sugar coma to honour this momentous occasion. Maybe this will help us survive the end of the week without killing someone. By the way, in medicine this is not a metaphor.

Child laborers in a coal mine. Source: The History Place photograph of American child labourer from 1908-1912 by Lewis Hine

Let’s talk working hours. I want to know what genius came up with a 40hr working week.  I am not that strong in history but I grew up in the Soviet Russia and the 8 hr day was celebrated a source of pride and a supreme achievement by unions and blue collar workers. The Industrial Revolution of the 18th century had a lot to answer for with explosion of factory-based manufacturing and resulting insane working hours. The British Factory Act of 1833 went soft and regulated child labour, limiting the work day of 14-18 year olds to 12hrs and 9-13 yo to 8 hrs. They were so concerned with kids’ education that they told under 9s to stay at school. In comparison to those conditions my working week seems like a walk in the park. Our civilised society is way more civilised nowadays and we should be grateful, right?

Well, actually, who says that a 40hr week is evolutionary appropriate at all? In 1966 an anthropologist by the name of Marshall Sahlins wrote “Notes on the Original Affluent Society” in which he described the lifestyle of modern and ancient hunter-gatherers, estimating their work day to be between 3-5 hrs to the total of 14-20hr working week. Closer to home, Jamie Scott wrote a nice report on the lifestyle of Vanuatu and he also mentioned that the villagers there seemed to have a lot more leisure and play time.

Now I am far from an expert on anthropology and by no means advocate discarding our society, culture and coffee machines to go live in the bush and eat ‘roos or whatever you can catch in your part of the world. But, dayam, a 20hr week sounds way more attractive than a 70 hr limit for hospital doctors recommended by the Australian Medical Association (which is successfully circumvented by hospitals and doctors themselves).

For those interested in an overview of the working conditions of Aussie doctors-in-training (or hospital residents and registrars) read this report on safe working hours from Andrew Lewis, an industrial relations advisor for AMA. Good thing they got a non-doctor to write it. Because doctors are masters at bitching about  their lack of sleep, nutritious food and any resemblance of personal life. However, that whining tends to come with a whiff of hidden pride. The expectations of our seniors (“back in my days we slept in the elevators”), peers and patients make this screwed up lifestyle “a rite of passage.”

Of course, doctors and nurses don’t have a monopoly on insane working conditions. But the media prefers juicy stories of sleepy surgeons armed with a scalpel than  tired cranky lawyers (armed with a Monblanc pen?). The talk inevitably becomes a tad hysterical as it turns to the risk to the community: “jeopardising patients’ safety… Impaired judgement…”  Fair enough, I say. I’d be worried too if I knew that a guy who is about to do a lumbar puncture on my daughter has been working for the last 17hrs. Apparently being awake (not just working, but AWAKE) for 18 hrs is comparable to a blood alcohol level of 0.05. Cool, I can come to work after a bottle of Shiraz and nobody will notice anything different.

Still, forgive me if I am more interested how this lifestyle is affecting my body and my mind. We all know it’s bad but how bad? Can you suck it up for a few years and hope to repair the damage when you have the money to afford holidays in the Pacific and a personal chef? Or is it something that we can mitigate by sleeping in till 8am on the weekend (oh, the luxury!)?

Not a place to be when you are stressed…

Here are some studies that I personally found quite interesting.

