Hello all,

Anyone else having duty hour problems? My program is one violating SOB!..I have a service where I have 9-10 patients daily and as soon as I discharge one, I get a new one...Tomorrow is call day and I only have to admit 2 because I have 8 pts right now.

It is a real big mess and my duty hours are way over the limit. No days off in 7 days (going to be 9 before get a day off), 94 hours last 7 days, 32.5 hour day, 5days with less than 10 hours between shifts, and I am not in the worst shape of my fellow interns (one girl worked 106 hours in a 7 day (no days off) stint.

Is it just my program or does anyone else feel bamboozled by the "untruths" told during the interview trail (you know- average week is 55-60 hours... and we didnt have anyone over the 80 hr limit this year..)

Is this the way it really is? If so, i feel like both a paper pusher, document maker, social worker and feel like I am not learning anything about real medicine (cant make it to either conference (neither can any of my fellow interns and rarely residents for that matter): no physical diagnosis tips, no mini lectures, no time to look up why Amphotericin in some Crypto menigitis cases and Fluconazole in others... etc! This was my first day home before 730 pm and I couldnt wait to feel what the sun against my skin felt like again....Alas, it was raining when I stepped foot outside of the hospital....cest la vie...
Thanks for letting me vent! Off to bed.

Hello all,

Anyone else having duty hour problems? My program is one violating SOB!..I have a service where I have 9-10 patients daily and as soon as I discharge one, I get a new one...Tomorrow is call day and I only have to admit 2 because I have 8 pts right now.

It is a real big mess and my duty hours are way over the limit. No days off in 7 days (going to be 9 before get a day off), 94 hours last 7 days, 32.5 hour day, 5days with less than 10 hours between shifts, and I am not in the worst shape of my fellow interns (one girl worked 106 hours in a 7 day (no days off) stint.

Is it just my program or does anyone else feel bamboozled by the "untruths" told during the interview trail (you know- average week is 55-60 hours... and we didnt have anyone over the 80 hr limit this year..)

Is this the way it really is? If so, i feel like both a paper pusher, document maker, social worker and feel like I am not learning anything about real medicine (cant make it to either conference (neither can any of my fellow interns and rarely residents for that matter): no physical diagnosis tips, no mini lectures, no time to look up why Amphotericin in some Crypto menigitis cases and Fluconazole in others... etc! This was my first day home before 730 pm and I couldnt wait to feel what the sun against my skin felt like again....Alas, it was raining when I stepped foot outside of the hospital....cest la vie...
Thanks for letting me vent! Off to bed.

Which program is this so I will be sure to avoid them?

Hello all,

Anyone else having duty hour problems? My program is one violating SOB!..I have a service where I have 9-10 patients daily and as soon as I discharge one, I get a new one...Tomorrow is call day and I only have to admit 2 because I have 8 pts right now.

It is a real big mess and my duty hours are way over the limit. No days off in 7 days (going to be 9 before get a day off), 94 hours last 7 days, 32.5 hour day, 5days with less than 10 hours between shifts, and I am not in the worst shape of my fellow interns (one girl worked 106 hours in a 7 day (no days off) stint.

Is it just my program or does anyone else feel bamboozled by the "untruths" told during the interview trail (you know- average week is 55-60 hours... and we didnt have anyone over the 80 hr limit this year..)

Is this the way it really is? If so, i feel like both a paper pusher, document maker, social worker and feel like I am not learning anything about real medicine (cant make it to either conference (neither can any of my fellow interns and rarely residents for that matter): no physical diagnosis tips, no mini lectures, no time to look up why Amphotericin in some Crypto menigitis cases and Fluconazole in others... etc! This was my first day home before 730 pm and I couldnt wait to feel what the sun against my skin felt like again....Alas, it was raining when I stepped foot outside of the hospital....cest la vie...
Thanks for letting me vent! Off to bed.

This might just be july and you are still getting you efficiencies together . . . you are supposed to have 4 days off in 7 averaged over 30 days (at my program we like to take every other weekend off [two days in a row is nicer than a random one here or there], so sometimes you regularly go 14 days straight without a day off), same with 80 hours a week averaged over 30 days. The 10 hours between shifts is a "should" statement in the ACGME rules and is not a hard and fast rule unfortunately. 32.5 hour day is the only clear violation so far, but sometimes I've always thought that if you're just tying up loose ends and tucking in patients before checking out that rarely its ok to go over 30.

I guess if this continues into the new next months and you are regularly still putting in 80+ hours per week, averaged over 30 days, and are always working more than 30 straight, then you have a tough choice to make . . . suck it up, begin to look elsewhere, or report your program (which will not make you very popular unfortunately)

Plus, I always thought there was a number of required didactics hours every year - at my program unless you are running a code, are in the middle of a procedure, or are having to admit a patient from the ED (patients being admitted need orders within 30 mins of the call from the ED), then our conferences are protected time. We don't even have to answer nurse pages.

Sorry man.

Started GM right off the bat. I averaged 78 hours during the rotation with one day in seven off plus a Golden Weekend thrown in. On call every fourth day.

