Question about residency work hours

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Originally Posted by digitlnoize

... I have found that the best teaching hospitals have enough attendings that the service CAN function without the residents. This way, the residents main activity is to learn, and there are enough attendings so no one has to work insane hours...!

you keep cryptically citing these "best teaching hospitals", but I seriously question that. First, I suspect many SDN residents are at places that are among the best in their respective specialties. Yet it really isn't residents weighing in on your side here. Second, some of the bigger named academic centers are the ones with the worst track record in terms of breaches of duty hours. Third, I think you need to be a resident to give a reasonable evaluation of what's good resident training. What looks great to you as a med student could end up leaving you seriously deficient in your training as a resident. You have to realize that during residency your focus will shift. It starts out scary with long houred weeks and long overnight calls. But as you get to the later years it becomes more of a how can I see and do everything I need to before I graduate to attending and start to work without a net issue. A lot of us feel like the number of hours left in our residency are barely enough as is, and we got a much better running start as interns than the people a year behind us. It's why there's another thread on SDN why neurosurgeons are upset with the duty hour rules and why there's some buzz, as described by Prowler above that maybe residency is going to need to be lengthened as duty hours get cut back. A lot of your arguments and your view of what is among the best hospitals for residency are going to change once you get to residency. Best to realize that you don't have the necessary perspective yet, not keep trying to argue that you logged enough hours as a med student to know something about residency training. The whole "I'm not a resident but I stayed in a Holiday Inn Express last night" style argument is not a winner.

I appreciate the idea of changes in hours as a means to reduce errors. Unfortunately, the studies I've seen have only shown that increased hand-offs increase errors. I have yet to see a study linking reduced hours with reduced errors. Or even increased hours with increased errors.

Seeing the new interns with the new hours, there is no doubt that the mentality is completely different. They know they are out of the hospital at 6p and there is no or very little personal investment in the patients. Perhaps it will be different next year when they're the ones stuck alone all night. Then again, what sort of training are they getting when there is always someone to hold their hand? And what will happen when they have to make an independent decision at 2a next year?

Seeing the new interns with the new hours, there is no doubt that the mentality
is completely different. They know they are out of the hospital at 6p and there
is no or very little personal investment in the patients.

I've neve understood this argument. The day team has always been the primary team for the patient. Call is, and always has been, about the patients that you have NO personal investment in. Call is when its you you take someone, often someone with no experience as a physician, hand them a list of 80 patients, and say 'keep everyone alive, handle all the admissions to all services, and see you tomorrow'. Also under the old system three quarters of the patients on your service were admitted by other call teams, you learned aboutthem in the morning just like with night float. In what way does getting rid of this system change our personal investment in the patients?

Then again, what sort of training are they getting when there is always
someone to hold their hand? And what will happen when they have to make an
independent decision at 2a next year?

I think a lot of programs are giving Interns a month's worth of night float. The amount of time you spend alone at night hasn't changed in that model, all that's changed is that you get it out of the way in 1 or two week blocks, where you're awake, rather than being on call every fourth night.

That's one of the ideas behind new work hour rules: the time to start making independent decisions should not also be the time when you've already been working for 20 hours in a row. Instead, you get to deal with those attending-less nights after a full day of sleep.

The amazing thing is that people seem to think that there is somehow more teaching involved if you are less coherent. We are spending the same number of hours in the hospital as before. The difference is that rather than squandering part of our education on exhausted nightmares of call nights and blurry post-call half days we now are fully conscious for all of the 12 hour shifts (plus sign out and wrap up work) that we participate in.

We do not have a night float system. Our interns only admit during their inpatient months, whereas the remainder of the residency program has 4 call nights/month. Yes, they manage the patients during the day, but they miss out on all the admissions which are often in the middle of the night. The miss out on the patients crashing when it's just you and the nursing staff in the middle of the night.
In the middle of the day, you've got so many other staff that you aren't really acting independently at all.

I agree, though, that night float would help with this.

Originally Posted by zoner

i mean, i am so sorry to keep posting, but is it just me or that 30 or 28 hours shift without sleep is like one of the worst thing that can be put upon a human being to endure?

hahaha

I know that has already been extensively commented on, but this is funny for so many different reasons.

