The transit crisis for doctors in training

By 6 a.m. that Friday, hour 25 of a long call shift in the hospital, a routine restlessness had set in. Yet, I found solace knowing that I helped patients in distress overnight. Shortly after 9 a.m., I was done with my patient care tasks – so close to embracing sleep and yet so far.

As I began driving home, my fatigue was about to get the better of me. I missed the exit to get off the highway. More tragically, I failed to see a tractor-trailer that was trying to switch lanes. A shrill honk woke me just in time to reach for my brakes, as the 18-wheeler ahead of me came to a screeching halt. No more than two millimeters separated my car’s front bumper and the 50,000-pound semi-truck’s trunk. Less than a second of reaction of time likely made the difference between life and death.

I drove to the car rental garage in trepidation and hypervigilance. Once I was home, I could not get any sleep. I kept reliving the trauma of that rendezvous with kismet.

Before moving to Boston for my surgery training, I spent a month trying to find the “perfect” apartment. After talking with colleagues and mentors, I prioritized proximity to the hospital. Surgery residency often has long hours and, not infrequently, we start and finish our workday at odd hours of the day and night. Living close to the main hospital where I can walk to work in under 10 minutes has proven critical many times.

In choosing my residence near our primary clinical site, I was oblivious to off-site clinical rotations, where we spend one to four months every year. These rotations expose us to general surgery in a diverse, more community-oriented setting. Indeed, they are a period of immense growth. The opportunity to serve a different and more diverse patient population also comes with new groups of peers and mentors, new skills, and the chance to operate with greater autonomy.

Yet, as an international student who took a year to navigate a driver’s license in the US and does not own a car, I find geographically separated hospital rotations a constant bittersweet experience. Over the years, I have been grateful to my co-residents who have carpooled and given me a ride to the off-site clinical site. I have also frequently benefitted from the Boston public transportation system. I began to find joy in the 90-minute train or bus rides between the hospital and home, even if it meant reaching home significantly later and spending nearly 3 hours in commute every day. Despite earnest efforts, sometimes duty calls at such early hours of the day or the shift is structured in such a way that relying on taxi/car share services, or renting a vehicle remain the only viable options.

Several hospitals, including mine, do not offer free parking privileges to trainees.  Rent in Boston for a humble studio close to the hospital consumes over 5 percent of the monthly salary. Even with “employee benefits,” monthly rent for an economy vehicle goes well above $2,000, with additional vehicle insurance fees. Public transportation, when possible, helps reduce that cost at the expense of doubling or tripling the commute length, but is often not an option to reach the workplace before dawn.

The struggles of offsite commuting have made me appreciate how virtually all other fields, from the tech industry to business and finance, cover work-related transportation costs. Work shifts of an extended duration are sometimes necessary and remain a hallmark of surgical education in the US. However, programs should, at the very least, ensure that resident physicians are able to reach home and back to work safely after extended shifts.

In fact, for many of my international medical graduate colleagues, obtaining a driver’s license can take months. Other colleagues who come from humble families frequently struggle to make ends meet with having to budget a majority of their salary towards rental vehicles, parking fees, and taxis. This puts a certain section of trainees at a disadvantage while levying additional major financial and emotional stress. These are often the same trainees that training programs have worked hard to recruit to create a diverse and inclusive workforce.

In my own program, bringing up transportation challenges has made little difference. It was sobering when I learned that last summer a 27-year-old resident doctor died in a car crash when his car swerved into oncoming traffic. Following a nightshift, the physician had fallen asleep at the wheel. 

Such news hits home. A nationwide study found that every extended work shift over 24 hours that was scheduled in a month increased the monthly risk of a motor vehicle crash by 9.1 percent and increased the monthly risk of a crash during the commute from work by 16.2 percent. In months with five or more extended shifts, the risk of falling asleep while driving or while stopped in traffic increases by 139 percent and 269 percent, respectively. Any program claiming to support equity and wellness must stop passing the buck on this major barrier.

Transportation challenges that are commonplace in surgical training also have profound legal and societal consequences. Drowsy driving causes one in five serious motor vehicle crash injuries resulting in hospitalization or death, and is associated with a 4- to 6-time increase in motor vehicle crashes. In the US, New Jersey and Arkansas have explicit laws which qualify “being without sleep for a period in excess of 24 consecutive hours” as reckless driving , which results in conviction of the driver for vehicular homicide.

How many more lives must be lost before hospitals develop intentional infrastructure around this critical part of our jobs? Lack of safe transportation options for fatigued residents are not only a violation of the Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirement but also violates the ACGME Institutional Requirement.

There are several ways in which programs can address this important issue and likely prevent motor vehicle accidents. An easy, environmentally responsible solution would be to organize a shared transportation system, such as a bus or van, between the central hospital and the offsite clinical site. A second possibility could involve a transportation stipend, or direct reimbursement of all travel expenses for trainees who are off-site. A third alternative could involve the hospital or department facilitating a car-pooling system or making a vehicle available for borrowing, at no cost to the resident physician.

The inability to provide necessary transportation for trainees working long hours is a readout of the apathy that departments tend to have for dealing with resident’s financial struggles. Until programs make changes to ensure safe transit to off-site clinical work locations, many physicians in-training will remain disappointed and mistrustful of residency training.

Indeed, transportation problems are far more significant in areas where public transportation is less robust. Yet, even in a city like Boston, the extended travel times have had a profound impact on my education. As training programs embark on the journey to become more inclusive and diverse, the road to that goal goes through solving the work transit crisis for doctors.

Divyansh Agarwal is a surgery resident physicias at Massachusetts General Hospital.