If you're working more than that, then it's because your hospital either isn't covered well enough, doesn't take care of the residents well enough, you need to be more efficient, or the system you use to admit/discharge is flawed. I never carried more than 6 patients at a time during GM with four overnight admits being the max before the hospitalists started admitting and total short call admits for the entire team was always four for the day.

Using Epic, it takes me about 45 minutes (with H and P thrown in) to admit someone and get them completely tucked in for the night. Using the same system, it takes me about 15-20 minutes to discharge someone depending upon whether or not I'm sending them to a nursing home or not.

If someone is on your General Medicine service for more than 3-4 days, then they have been there for too long. At that point, they either need to be turfed or you need to rethink your approach.

And, the rules are that you can not average more than 80 hours per week over four weeks. You're also not supposed to work more than 30 hours at a time, which means that if you get there at seven on your call day, then you better be leaving at one in the afternoon the next day. Hopefully, your attendings are smart enough to do working rounds when you're post-call.

OMG, you wouldn't believe how lucky I am. I scrambled into this cush IM program which is basically a vacation. I work only 40-60 hrs a week and am working 1 on 1 with attendings. I am also learning a lot. I get most weekends off too.

OMG, you wouldn't believe how lucky I am. I scrambled into this cush IM program which is basically a vacation. I work only 40-60 hrs a week and am working 1 on 1 with attendings. I am also learning a lot. I get most weekends off too.

not helpful

Thanks all, I love the thoughts! I have another one... recently one of the residents told us that she belives that on 30hr overnight calls if you end up napping for any amount of time (i.e. 2 hrs or 5hrs) that you can (according to ACGME rules) can stay that much longer than 30 hrs (i.e. 32 and 35 hours,respectively in keeping the example going here)... So instead of leaving at 1pm you would then leave at 3 or 5pm and it is ok. I am like, you were an intern last year, shouldnt you know for sure which is the case. I asked some other residents about this and they said that they were pretty sure that this is not legal.

Anyhow, my main gripe is that I do not have time to actually sit and think about why I am doing what I am doing for a patient (i.e. I barely have time to look into my MGH redbook so that IT can tell me what to do let alone look at the why). The work hours suck, but if I felt like I was becoming the best physician I could be because of the process I would not be a vociferous. However, I feel like it is all work and no learning which really is like any other job and that is not why I loved internal medicine in the first place.

Finally, I had 11 patients coming off of call and this too is 1 more than the legal limit. I just think that there is a huge lack of communication from the administration and the interns and residents at my program. We do not have a strong charismatic leader and it shows.

But to the poster who said it is all about efficiency is right. That will get better and I should be able to attend at least 30 minutes of lunch lectures on some days.

great post gibble and jdh--- ya, we spend alot of our time trying to find dispo for our patients. Last week I had to use one of our spanish interpreters to call a patient's home to see if we could send information for his f/u procedure (as an outpatient) to the house (we were not sure if it was his permanent address or not). So I should have also took a month during med school to learn about social work issues it seems.

Oh and 3-4 days for pts on our service is laughable... it takes that just to get them dispo-ed.

recently one of the residents told us that she belives that on 30hr overnight calls if you end up napping for any amount of time (i.e. 2 hrs or 5hrs) that you can (according to ACGME rules) can stay that much longer than 30 hrs (i.e. 32 and 35 hours,respectively in keeping the example going here)... So instead of leaving at 1pm you would then leave at 3 or 5pm and it is ok.

This is GARBAGE.

If you are in house, you are working ie. "on duty". Wether you got a nap or not is irrelevant. 30 hours is the max you should be working. Like I said before, you may rarely go a little over and not report it if you're doing it to make sure patient's are tucked in, but even this is against work rules. Your fellow residents should be helping each other out to make sure you can bounce at 30 hours, or before.

Oh and 3-4 days for pts on our service is laughable... it takes that just to get them dispo-ed.

Word

I once had a patient stay for 4 months 2* to dispo issues (homeless illegal alien on dialysis)

This is GARBAGE.

If you are in house, you are working ie. "on duty". Wether you got a nap or not is irrelevant. 30 hours is the max you should be working. Like I said before, you may rarely go a little over and not report it if you're doing it to make sure patient's are tucked in, but even this is against work rules. Your fellow residents should be helping each other out to make sure you can bounce at 30 hours, or before.

Exactly, if you're in house, then you ARE working even if you're sitting around watching television or sleeping in the call room...whenever that happens to be.:(

This is GARBAGE.

If you are in house, you are working ie. "on duty". Wether you got a nap or not is irrelevant. 30 hours is the max you should be working. Like I said before, you may rarely go a little over and not report it if you're doing it to make sure patient's are tucked in, but even this is against work rules. Your fellow residents should be helping each other out to make sure you can bounce at 30 hours, or before.

This is truth. Anything over 30 hours (napping or not, voluntary or not) is an ACGME violation.

Now, if you're staying to do those things on your own instead of signing out then that's your fault (but still a violation). In July it's more commonplace for interns to want to stay a little longer so they aren't signing things out to their teammates which they probably would have been able to complete during those 30 hours if they were a little more efficient.