Also, I categorize the notion that "keeping this schedule would harm my health" into the same general bin as statements such as "this full colonic will cleanse me of toxins" Like, what does that even mean? I pull 30+ hour shifts more than ever. I pretty much feel fine. I'm not exactly sure in what manner my health has been harmed.

In a few years, are the kids going to think that a 16hr shift is absolutely insane and potentially lethal?

Originally Posted by sacrament

hahaha

I know that has already been extensively commented on, but this is funny for so many different reasons.

Also, I categorize the notion that "keeping this schedule would harm my health" into the same general bin as statements such as "this full colonic will cleanse me of toxins" Like, what does that even mean? I pull 30+ hour shifts more than ever. I pretty much feel fine. I'm not exactly sure in what manner my health has been harmed.

In a few years, are the kids going to think that a 16hr shift is absolutely insane and potentially lethal?

I'd rather have a few 30 hour shifts and more time between them than 14 hrs 6 days a week, every week.

Originally Posted by johnnydrama

I'd rather have a few 30 hour shifts and more time between them than 14 hrs 6 days a week, every week.

Absolutely. Take the pain, and then enjoy your time off. My fellowship currently clumps call into really intense two week blocks, where you can potentially pull an all-nighter every other night for 14 days. But then we have no call at all for 6-8 weeks. I would much rather do it this way. If they'd let me, I would just stay on call continuously for several days straight, catching a nap here and there, and then do no call for months. But I haven't sold anyone on that.
I'm worried this post just gave digitlnoize a hemorrhagic stroke.

Originally Posted by Roguelyn

We do not have a night float system. Our interns only admit during their inpatient months, whereas the remainder of the residency program has 4 call nights/month. Yes, they manage the patients during the day, but they miss out on all the admissions which are often in the middle of the night. The miss out on the patients crashing when it's just you and the nursing staff in the middle of the night.
In the middle of the day, you've got so many other staff that you aren't really acting independently at all.

I agree, though, that night float would help with this.

I would agree that those reisdnecies that are trying to keep a call system in place rather than switching to a night float syatem are not doing their interns any favors.

Originally Posted by cabinbuilder

No, you do not have to stay up for 30 hours. You just have to be "on duty" and in the building usually. I had a very nice residency where we did one weekend day call a month and usually 2 weekday nights a month. I never stayed up for the 30 hours straight. Usually on the worst nights I struck a deal with the ER so I could at least lay down from midnight to 4:30 then I would do any other admits needed and get ready for my morning report presentation at 7:30 (we had to present 3 patients from the night before). Our total shifts then were from 7:30am through 1pm the next day. We went home after the noon lecture.

I found that having newborn children prior to medical school really helped me as I thought being on call was way easier than doing the mom thing. Also, I found it helpful to go home after clinic at 5pm and take a shower and get freshened up before going back at 7pm.

I will say I never worked an 80 hour week in residency. The most I put in was 55-60 and that was on medicine/hospitalist service because the attendings rounded late and we had to be present for that.

Can I ask what field you did your residency in and where?
I'm also someone who does not do well on sleep deprivation and yes, frankly, this is one of the reasons I'm holding back on attending medical school. If I can't take care of myself adequately, then I won't be able to care for my patients. How often did you feel this way during residency (that last question is for everyone, of course).

Originally Posted by Perrotfish

I've neve understood this argument. The day team has always been the primary team for the patient. Call is, and always has been, about the patients that you have NO personal investment in. Call is when its you you take someone, often someone with no experience as a physician, hand them a list of 80 patients, and say 'keep everyone alive, handle all the admissions to all services, and see you tomorrow'. Also under the old system three quarters of the patients on your service were admitted by other call teams, you learned aboutthem in the morning just like with night float. In what way does getting rid of this system change our personal investment in the patients?

Who exactly do you think is covering your daytime patients? YOU ARE. I'm still plenty invested at night, because a large portion of the patients are mine (often more than half).

Originally Posted by Perrotfish

I would agree that those reisdnecies that are trying to keep a call system in place rather than switching to a night float syatem are not doing their interns any favors.

Residency isn't meant for doing favors for interns. It's meant for what's best for everyone. Not every program is set up to allow for night float, and many places don't have enough people to dedicate 1-2 people to doing nights all year round.