1. Acute sleep deprivation resulted in increased hunger and the activation of anterior cingulate gyrus reflected hedonic stimuli in the absence of fasting blood glucose changes. In other words, if you are sleep deprived, those cookies in the jar will call your name with an irresistible siren song. http://www.ncbi.nlm.nih.gov/pubmed/22259064?dopt=Abstract

2. Adults working more than 40hrs a week were 5 times more likely to have suboptimal glycemic control as measured by HbA1C >= 7% than those who worked 20hrs or under. So if your diabetic or pre-diabetic your working hours alone will make your doctor frown and reach for the script pad. http://www.ncbi.nlm.nih.gov/pubmed/21246586?dopt=Citation

3. An observational study of nearly 17000 Australian full time workers looked at the relationship between working hours and increased BMI. They found that the relationship between long hours and obesity seemed to be mediated by the lack of sleep. This might make you think that it is possible to mitigate the effects of long hours by just increasing your sleep time however…

http://www.ncbi.nlm.nih.gov/pubmed/20734126?dopt=Citation

4. …a study of Japanese white collar workers found that longer working hours had a negative effect on total sleep hours, sleep efficiency and daytime dysfunction. The effect was noticeable at 50hrs a week and the more hours they worked the worse their sleep quality was rated.

http://www.ncbi.nlm.nih.gov/pubmed/20561174?dopt=Citation

Just a note, the whole patronising “Just sleep more” really tends to push my buttons. It’s a bit like “Just eat less and move more” in its sheer unhelpfulness. Do we really think that those poor buggers who lie in bed for hours struggling to nod off because they like it? You can’t get that deep recovery sleep by willpower alone. Try telling any doctor on call that they should stop tossing and turning and get back to their restorative snooze… with a pager next to their ear.

5. Markers of oxidative stress were increased after a 16hr shift in medical residents and an 8 hr shift non-healthcare workers (so once again, you don’t get a free pass if you are in another field). http://www.ncbi.nlm.nih.gov/pubmed/20811270?dopt=Citation

6. Psychological stress has been found to cause very real physiological phenomena contributing to many diseases. This excellent review of the role of stress in the gut disorders concluded: http://www.jpp.krakow.pl/journal/archive/12_11/pdf/591_12_11_article.pdf

From Konturek et al ” Stress and the gut: pathophysiology, clinical consequences, diagnostic approach and treatment options”

“1) exposure to stress (especially chronic stress) is a major risk factor in the pathogenesis of different diseases of gastrointestinal tract including gastroesophageal reflux disease (GERD), peptic ulcer, functional dyspepsia, inflammatory bowel disease (IBD), irritable bowel disease (IBS), and other functional disorders of GI tract;

2) the dysregulation of brain-gut-axis plays a central role in the pathogenesis of stress- induced diseases;  

3) Stress increases intestinal permeability, visceral sensitivity, alteration in GI-motility and leads to profound mast cell activation resulting in release of many proinflammatory mediators

These articles are just a few in a sea of plenty. The scientific evidence is pretty conclusive and pretty overwhelming. Long hours = bad, psychological stress = very bad, lack of sleep = very very bad.

So it’s kind of bewildering that we choose to bury our heads in the sand and carry on with a stiff upper lip. Good luck repairing your leaky gut and undoing the oxidative damage with your superhuman willpower. I’m not suggesting that you should give up your career and go all hippie, greeting sunrise in the nude and weaving loin cloths out of bush plants. Sometimes the acknowledgment that this is not just in your head, but in your gut, your nervous, endocrine, immune and cardiovascular systems, can go a long way.

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15 thoughts on “Musings on a 40 hour week

  1. I have just turned 58. I’ve worked in a chronicaly stressful professional environment for 13 years straight. My stomach is permanently bloated – as if I drink beer a lot. I never drink beer and hardly drink alcohol. My weight is very high, I eat a lot for energy although I try to follow the paleo diet. Various factors have led me to this decision – I am leaving my professional partnership and starting a new career in which I will manage my time and in which I won’t be subject to the priorities of others – my demanding clients. I will not earn as much but then again I won’t die young from exhaustion, heart attack or stroke. I am taking control. The 40 hour work week is in-human and anti-genetic. I want to live. God bless you Anastasia.

    • Hi John, I am sure it was not an easy decision for you. But ultimately, you cannot buy health. It’s never too late to step away from the rat race, especially if you become aware that it is affecting your wellbeing. Congratulations, wish you all the best.