-The Trifling Jester

to be honest
many programs violates work hour rules
just hang on man.
if you are img you will have tough time in getting into new program once u leave it.believe me
if not..yes leave it and find a better one...

even i cant study anything..i hardly get time to sleep
go to hospital.take follow up of all patients..and gettng adapted to the hospital system..its discouraging every day..

But hang on man..once you are senior it wont be much pain..internship is tough everywhere...it can vary from 60 to 100 hours...but think twice before leaving program.

Using Epic, it takes me about 45 minutes (with H and P thrown in) to admit someone and get them completely tucked in for the night. Using the same system, it takes me about 15-20 minutes to discharge someone depending upon whether or not I'm sending them to a nursing home or not.

Are you saying 45 minutes of computer time only? Epic has its efficiencies, but never in my three years of residency could I take report on an admit, look up old interview, interview & examine, enter admit orders, and write H&P on an average patient in less than 90 minutes or so, no matter how many "dot-phrases" I had in my arsenal.

Are you saying 45 minutes of computer time only? Epic has its efficiencies, but never in my three years of residency could I take report on an admit, look up old interview, interview & examine, enter admit orders, and write H&P on an average patient in less than 90 minutes or so, no matter how many "dot-phrases" I had in my arsenal.

I would have to agree. Especially as an intern to go over the admission with my resident and then the attending would be at minimum a 90 minute endeavor.

Thanks all, I love the thoughts! I have another one... recently one of the residents told us that she belives that on 30hr overnight calls if you end up napping for any amount of time (i.e. 2 hrs or 5hrs) that you can (according to ACGME rules) can stay that much longer than 30 hrs (i.e. 32 and 35 hours,respectively in keeping the example going here)... So instead of leaving at 1pm you would then leave at 3 or 5pm and it is ok. I am like, you were an intern last year, shouldnt you know for sure which is the case. I asked some other residents about this and they said that they were pretty sure that this is not legal.

Anyhow, my main gripe is that I do not have time to actually sit and think about why I am doing what I am doing for a patient (i.e. I barely have time to look into my MGH redbook so that IT can tell me what to do let alone look at the why). The work hours suck, but if I felt like I was becoming the best physician I could be because of the process I would not be a vociferous. However, I feel like it is all work and no learning which really is like any other job and that is not why I loved internal medicine in the first place.

Finally, I had 11 patients coming off of call and this too is 1 more than the legal limit. I just think that there is a huge lack of communication from the administration and the interns and residents at my program. We do not have a strong charismatic leader and it shows.

But to the poster who said it is all about efficiency is right. That will get better and I should be able to attend at least 30 minutes of lunch lectures on some days.

Hang in there, it will get better as you become more efficient. July is about learning how to play the game, so you can finally start to learn medicine. We all go through it, and somehow all survive!

And FYI, the cap for an intern is 12 patients, not 10, there is another thread on that topic.

Plus, I always thought there was a number of required didactics hours every year - at my program unless you are running a code, are in the middle of a procedure, or are having to admit a patient from the ED (patients being admitted need orders within 30 mins of the call from the ED), then our conferences are protected time. We don't even have to answer nurse pages.

Sorry man.

Yes, ACGME has a requirement to attend 60% of didactics.

Hang in there, it will get better as you become more efficient. July is about learning how to play the game, so you can finally start to learn medicine. We all go through it, and somehow all survive!

And FYI, the cap for an intern is 12 patients, not 10, there is another thread on that topic.

I think that has changed. At all my interviews last year, I was told 10. And sure enough, it is 10 during my intern year.

I think that has changed. At all my interviews last year, I was told 10. And sure enough, it is 10 during my intern year.

Really?? I hadn't heard that. In June, I was carrying a team of 24 pts as a 3rd yr resident with 2 interns.

Anyway, if it has changed, great, because it needed to. I also posted a link to the ACGME requirements for IM programs in another thread, but I'll post it here.

Let me know if you find anything different.

http://www.acgme.org/acWebsite/downloads/RRC_progReq/140_im_07012007.pdf

I stand corrected! The regulations regarding the max number of patients changed on July 1, 2009. Here is the PDF with the new regulations for IM:

http://www.acgme.org/acWebsite/downloads/RRC_progReq/140_internal_medicine_07012009.pdf

This is truth. Anything over 30 hours (napping or not, voluntary or not) is an ACGME violation.

Now, if you're staying to do those things on your own instead of signing out then that's your fault (but still a violation). In July it's more commonplace for interns to want to stay a little longer so they aren't signing things out to their teammates which they probably would have been able to complete during those 30 hours if they were a little more efficient.

-The Trifling Jester

Interns these days are spoiled. Not only do they think they're overworked handling 10 patients, but they also have the mentality that they can get an hour or 2 of sleep time on a long call and still get out by noon because they can pass off their remaining work/notes to their resident. :rolleyes: I'm all for getting my interns out on time, but my expectation is that they're working all night. Hell, when I was an intern, if I needed to get some shuteye, then past the 30th hour I'd run and hide to get my remaining work done while avoiding the watchful eyes of my seniors. These duty hour rules are counter to the patient ownership and responsibility mentality that we're trying to instill in our interns. Bah humbug!