Originally Posted by Perrotfish

...

That's one of the ideas behind new work hour rules: the time to start making independent decisions should not also be the time when you've already been working for 20 hours in a row. Instead, you get to deal with those attending-less nights after a full day of sleep.

The amazing thing is that people seem to think that there is somehow more teaching involved if you are less coherent. We are spending the same number of hours in the hospital as before. The difference is that rather than squandering part of our education on exhausted nightmares of call nights and blurry post-call half days we now are fully conscious for all of the 12 hour shifts (plus sign out and wrap up work) that we participate in.

I could almost buy your argument except for the fact that in my experience you end up MORE TIRED under a night float system than with a handful of 30 hour shifts. The 30 hour shifts are finite. You get a post call day. Sometimes you even get an hour or two in the call room. On night float it's an every night thing for up to 6 nights a week for a month. You get crummy sleep during the day. You are in the hospital literally every day for a month at a time. The day team loads you up with work because you are coming in fresh, not simply staying on. You often don't even get access to a call room because in the program's view it's not a call, it's a shift. So you are more consistently incoherent under this model IMHO. Even if you are a little punchy at the end of a 30 hour shift, it was only twice a week. With night float you go through an entire month in a fog.

Originally Posted by johnnydrama

I'd rather have a few 30 hour shifts and more time between them than 14 hrs 6 days a week, every week.

Yes you would. A lot of the premeds and med students don't get this yet. It's not even a close call in my mind, having worked under both systems.

Originally Posted by Law2Doc

Yes you would. A lot of the premeds and med students don't get this yet. It's not even a close call in my mind, having worked under both systems.

As others have mentioned, this is highly variable. It IS nice to have that post-call day, but it's also nice to get sleep every night.

It all depends on how you like your pain: bolus or infusion?

Let's talk about the really important stuff. Better to have a month with 2 black weekends and 2 gold weekends or 1 day off per week? Discuss.

Originally Posted by TheProwler

Residency isn't meant for doing favors for interns. It's meant for what's best for everyone. Not every program is set up to allow for night float, and many places don't have enough people to dedicate 1-2 people to doing nights all year round.

I don't understand how a program can be too small for a night float program but large enough for a q4 call system. You can't be on for an entire day after a night on call, so either way you have someone trading a day in the hospital for a night in the hospital.

In terms of the long term viability of a program, what's best for Interns' education is what's beset for everyone, because this year's Interns are next years senior residents. The poster wasn't wrong that taking away those much more indepentent nights is going to produce a geneation of R2s that don't really know how to make decisions on their own. Night float is an important compent of then new work hour rules, and I think that residencies that aren't finding a way to implement a night float system in favor of keeping a call system that simply excludes Interns are shooting themselves in the foot.

Originally Posted by Perrotfish

I don't understand how a program can be too small for a night float program but large enough for a q4 call system. You can't be on for an entire day after a night on call, so either way you have someone trading a day in the hospital for a night in the hospital.

APD addressed this earlier in the thread:

Originally Posted by aProgDirector

4. A shift based system is inherently 20-25% less "efficient" than a call based system. This means that when you switch to shifts from call, either 20% of patients need to be covered by a different system, or you need 20% more people to cover the work. Since residency programs can't simply hire more people, usually this means that people on tranditionally less busy rotations (i.e. electives) need to cover shifts on the busier rotations.

For small programs (mostly surgery and surgical subspecialties)...that 20-25% is the tipping point. There isn't enough redundancy when you only have 3-5 residents per year.

Originally Posted by Perrotfish

I don't understand how a program can be too small for a night float program but large enough for a q4 call system.

Try doing the math.

In terms of the long term viability of a program, what's best for Interns' education is what's beset for everyone, because this year's Interns are next years senior residents. The poster wasn't wrong that taking away those much more indepentent nights is going to produce a geneation of R2s that don't really know how to make decisions on their own. Night float is an important compent of then new work hour rules, and I think that residencies that aren't finding a way to implement a night float system in favor of keeping a call system that simply excludes Interns are shooting themselves in the foot.

See above.

Originally Posted by TheProwler

Try doing the math..

