Bernard M. Jaffe, MD Professor of Surgery Department of Surgery Tulane University School of Medicine New Orleans, LA

I had a revelation one recent Saturday morning while listening to Car Talk on National Public Radio. A caller complained to the hosts, Click and Clack, about having to wait on the phone through an advertising break. Obviously envious, he related that he asked his employer for the same 3-minute break every 15 minutes that they enjoyed. The rather pointed, negative response from his employer was "Go howl to the moon." Needless to say, the usually light-hearted radio personalities were not amused. Click and Clack unnecessarily explained the need for commercials and defended their breaks. I agreed with them, but then I suddenly realized that we surgeons don't get breaks, at least not electively. I do not count waiting in the lounge for a case to begin as a break.

Yet breaks have become a fact of life in our society. Think about it. You go to the bank, and only one window is open; the consistent explanation is that the other tellers are on break. It never seems to matter how long the line is; employees routinely exercise their prerogative to use their precious intermittent moments of time off.

It can be even more frustrating. You are in a line to a cashier, but just as you approach the counter, the register is closed to allow the employee to take a break. No amount of remonstrating is effective; the supervisor's hands are tied. The employee's rights prevail.

It is easy to blame the work ethic that has evolved in our country, and there is some truth to that contention. But the problem goes deeper and has a historical component. Earlier this century, unions negotiated brief moments of respite for the employees, and the pattern stuck so that it is now a fact of life. Employees expect relatively frequent breaks, and they won't accept or stick with jobs that don't offer them.

Since I never grew up or worked in the break culture, I am not sure how I feel about them. It is clear that surgeons should not stop operating on anesthetized patients for a few minutes to enjoy a brief cup of coffee and an episode of social conversation. In contrast, when I spent time training in England, the tradition was to break at 4:00 pm for tea, regardless of the status of the patient. A sterile sheet was placed over the field, and all of us, including the anesthesiologist (called the anesthetist), adjourned to an adjacent room for a spot of tea. I never understood the pattern nor developed a hankering for tea (although the cucumber sandwiches were tasty).

While we surgeons do not take breaks in the operating room, our anesthesia colleagues do. In my experience, it is unusual to complete a major case with the same anesthesia team from start to finish. Somehow, they feel they need time out. The same is true for our nurses. While their breaks are not frequent, they are as regular as clockwork. It can become a huge problem during the counting of needles, lap pads, and instruments when the relief does not know what transpired previously. Normally explicable discrepancies become enigmas in the absence of the original circulating nurse, who could easily explain what had occurred. Somehow, no matter how strongly we object, breaks always seem to occur at the worst possible moments and most critical times.

Recently the courts have ruled that surgeons are not "captains of the ship," ie, not responsible for everything that goes on in the operating room. For better or worse, anesthesiologists and nurses can now be held accountable for their actions and omissions. Under these new circumstances, I cannot understand their seemingly casual approaches to continuity. I am concerned that it puts them at unnecessary risk.

I have to be careful in these discussions, lest the Accreditation Council for Graduate Medical Education (ACGME) determine, based on flawed data, political influence, or whimsical fancy, that residents need prescribed breaks within their 30-hour consecutive work periods. I imagine that the ACGME might claim that patient safety would be better protected if the trainees were refreshed. However, based on the bank teller, cashier, and salesperson experiences, I see little validity to that argument.

The cashier and bank teller mentality also does not apply to office hours. Can you imagine taking a break with patients in the waiting room? It is tough enough to keep on schedule, even when we work straight through. Emergency visits, new patient evaluations, and unanticipated clinical problems all take their toll. Most individuals understand delays caused by medical issues, because they would want the same consideration if their lives or health were at stake, but it does not prevent them from complaining, and our receptionists often take a beating on our behalf. However, there is no way patients would tolerate being asked to wait while we or our nurses took a time out for a quick coffee or even an inhaled lunch. In addition to the adverse impact patient waiting has on our practices, recently courts have found physicians liable for extra time patients have had to wait and be nonproductive.

Something else to consider is that cashiers, salespeople, tellers, nurses, and even some anesthesiologists work shifts; with the new ACGME-mandated work-hour limits, our residents fall into that category. They all know that at a specified time, their shift ends and they can go home to their families or another activity. A few minutes of inactivity here or there does not influence when they go off duty. The same is not true for surgeons. We work until our patients have been cared for, regardless of the time. Two 15-minute breaks would delay our arrival home or at dinner or play time by 30 minutes. More breaks would mean still longer days and nights at work and fewer social or familial contacts. Shift workers might argue unsympathetically that we earn so much more money than they do that we are not entitled to breaks. However, I can assure you that this does not apply to the Car Talk brothers, Click and Clack.

So, I guess callers will have to continue waiting on the phone until the commercials are completed, and all of us (employees who can take breaks and surgeons who cannot) will have to wait in line while cashiers and bank tellers finish their coffee, at least until the world does a 180°. It's all a component of the same puzzle that allows plumbers to charge you more for a home pipe repair than surgeons can bill for a trip to the hospital to suture a laceration. But that's a matter for another editorial.