Interns these days are spoiled. Not only do they think they're overworked handling 10 patients, but they also have the mentality that they can get an hour or 2 of sleep time on a long call and still get out by noon because they can pass off their remaining work/notes to their resident. :rolleyes: I'm all for getting my interns out on time, but my expectation is that they're working all night. Hell, when I was an intern, if I needed to get some shuteye, then past the 30th hour I'd run and hide to get my remaining work done while avoiding the watchful eyes of my seniors. These duty hour rules are counter to the patient ownership and responsibility mentality that we're trying to instill in our interns. Bah humbug!

Sorry, but interns are overworked if they're carrying 10 patients. You can't provide superb patient care with 10 patients at a time (sure you might keep them alive, but all the little things...the frustratingly long conversations that make the little old ladies feel special, etc., aren't getting done), particularly on a call night. And beyond providing good patient care, forget about actually learning something with ten patients on board. (What a novel concept!!!)

At my hospital, the interns cap at 8 pts., and even that's a stretch for the very best of residents. There is a HUGE difference between just moving the meat/getting it done and providing patients with the care they truly deserve.

I'm tired of this BS mentality in medicine that I have bolded in your post above. Grow up.

I grab shuteye on my 12 hr night shifts. :)

Sorry, but interns are overworked if they're carrying 10 patients. You can't provide superb patient care with 10 patients at a time (sure you might keep them alive, but all the little things...the frustratingly long conversations that make the little old ladies feel special, etc., aren't getting done), particularly on a call night. And beyond providing good patient care, forget about actually learning something with ten patients on board. (What a novel concept!!!)

At my hospital, the interns cap at 8 pts., and even that's a stretch for the very best of residents. There is a HUGE difference between just moving the meat/getting it done and providing patients with the care they truly deserve.

I'm tired of this BS mentality in medicine that I have bolded in your post above. Grow up.

Sorry son, but medical students don't know jack about being overworked or "providing patients with the care they truly deserve."

Sorry son, but medical students don't know jack about being overworked or "providing patients with the care they truly deserve."

Creative response given the fact that you didn't adress any of the issues I raised. Your attitude in this post fits with your post above, which is unfortunate. Yet another case of the "I'm further up the totum pole so I have the right to be an ass" mentality.

Nevertheless, I beg to differ given the fact that I'm finishing my fifth straight month of inpatient medicine, the last two as subI's. I'm carrying seven patients right now and have been lucky to be surrounded by some absolutely amazing residents this month. They're dedicated, bright, and certainly harder workers than I'll ever be. Yet they still complain that 8 is too many as all the things that they would like to do for patients can't get done.

Keep in mind that a patient load of 7-10 seems outrageous as a medical student and intern, but handling a large patient load gets easier as you get further along in residency.

Speaking from experience, if someone would have told me when I was an intern that I would be responsible for 16-24 ICU patients, all sicker than snot, I would not have believed them. But, it all works out.

We build up the experience as we go along in our training. In the end, you are shocked with what you can handle.

However, I am always impressed by the hospitalists that manage up to 30 patients for weekend coverage....

Some hospitalist groups expect their physicians to carry 20-30 patients. It is not unreasonable to expect an intern to be able to carry 10. What will you do as an upper level resident when you have to supervise more patients? You're just going to jump from carrying 5-8 patients to supervising 24?

Those who have been through the training may sound like they're being "an ass" but their experience tells them what's needed to properly practice medicine.

-The Trifling Jester

Sorry, but interns are overworked if they're carrying 10 patients. You can't provide superb patient care with 10 patients at a time (sure you might keep them alive, but all the little things...the frustratingly long conversations that make the little old ladies feel special, etc., aren't getting done), particularly on a call night. And beyond providing good patient care, forget about actually learning something with ten patients on board. (What a novel concept!!!)

At my hospital, the interns cap at 8 pts., and even that's a stretch for the very best of residents. There is a HUGE difference between just moving the meat/getting it done and providing patients with the care they truly deserve.

I'm tired of this BS mentality in medicine that I have bolded in your post above. Grow up.

8 patients is a stretch for "the very best"?!? No it isn't.

This is where ACMGE rules and the entitlement of trainees starts to crack me up. It is the norm for private practice hospitalists (most of whom are right out of training) to cover 20-30 patients. If you don't learn to be efficient as a trainee, your patients will suffer more when you are a staff. If you want to spend your time conversing with little old ladies in the middle of the night, get a social work degree.

I guess I also need to grow up or maybe, just maybe, your expectations of what an internist actually does everyday are a tad unrealistic.

8 patients is a stretch for "the very best"?!? No it isn't.

This is where ACMGE rules and the entitlement of trainees starts to crack me up. It is the norm for private practice hospitalists (most of whom are right out of training) to cover 20-30 patients. If you don't learn to be efficient as a trainee, your patients will suffer more when you are a staff. If you want to spend your time conversing with little old ladies in the middle of the night, get a social work degree.