I've done the math and I've seen night float systems implemented in tiny residencies. A q4 call system means 1/4th of your working days on a given rotation are basically traded traded for nights. Someone other than the post call person needs to cover your days, 1/4th of the time, because the post call person needs to be gone by noon. Night float works the exact same way except that rather than missing every fourth day for a month you lose one entire week to night float on a one month rotation. You spend the same number of nights in the hospital and you spend the same number of hours in the hospital, so how do you need more manpower than you do with the other system? It doesn't require any more people than before.

BTW condescending lines like 'try doing the math' or 'This is hardly even worth dignifying with a response' might shut up your subordinates, but in the rest of the world they just make it sound like you don't have anything better to say. You should learn to leave this habit at the door of the hospital or you're going to end up paying for it with a lot of unnecessary misery (and alimony). If you really don't want to respond to a comment just don't respond.

Originally Posted by Law2Doc

I could almost buy your argument except for the fact that in my experience you end up MORE TIRED under a night float system than with a handful of 30 hour shifts. The 30 hour shifts are finite. You get a post call day. Sometimes you even get an hour or two in the call room. On night float it's an every night thing for up to 6 nights a week for a month. You get crummy sleep during the day. You are in the hospital literally every day for a month at a time. The day team loads you up with work because you are coming in fresh, not simply staying on. You often don't even get access to a call room because in the program's view it's not a call, it's a shift. So you are more consistently incoherent under this model IMHO. Even if you are a little punchy at the end of a 30 hour shift, it was only twice a week. With night float you go through an entire month in a fog.

1) I guess the exhaustion is operator dependent. I get exhausted with 30 hour shifts and I sleep very well during the days of a night float shift.

2) The better night float systems I have seen are not one month a year, they're one week per month. I could see where a month of nights could be rough, since you would be out of contact with your family and friends for that entire time. You also shouldn't be in the hospital every day for a month, you still get one day off a week in any event, the work hour rules apply to nights as well.

3) As for the residents loading you up with work I think that'sa benifit of the system: more of the scut gets shifted to the night float, so more of your day time in the hospital is dedicated to learning. At several of the programs I was at it was expected that the night float team would have skeleton notes written before the day team wrote up (vitals, labs, etc), and the generic patients would have things like med reqs or discharge paperwork ready to go. This made the day teams' job much more focused on the patients management, prerounding with students, teaching, etc.

Originally Posted by johnnydrama

I'd rather have a few 30 hour shifts and more time between them than 14 hrs 6 days a week, every week.

Yes, me too!

Originally Posted by Perrotfish

I've done the math and I've seen night float systems implemented in tiny residencies. A q4 call system means 1/4th of your working days on a given rotation are basically traded traded for nights. Someone other than the post call person needs to cover your days, 1/4th of the time, because the post call person needs to be gone by noon. Night float works the exact same way except that rather than missing every fourth day for a month you lose one entire week to night float on a one month rotation.

I'm often Q3, and you have to be averaging Q4 in order for night float to work in surgery, because you can only do 3 months of night float per year. Not only that, but if I came in at the time that people usually wanted to sign out and stayed until after our morning conferences, it would be a 15 hour shift every night. That would never come in under hours. The alternative would be making the day crew stay 1-2 hours later or missing all of our conferences, neither of which is a good option. If you're at a place with 8+ residents per year, then night float becomes a very different animal.

BTW condescending lines like 'try doing the math' or 'This is hardly even worth dignifying with a response' might shut up your subordinates, but in the rest of the world they just make it sound like you don't have anything better to say. You should learn to leave this habit at the door of the hospital or you're going to end up paying for it with a lot of unnecessary misery (and alimony). If you really don't want to respond to a comment just don't respond.

Thanks for the implications about my marriage, but you're way off base.

Maybe you think this deserved a gentle response:

R U freaking kidding me, even a kindergartner knows this.

but I didn't. Especially since a kindergartner wouldn't cite a study about general surgeons who have done a median of zero laparoscopic cholecystectomies and then act snide about it.

Originally Posted by Perrotfish

1) I guess the exhaustion is operator dependent. I get exhausted with 30 hour shifts and I sleep very well during the days of a night float shift.

2) The better night float systems I have seen are not one month a year, they're one week per month. I could see where a month of nights could be rough, since you would be out of contact with your family and friends for that entire time. You also shouldn't be in the hospital every day for a month, you still get one day off a week in any event, the work hour rules apply to nights as well.