  2. I think the idea of the 8-hour day was 8 hours of work, 8 hours of sleep, 8 hours for whatever else a human wants to do for leisure. Hah – they didn’t count on the hellish 20-miles-in-2-hours Washington DC commute. :P

    If a job WERE “only” 8 hours a day, without expectations of earlier starts and later finish times and extra work, if they didn’t involve long commutes or extra stuff crammed in after “work” ended (I know a lot of teachers who routinely put in another 3 hours after the kids leave school, and then often go to second jobs) – it might be just fine for the vast majority of people, especially if they occurred when people are actually awake and functioning naturally instead of shift work (even worse, ROTATING shift work!). I wonder how common that 8-hour day IS any more?

    Thanks also for your list of studies about specific problems with too much work and too little sleep; I have a hubby who needs to read those. :-)

    • Spot on! If you add to that the hours of sitting down indoors under the artificial light, staring into the blue screen – 8 hours can be a loooong time in health terms. Commuting sucks. I have deliberately moved from Sydney to a lovely coastal town (you see my view in my banner) and I do not miss my 4hrs on the train daily, not one bit. Sure, I don’t have the city buzz or a 100 restaurants at my doorstep but that was a lifestyle decision I chose to make. Glad your hubby will make use of the studies.

  3. I have a theory (probably stolen from someone else) that we are, in many ways, at war with culture. Genes vs. memes, if you will. The memes do not have our best interests at heart, and the kind of shift work you describe is a perfect example.

    • Unfortunately, Sam, we continue to make these cultural standards acceptable and indocrinate newcomers into the same mentality. Working 12hrs because your boss expects you to for no extra pay will not shock anyone. It all comes down to personal priorities. If this is what you truly want and you are prepared to make sacrifices for it – go for it.

  4. Henry Ford found workers production dropped when they worked more than 40 hours per week. He worked in 8 hour increments. Production per hour dropped when the plant ran 6 days per week. 7 hours/day was what the horses were good for on the farms. Not too much study, but just a little.

  5. I’m curious about the rationale for the medical resident program (which seems to ve the model in north america as well) requiring extended work shifts. Is there a shortage of residents? Is it some bizarre belief by the medical establishment that they become inured to the sleep deprivation?

  6. Anastasia,
    I came from a cooperate background where working 70 hours a week (plus the 1 hour commute time) was considered a loyal employee. It was not good for me NOR for my family that I almost lost during my short 3 year tenure there. Now I work about 35 hours a week. It helps that my office is 30 feet from my home so no more time stuck in traffic. A big plus!!

    On a business note, I would love to help assist with the costs of running this blog. Even though I may be financially assisting you I don’t expect to have any control over what you write, all I request is a small text or graphic ad in the right navigation linking over to my clients. I represent both Rockpointe.com and JRSmedical.com. In exchange for a simple request such as a small ad (180 x 90) for both clients I could pay you a small annual fee to assist with costs. Let me know if you are interested or have any other ideas in mind.

    Either way, I wish you the best!!

    David

  7. Great points, Anastasia. I too am a new medical resident and I completely agree with your reasoning. My first week I worked 86 hours, averaging 5 hours of sleep a night, and being extremely stressed out to the point that I didn’t feel human. It’s bad for residents and bad for patients. Thankfully, for me this schedule should only last a year since I’m planning to go down a residency path that involves better hours with much less hospital time (preventive med). I’m heading to Boston as well for AHS, which should be fabulous. Hope to meet you there! -Tom

    • It’s brutal. Great to hear you have a light at the end of the tunnel. Come up for a chat when you see me in Boston, we can bitch about our schedules together :)

  8. You should move to Sweden where even doctors have work rights! Overtime is regulated, maternity leave and paternity leave and god knows what! When I was working there a couple of years ago it was prohibited to work more than 200 hours a year without special permission, this applied to doctors as well…

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