I guess I also need to grow up or maybe, just maybe, your expectations of what an internist actually does everyday are a tad unrealistic.

I beg to differ on your stats. Where did you get this data? Judging from the groups I looked at and the one I work with, I think the norm is moreso in the 18-22 range. Anymore than this and patient care definitely suffers, even as an attending. I think care is optimal in the 15-18 range.

I beg to differ on your stats. Where did you get this data? Judging from the groups I looked at and the one I work with, I think the norm is moreso in the 18-22 range. Anymore than this and patient care definitely suffers, even as an attending. I think care is optimal in the 15-18 range.

I know the hospitalist service where I am a fellow and several surrounding hospitals usually carry about 15 patients on any given day. However, on the weekends, depending on the number of hospitalists working, it is not unusual to carry 25-30.

8 patients is a stretch for "the very best"?!? No it isn't.

This is where ACMGE rules and the entitlement of trainees starts to crack me up. It is the norm for private practice hospitalists (most of whom are right out of training) to cover 20-30 patients. If you don't learn to be efficient as a trainee, your patients will suffer more when you are a staff. If you want to spend your time conversing with little old ladies in the middle of the night, get a social work degree.

I guess I also need to grow up or maybe, just maybe, your expectations of what an internist actually does everyday are a tad unrealistic.

I'm talking about interns here, not senior residents or hospitalists. I'm telling you that I've seen some very bright interns have a hard time with eight patients, particularly while early on in the year.

I don't argue the fact that seniors should be capable of managing more patients. But the big difference here is that they're not writing every order, following up on every lab, making all the BS social work-like phone calls, etc.

Hospitalists have been at it for much longer and are hence appropriately seasoned.

I'm talking about interns here, not senior residents or hospitalists. I'm telling you that I've seen some very bright interns have a hard time with eight patients, particularly while early on in the year.

I don't argue the fact that seniors should be capable of managing more patients. But the big difference here is that they're not writing every order, following up on every lab, making all the BS social work-like phone calls, etc.

Hospitalists have been at it for much longer and are hence appropriately seasoned.

Interesting. Especially considering that this is coming from a person that has no idea what it is like to be an intern, let alone a senior resident. You don't know because you have not gotten to that point yet.

I will be the first to tell you that being a supervising senior or fellow is a hell of a lot harder than being an intern. You are responsible for so much more regarding patient care than in 1st year. Just writing orders and notes, I'll take that any day. I am responsible for making sure you have your act together before rounds, your orders are done properly, results are followed up on, patients get the proper dose of meds, reviewing radiology, and finally, that you do the thousand of stupid things that you could do that might kill my patient (obviously I could go on). Not to mention supervising for procedures.

I am not here to attack you. But, you have lost your argument. If you are that concerned about patient load, I hope you are not considering internal medicine.

I think all labslave is saying is that carrying 10 patients as an intern is not the same as carrying 10 patients as a resident. Answering every page, corresponding with all consult services, putting in orders, writing up admissions, discharges and progress notes all take time and are tasks the resident doesn't have to do. That's why residents can carry more patients. Obviously they have much more responsibility so everyone ends up working equally hard.

Acherona said it all. Senior residents definitely have it tough, no argument there.

Carrying ten patients, particularly if many of them are complex, can be too many for an intern, and I will stand by that despite the comments here. I have seen too many bright people struggle (to do an incredible job, which should be the baseline expectation) with eight to believe otherwise.

Peace out.

I disagree with lab slave on this, and agree with tigerz...
we used to have 1 resident, 1 intern services @my hospital and I had 16 patients as a 1st or 2nd month intern. Technically, only the 1st 12 were mine and other 4 or so belonged to the resident, but in reality I got/took all the nurse pages, etc. I don't think 10 patients is too many for an intern, particularly not at the end of the year. Everyone understands that interns are not as efficient at the beginning of the year and things will take longer. The 30 hour work rule holds whether or not you manage to get an hour or two of sleep on call...not true that you can stay 32 or 35 just because you got a few hours sleep. It might be better to just sleep 30minutes and use the other hour to do work, so you can get out on time...but I know that can be brutal.

I personally would have killed to only be able to admit 2 patients on call 'cause I already had 8 as an intern...we'd usually go into call with 6-8 and then admit 5-7 more, on certain services. But I understand the intern patient cap has been lowered...might be a good thing.

As far as the days off, they don't have to give you one every single week. It's averaged over 4 weeks. As a cards fellow, I've worked 15 or more days in a row with no days off...but then getting whole weekends off. I'm not taking 30 hour calls, though, which makes a difference.