3) As for the residents loading you up with work I think that'sa benifit of the system: more of the scut gets shifted to the night float, so more of your day time in the hospital is dedicated to learning. At several of the programs I was at it was expected that the night float team would have skeleton notes written before the day team wrote up (vitals, labs, etc), and the generic patients would have things like med reqs or discharge paperwork ready to go. This made the day teams' job much more focused on the patients management, prerounding with students, teaching, etc.

1. You might not see night float the same as a resident rather than as a med student.
2. Many night float systems are anywhere from 2-6 weeks up to 3 times per year. Only one week of night float at a time is kind of problematic because it screws up rotations/electives if someone is changing service more frequently. I doubt many places do this because you want to do things in blocks to work with the electives.

As for my comment about being in the hospital every day of the month-- think about it. If you get one day off in 7 and you are working six nights, your day off will start in the hospital. Meaning if you work Sunday night through Friday night, and get Saturday night off, you are still in the hospital on Saturday morning after you Friday overnight. So there's never a day you aren't in the hospital. Sure you get a day off, but you are still in the building Part of every day.

3. Possibly, although you are assuming the work us finite and that shifting things to the night frees up the day folks for more valuable things. In fact the work never runs out, and i Doubt the scut to work ratio changes much -- it just means the night time person is busier. Never doubt the ability to generate enough scut to fill capacity.

Originally Posted by Perrotfish

I've done the math and I've seen night float systems implemented in tiny residencies. A q4 call system means 1/4th of your working days on a given rotation are basically traded traded for nights. Someone other than the post call person needs to cover your days, 1/4th of the time, because the post call person needs to be gone by noon. Night float works the exact same way except that rather than missing every fourth day for a month you lose one entire week to night float on a one month rotation. You spend the same number of nights in the hospital and you spend the same number of hours in the hospital, so how do you need more manpower than you do with the other system? It doesn't require any more people than before.

It's not that simple, as others have stated. There is definitely an increased demand for manpower with the new ACGME rules. It's not as simple as swapping call for night float.

The new rules have mandated changes that decrease scheduling flexibility and redundancy...

-The mandate of no more than 16 hours worked for interns decreases redundancy - used to be the post-call person would overlap with the team taking over by as much as 6-8 hours (so you don't really lose 1/4 of your working days as you stated...more like 1/5); this is not the case with night float where for most places the overlap is only an hour at most

-The 10hr/8hr off rules further decrease flexibility in the scheduling because in reality working back to back to back 16 hours violates the 10 hr rule

-The mandate of no more than 6 consecutive nights of night float decreases scheduling flexibility

-The mandate of no more than 3 months of night float is an important point as well. Not all of us had the luxury of having Q4 or greater call as interns.

I can't speak for prowler's tone...but I think in general the residents who are responding on this thread are annoyed at having people who haven't done either system tell us what is and isn't feasible, or what is and isn't healthy. It's not like we are masochists...we would all love a cushier schedule if it was realistic. But for an outsider to tell us what our programs should be doing without any understanding of the structure or service needs of those programs is extremely frustrating.

Originally Posted by southernIM

...but I think in general the residents who are responding on this thread are annoyed at having people who haven't done either system tell us what is and isn't feasible, or what is and isn't healthy. It's not like we are masochists...we would all love a cushier schedule if it was realistic. But for an outsider to tell us what our programs should be doing without any understanding of the structure or service needs of those programs is extremely frustrating.

Yep.

Originally Posted by Law2Doc

1. You might not see night float the same as a resident rather than as a med student.
2. Many night float systems are anywhere from 2-6 weeks up to 3 times per year. Only one week of night float at a time is kind of problematic because it screws up rotations/electives if someone is changing service more frequently. I doubt many places do this because you want to do things in blocks to work with the electives.

Exactly. We have to plan our vacations and conferences around certain electives, as well as our call schedule, because they're changing their schedules to accommodate us.

As for my comment about being in the hospital every day of the month-- think about it. If you get one day off in 7 and you are working six nights, your day off will start in the hospital. Meaning if you work Sunday night through Friday night, and get Saturday night off, you are still in the hospital on Saturday morning after you Friday overnight. So there's never a day you aren't in the hospital. Sure you get a day off, but you are still in the building Part of every day.