As an intern, it's not so much just how many patients you carry, either. If you don't have help (social workers, good phlebotomy service, etc.) it can be really hard to get stuff done efficienty. The higher ups are ALWAYS going to blame you for being inefficient. Always. The best you can hope for is to have a cool upper level who is willing to help with stuff. Signing off a bunch of crap to your fellow interns when you leave, esp. procedures or social work stuff, is kind of uncool, though may turn out at times to be inevitable. Sometimes, if you get stuck with a patient who is just being housed/chronic, you have ot figure out that you can write briefer notes and assessment/plan for those types, in order to save yourself some time...still want to thorough enough, but don't have to reinvent the wheel daily. You can try and prewrite some notes in the middle of the night, too, if you can (or if computer system has a function to save unsigned/unfinished notes) then later add in the daily exam, current labs, etc. right before or after rounds in the a.m. Getting crap done early in the morning is key to getting out on time.

"I personally would have killed to only be able to admit 2 patients on call 'cause I already had 8 as an intern..."

My senior residents were saying it doesn't really matter how many patients you have when you admit, as long as the team is under cap, because the resident is expected to redistribute the patients among the interns if one maxes out. No way to avoid 5+2 >:(

Don't tolerate any violations. Otherwise, someone may report your program and your program may go on probation. I suggest that you speak with your program director about this before other people complain to the ACGME.

Don't tolerate any violations. Otherwise, someone may report your program and your program may go on probation. I suggest that you speak with your program director about this before other people complain to the ACGME.

Are you serious?

OP, make complaining to the PD about work hours your first impression to the program at your own peril. Its highly unlikely that your complaint will save your program from ACGME scrutiny, but very likely this could wreck your reputation at your hospital. Furthermore, after that, if someone does make an anon. complaint to the ACGME, who do you think they will assume it was?

Really bad advice.

"I personally would have killed to only be able to admit 2 patients on call 'cause I already had 8 as an intern..."

My senior residents were saying it doesn't really matter how many patients you have when you admit, as long as the team is under cap, because the resident is expected to redistribute the patients among the interns if one maxes out. No way to avoid 5+2 >:(

Hit my 5 admissions last night on call. Got paged for a 6th one. The resident looked incredulous when I politely informed her that's the new intern cap.

Of course, I also didn't like being punished for being efficient. My co-intern on call had completed 1 admission at the time.....

Are you serious?

OP, make complaining to the PD about work hours your first impression to the program at your own peril. Its highly unlikely that your complaint will save your program from ACGME scrutiny, but very likely this could wreck your reputation at your hospital. Furthermore, after that, if someone does make an anon. complaint to the ACGME, who do you think they will assume it was?

Really bad advice.

I don't think this is necessarily true. Of course, the culture at every program is different and the OP's program may be malignant. However, ACGME/RRC compliance should be on the radar of every PD and chief resident. Consequently, even if the OP doesn't feel comfortable discussing with the PD, s/he should at least consider discussing with one of the Chiefs. People may be skeptical about this -- but part of the chiefs' job is to monitor duty hours compliance. Consequently, they "should" want to know about violations so that changes can be made. Every program has a vested interest in getting the best ACGME/RRC review cycle possible - no one wants probation or a one year cycle review!!! (each site visit is tons of work!).

To the OP: if things don't change over the next couple of months---speak up...at least to a chief (who could then convey your concerns to the PD under terms of anonymity - if that is your preference)

so, it really hasnt been better lately and in fact some of my co-interns have begun to speak about how they too feel like we have were sold steak but wound up with hamburger. (the really fatty kind...chuck 80/20% with extra gristle). The program, while not tops, would surprise many but then again, maybe the jokes on me and it is well known on the malignant list. Either way, lots of paperwork/social services and no time for teaching/lectures/making it in under 80 per week. And the beat goes on....

Either way, lots of paperwork/social services and no time for teaching/lectures/making it in under 80 per week. And the beat goes on....

This is the crux of the problem. To get under 80 hrs, we cut back on the amount of work housestaff have to do but we cut back more on the didactic part of training.

This is the crux of the problem. To get under 80 hrs, we cut back on the amount of work housestaff have to do but we cut back more on the didactic part of training.

don't they have some kind of "intern assistants" at michigan? i heard this while interviewing last year, where they have people who fill out paperwork, do discharges, etc for the interns/residents.

i imagine that would be more than helpful to help regulate duty hours.

don't they have some kind of "intern assistants" at michigan? i heard this while interviewing last year, where they have people who fill out paperwork, do discharges, etc for the interns/residents.

i imagine that would be more than helpful to help regulate duty hours.

This is correct.
While I have only observed this and not experienced it, firsthand, I believe that these assistants certainly help the residents/interns. I have seen them make calls to outside hospitals to obtain labs/records -- and help coordinate various to-do items for discharge (social work, PT/OT). Seems awesome, to me!

Are you serious?

OP, make complaining to the PD about work hours your first impression to the program at your own peril. Its highly unlikely that your complaint will save your program from ACGME scrutiny, but very likely this could wreck your reputation at your hospital. Furthermore, after that, if someone does make an anon. complaint to the ACGME, who do you think they will assume it was?

Really bad advice.

I agree with gastrapathy.
I think this is horrible advice.
Furthermore, a complaint from an intern at this point in the year to a PD about work hours is unlikely to be taken seriously because everyone knows that interns take a long time to do stuff at this point in the year. THey will just assume you are "inefficient" and YOU will get blamed. That doesn't mean I think all this stuff is OK, but just that you need to realize that it is what it is - this type of stuff is just a rite of passage unfortunately. If you had a nice resident and attending, they would probably be helping you more so that you'd get out on time. Also, if your program cared about work hours, they'd probably have a day float system or something so that you'd all get out on time. The reality is that the program is going to skate on this, unless they are serial violators of the work hours in a serious way. The ACGME doesn't enforce the duty hours so strictly that they're going to ding a program much, or probably at all, based on some certain interns not leaving on time all the time. The program can just say that they told you to leave on time but you didn't leave and sign stuff out...

p.s. This will get better. Just put your head down and take it, unless your program is ridiculously malignant in other ways besides the work hours thing.

Slightly different perspective here - try to remember the fact that intern year is only 1 year, and that it does get better. Intern year sucks, so really its just about survival and trying not to lose yourself. Otherwise, work hard, and you'll come out the other end stronger.

And as for the above posts that being a senior is somehow worse than an intern is ludicrous. No resident I know would rather be an intern. I'm sure the above poster really looks forward to that time of the year when there's an intern retreat and the residents take over intern duties. Sure, it may be scarier to be a resident making decisions, but it sure isn't as physically demanding or time consuming. I mean, would you rather be the foreman or the actual guy doing the construction?

Also, stop it with the "when i was an intern. . " comments because all of our attendings when they were interns admitted and held lists 3-4 times larger than anyone who trained within the last decade (also ZERO work hour restrictions). So in their eyes and by that logic, we all suck (think about it next time you make that comment, you're really then commenting on how lousy a training YOU had as well).

Also, stop it with the "when i was an intern. . " comments because all of our attendings when they were interns admitted and held lists 3-4 times larger than anyone who trained within the last decade (also ZERO work hour restrictions). So in their eyes and by that logic, we all suck (think about it next time you make that comment, you're really then commenting on how lousy a training YOU had as well).

This is slightly off-topic but wanted to take a second to address the comment. While I agree with the balance of the statement, and while I know that our attendings worked longer and (likely) harder...we need to temper our descriptions of the past. As I'm sure many will say, the patient populations are not comparable. Just think, patients used to be hospitalized for prolonged periods of time for relatively pedestrian ailments (by today's standards). Currently, so much can be managed as an outpatient - so the degree of acuity for inpatients is much higher. Additionally, many of the easy/simple admissions are being shuttled to "observation/chest pain/etc" units so that patients that actually end up on the wards tend to have complicated problem lists, etc etc. I'm preaching to the choir but just didn't want to let this slip by :-) <stepping off my little soap box, now>

Also, stop it with the "when i was an intern. . " comments because all of our attendings when they were interns admitted and held lists 3-4 times larger than anyone who trained within the last decade (also ZERO work hour restrictions). So in their eyes and by that logic, we all suck (think about it next time you make that comment, you're really then commenting on how lousy a training YOU had as well).

Not sure what you're saying here. I trained in large part before work hour rules. I think that the work hour rules are a net negative for medical training. No one can measure the mistakes (and particularly, the neglect) caused by the endless turnover of patients or the loss of the culture of ownership. I lament the lost teaching time. Its our own fault but making sure residents comply with work hours has become more important than patient care or teaching.

To the OP: if things don't change over the next couple of months---speak up...at least to a chief (who could then convey your concerns to the PD under terms of anonymity - if that is your preference)

If you decide to do this, try not to make it a first impression. Wait until they've worked with you.

Not sure what you're saying here. I trained in large part before work hour rules. I think that the work hour rules are a net negative for medical training. No one can measure the mistakes (and particularly, the neglect) caused by the endless turnover of patients or the loss of the culture of ownership. I lament the lost teaching time. Its our own fault but making sure residents comply with work hours has become more important than patient care or teaching.

The comment wasn't really directed at you, but rather a few posts above that seem to be coming from fellows or residents in which the ACGME caps were previously 12 or 15. I agree with the above sentiment that ownership of patient care should be a priority, but I fail to see why work hour restrictions (which I take as guidelines, obviously one should never leave if having an unstable patient) is necessarily antagonistic to the culture of ownership. I do agree with you though that dedicated teaching time is certainly a casualty.

Addressing the other post, I do agree that modern medicine is very different from the yesteryears. Just looking at acute MI, which used to be treated with bedrest and aspirin, now requires a whole activation of the cath lab system and a cutoff time to ballooning. The biggest change nowadays I think compared to yesteryear is that the average hospital stay is much less, on the order of days, making turnover on the 10 patient list quite frequent. But ultimately my point wasn't to say that attendings of the days of giants are necessarily better, because they're not; the training system today will still produce great clinicians. But why is it that every physician always has some sort of chip on their shoulder's about how much better they were trained? Are we that insecure as people?