Add to this the fact that you're likely to match somewhere that's not right by your family, and if you ever want to visit them, you'll need a full weekend to do so. When I did OB/gyn in med school, they would do Friday/Sunday call, which sucked for that weekend, but it meant you had the next weekend completely off and could go somewhere for the weekend.

3. Possibly, although you are assuming the work us finite and that shifting things to the night frees up the day folks for more valuable things. In fact the work never runs out, and i Doubt the scut to work ratio changes much -- it just means the night time person is busier. Never doubt the ability to generate enough scut to fill capacity.

This can't be overstated...

If it seems like you don't have much to do, people will end up asking why you didn't check out this, that and the other thing.


And Perrotfish, I apologize for the tone. Busy at work, busy at home, haven't had vacation in a while....stress adds up. I can't pull off the impartial tone that L2D always has. I should have clarified more anyway - the math may seem like it works in a vacuum, but when you add in people's vacations, electives, conferences, there are a lot more moving parts. Then there's one of the biggest things - you have a site visit from your ACGME/sub-committee-whathaveyou every 3-5 years, and they accredit you based on a lot of very specific things, and completely restructuring your curriculum to accommodate for a change in work hours could result in a new site visit. This can be highly stress-inducing for many people involved, and "what's best for the interns" is not necessarily best for everyone.

Lastly, you've left out the whole "indirect supervision, direct supervision immediately available, direct supervision present" component out, which is significant when your supervision is tied up in the operating room. http://www.acgme.org/acwebsite/dutyh...efinitions.pdf

An intern can't be on the floor doing any of the following: "evaluation and management of post-operative complications, including hypotension, hypertension, oliguria, anuria, cardiac arrythmias, hypoxemia, change in respiratory rate, change in neurologic status, and compartmant syndromes" while the senior resident is in the OR, until they've "demonstrated competency" (which isn't defined...).

There's a lot of stuff moving here.

Originally Posted by TheProwler

An intern can't be on the floor doing any of the following: "evaluation and management of post-operative complications, including hypotension, hypertension, oliguria, anuria, cardiac arrythmias, hypoxemia, change in respiratory rate, change in neurologic status, and compartmant syndromes" while the senior resident is in the OR, until they've "demonstrated competency" (which isn't defined...).

Really? Wow...fascinating how times are changed. That's all I did as an intern (with my Chief resident and attendings at home, not directly supervising me).

Originally Posted by Law2Doc

2. Many night float systems are anywhere from 2-6* weeks up to 3 times per year. Only one week of night float at a time is kind of problematic because it screws up rotations/electives if someone is changing service more frequently. I doubt many places do this because you want to do things in blocks to work with the electives.

Agree with everything except this part. If you have a q4 system it's pretty easy to switch to one where, in a 4 week block, each team/resident does 3 weeks of days bad one week of nights. My MICU and CCU rotations (in the 80/30 system) worked like this and it was pretty successful all things considered.

Of course, this was in a decent sized IM program. For surgery and other small programs this night not work. And that's the key here that the students and pre-meds (and ACGME for that matter) need to understand. There is no one size fits all system that will work for every specialty everywhere. Thinking this is the case is profoundly naive.

A far as q4 vs NF and person-power is concerned, here's the problem:

Let's say you have 4 teams on call q4. Each team covers 10 patients. So, the service covers 40 patients and all nights are covered.

Now, let's say you want to create a night float. You could take one of your teams and make it a "night team". Whether you do so for 1, 2, or 4 weeks is purely arbitrary. Now you have 3 day teams and one night team -- so now you can only cover 30 patients on the service. Plus the night team can only do 6 shifts in a row, so you need to either have a "random" NF shift or have one team do an overnight call once per week. No matter how you slice it, you need to either decrease the census from 40 to 30, or add another intern/resident (so that there are 4 day teams and one night team), and then also will need some random NF shifts to cover the holes. Either way, it's 20-25% less efficient.

And, this doesn't address the night -> day transition -- if you have a resident on nights and want to switch them to days, you're going to need another day off to make it feasible.