In days gone by/years ago, I also doubt that the house staff had to deal with the amount of BS paperwork that house staff have to deal with today. I'm willing ot be $500 that they didn't have to go to the wards at 4a.m. to sign all the DNR orders on a bunch of crosscover patients that the nurse just discovered expired at noon the previous day. And I'll bet they didn't have to fill out 16 page disability forms and FMLA forms for their clinic patients...LOL.

p.s. I don't necessarily think that lowering the patient cap for interns from 12 to 10 was a bad thing. I was just pointing out that it isn't just the number of patients that you carry that matters...I think it is everything...the amount of paperwork you have, the amount of help you have from senior resident and attending...the level of demands from nursing staff, the availability of phlebotomists, and on and on.

I also agree that being an intern is harder than being a senior resident, fellow or attending. It just sucks way more. And I always felt like I had at least an equal amount of responsibility as an intern...at least at my program, we were expected to step up and "be the doctor" and it's so much harder not to make mistakes when you don't have much experience to back up your decision making.

But why is it that every physician always has some sort of chip on their shoulder's about how much better they were trained? Are we that insecure as people?

You actually have to ask this? Do you work with other doctors?

Question for those that know about this. If my program continues to for lack of better word, suck so badly that I feel that my 3 years of residency will be a waste in comparison to what I should have learned somewhere else... what are my options? Can I transfer? Can I reapply and not do my intern year again at another institution (basically the same as the transfer question but with application needed)? Do I have to go through the match all over again and become an intern again elsewhere? Further, would this increase or decrease my chances at matching at a place that encourages learning and the mental aspect of internal medicine rather than (rant coming....)"someone else admits your patient, does a terrible job on H/P, you get 8-10 pts day, stay til 830 on your best days, go over 90 hours qweekly, no chance to go to either of the days 2 conferences and felt guilty if you actually had time to eat around 1530, and, finally, you get home and your urine looks worse than your AKI pts because you didnt even think once about getting a drink because you rounded on patients until 130pm." Bitter? No, that comes when I have to walk 15 minutes to my car after work is over since the shuttle that is supposed to be every 10 minutes is actually q30mins. Again, I feel better now. Thanks sdn'ers!

Question for those that know about this. If my program continues to for lack of better word, suck so badly that I feel that my 3 years of residency will be a waste in comparison to what I should have learned somewhere else... what are my options? Can I transfer? Can I reapply and not do my intern year again at another institution (basically the same as the transfer question but with application needed)? Do I have to go through the match all over again and become an intern again elsewhere? Further, would this increase or decrease my chances at matching at a place that encourages learning and the mental aspect of internal medicine rather than (rant coming....)"someone else admits your patient, does a terrible job on H/P, you get 8-10 pts day, stay til 830 on your best days, go over 90 hours qweekly, no chance to go to either of the days 2 conferences and felt guilty if you actually had time to eat around 1530, and, finally, you get home and your urine looks worse than your AKI pts because you didnt even think once about getting a drink because you rounded on patients until 130pm." Bitter? No, that comes when I have to walk 15 minutes to my car after work is over since the shuttle that is supposed to be every 10 minutes is actually q30mins. Again, I feel better now. Thanks sdn'ers!

Good luck with your situation.
Could you let me know where you are doing residency so I don't have to experience this? Thanks.

Yes, you can sometimes transfer to a different program. This might be tricky as you'll likely at some point need your PD's approval or a LOR from him/her. The best way to do it might be to tell them you need to leave for family or personal reasons, and try to go to a program in some other city. You can either reapply through ERAS for intern positions, and/or you can try to look for open spots. the NRMP has findaresident, which used to cost $70 to sign up for one year. You can basically get on there and look for open positions in any/all specialties. There are IM spots that open up periodically. Good luck.

Some hospitalist groups expect their physicians to carry 20-30 patients. It is not unreasonable to expect an intern to be able to carry 10. What will you do as an upper level resident when you have to supervise more patients? You're just going to jump from carrying 5-8 patients to supervising 24?

Those who have been through the training may sound like they're being "an ass" but their experience tells them what's needed to properly practice medicine.

-The Trifling Jester

Hospitalist carry alot of patients. I have worked on our hospitalists service (which I enjoyed enough to do as an elective) where we had an extremely long censuses but there were some big differences. Firstly, the hospitalist didn't come down and admit every patient as soon as they came in. The ER staff wrote the orders and the hospitalists came and saw the patient the next day or whenever they had time. Hospitalist work straight through and don't have clinic, lectures, rounds, or outpatient issues to deal with. They don't have to present the patient to anyone except maybe in a little blurb when they hand them off or running the list (if they decide to get there before 9 am to run the list). They may not get around to see a stable patient until 6 pm not 6 am. They work schedules such as 2 weeks on and 2 weeks off. Their patients issues are usually not as thoroughly addressed. Generally, they have nurse practitioners helping them. Hospitalist work is not comparable to residency training. Hospitalist have completed their training. Being scutted out is not learning to be tough it is loss of training resulting in deficiencies in knowledge. Programs that violate regulations need to be reported. Malignant upper levels need to be reprimanded. Malignant attendings need to be fired. Programs that can't get it right need to be shut down.