Originally Posted by aProgDirector

A far as q4 vs NF and person-power is concerned, here's the problem:

Let's say you have 4 teams on call q4. Each team covers 10 patients. So, the service covers 40 patients and all nights are covered.

Now, let's say you want to create a night float. You could take one of your teams and make it a "night team". Whether you do so for 1, 2, or 4 weeks is purely arbitrary. Now you have 3 day teams and one night team -- so now you can only cover 30 patients on the service. Plus the night team can only do 6 shifts in a row, so you need to either have a "random" NF shift or have one team do an overnight call once per week. No matter how you slice it, you need to either decrease the census from 40 to 30, or add another intern/resident (so that there are 4 day teams and one night team), and then also will need some random NF shifts to cover the holes. Either way, it's 20-25% less efficient.

And, this doesn't address the night -> day transition -- if you have a resident on nights and want to switch them to days, you're going to need another day off to make it feasible.

So on the call schedule who was managing the post-call team's patients? Did you just have 10 of your 40 patients sitting there unmanaged between noon and when the call team came on at 7 p.m.? Before they implemented the new work hour rules you already had one fourth of your residents missing on any given day. The only difference is that now yout have the night person missing all their days in a row, rather than just missing every fourth day for an entire month.

Here's one way this can work even with only 2 residents on a service. Say you have 8 residents a 4 year program, 2 residents/year, covering 4 services with 2 person teams of one senior and one junior resident. For each week in a given four week block you have a senior resident from one service and a junior resident from a second service cover night float. That leaves at least one resident to cover the days on every service. On the weekends night float has one resident/day, to let the other resident take a day off (which presumably is also what the day teams are doing, to allow everyone to get their day off). Everyone gets a day off, every night is covered, and every team always has at least one resident on service that is familar with the patients on service.

Originally Posted by Perrotfish

So on the call schedule who was managing the post-call team's patients? Did you just have 10 of your 40 patients sitting there unmanaged between noon and when the call team came on at 7 p.m.? Before they implemented the new work hour rules you already had one fourth of your residents missing on any given day. The only difference is that now yout have the night person missing all their days in a row, rather than just missing every fourth day for an entire month.

This again shows that you haven't really experienced either of these systems as a resident.

For medicine and other programs where teams take call as a whole...in a Q4 system the post-call team would stay, round on their patients, write the daily orders and progress notes, discharge patients, order studies. Then at noon they would sign out the service to the on call team who would cross cover them. Most of the work for the day was done and the on call team just followed up on studies and managed acute issues. So again as I said before, you don't really lose 1/4 of the manpower during the day time...the post call team contributes a lot of the daily work.


For surgical teams, it would typically just be one intern taking call at a time per service, so the remainder of the team could function without that one person on any given day. The post-call person still rounds, helps with floor work, and often will do a case or two before leaving. Again, in a tradiitonal call system the post call person would contribute a significant amount to the daily work.

Here's one way this can work even with only 2 residents on a service. Say you have 8 residents a 4 year program, 2 residents/year, covering 4 services with 2 person teams of one senior and one junior resident. For each week in a given four week block you have a senior resident from one service and a junior resident from a second service cover night float. That leaves at least one resident to cover the days on every service. On the weekends night float has one resident/day, to let the other resident take a day off (which presumably is also what the day teams are doing, to allow everyone to get their day off). Everyone gets a day off, every night is covered, and every team always has at least one resident on service that is familar with the patients on service.

The only services I know that are that small are surgical programs. How would you expect a surgical service to function if the senior resident is gone for a week every month? Who is going to do the senior level cases and run the service?

...

At this point you have a program director and several residents from different disciplines telling you that it increases the demand for residents and causes logistical difficulties for small programs. You can choose to continue telling us how wrong we are, but I would again advise you to wait until you've experienced life as a resident.

Originally Posted by southernIM

The only services I know that are that small are surgical programs. How would you expect a surgical service to function if the senior resident is gone for a week every month? Who is going to do the senior level cases and run the service?

There is evidence that night float significantly reduces the number of cases done by senior and Chief residents and it is therefore, frowned upon by the ABS which typically does not allow for elective or non-operative months PGY4 and 5+.

I cannot comment on whether or not the system would work as Perrotfish describes for other programs, but as SouthernIM very correctly points out, NF creates a real problem for senior surgical residents, for whom the bulk of their operative experience occurs during the DAY with elective, scheduled cases. No one is going to be doing a Whipple or even a redo laparoscopic hernia repair in the middle of the night. Even 1 week a month can translate into missing a large number of cases.

For medicine and other programs where teams take call as a whole...in a Q4
system the post-call team would stay, round on their patients, write the daily
orders and progress notes, discharge patients, order studies. Then at noon they
would sign out the service to the on call team who would cross cover them. Most
of the work for the day was done and the on call team just followed up on
studies and managed acute issues. So again as I said before, you don't really
lose 1/4 of the manpower during the day time...the post call team contributes a
lot of the daily work.

You still lose at least half of your man-hours for that day. This doesn't change under a night float system, the only difference is that rather than losing the entire team for part of the day you lose part of the team for the entire day. You have about the same number of man hours to do the work and advance the patients' care.

For surgical teams, it would typically just be one intern taking call at a time
per service, so the remainder of the team could function without that one person
on any given day. The post-call person still rounds, helps with floor work, and
often will do a case or two before leaving. Again, in a tradiitonal call system
the post call person would contribute a significant amount to the daily work.

Again, you have the same number of man hours per Intern per month, except now instead of having one Intern post call you have one Intern on night float. The scut that that Intern did post call is transfered to night float. Actually this sytem should gain the hospital man hours, since under a traditional system several of thehours that counted towards the 80 hour cap were at least theoretically supposed to be spent asleep during the call night. Under a night float system every one of those 80 hours is spent awake and working. And of course even in systems where you never slept you at least don't lose any manhours.

The only services I know that are that small are surgical programs. How would
you expect a surgical service to function if the senior resident is gone for a
week every month? Who is going to do the senior level cases and run the service?

If the only upper level on a service was taking call under the old system then clearly the system could function without the upper level resident, since he was post-call one day in four and needed to be out of the hospital by noon. This means they either it was an elective service where they didn't schedule cases for the afternoons of post call days, in which case you switch to not scheduling cases for the week of night float, or it was a service where the attending took the upperlevel cases without a resident on the days the resident was post call, in which case the attending just does that for the entire week of night float rather than doing it every fourth day of the call system. Again, the number of days in the hospital doesn't change.

At this point you have a program director and several residents from different
disciplines telling you that it increases the demand for residents and causes
logistical difficulties for small programs. You can choose to continue telling
us how wrong we are, but I would again advise you to wait until you've
experienced life as a resident

And when I disagree then I suspect that you'll advise me to wait until I'm an attending, and then a program director. I'm sorry but we've all worked in the same system and with the same call and night float schedules. Seniority might give me some perspective about how the two systems feel relative to one another, as L2D had mentioned, but the actual logistics of this is a simple math problem.

Originally Posted by Perrotfish

Y
If the only upper level on a service was taking call under the old system then clearly the system could function without the upper level resident, since he was post-call one day in four and needed to be out of the hospital by noon.

The idea of senior residents taking in house call on an elective surgical service is very new, and created by the new set of ACGME rules regarding "direct" vs "indirect" supervision as prowler pointed out.

the actual logistics of this is a simple math problem.

Except you continue to ignore the details of this math problem. It's not just trading night float vs call. It's night float + the 16 hr limitation (meaning the night float person cant stay late past their shift and contribute more work) + the 8hr/10hr rules (further restricting the ability to stay past the end of a shift) + the 6 day in a row limit (restricting flexibility for days off, eliminating golden weekends) + the direct supervision rule (increasing requirements for in house call for senior residents).

We are not saying it doubles or triples the work. But it does increase the workload.

Rather than bicker back and forth whether or not NF is possible based on simple math involving hours and coverage (which it generally isn't), perhaps a better model would be to weight hours based on resident level and likelihood of educational case involvement. That is, for a Pgy-1, roughly all hours are the same but for a chief day hours are much more useful.

Regardless, with the requirement for in-house senior supervision of interns, the ACGME has effectively turned internship in to a paid, 5th year of medical school, and 2nd year in to internship.

Originally Posted by Perrotfish

Again, you have the same number of man hours per Intern per month, except now instead of having one Intern post call you have one Intern on night float. The scut that that Intern did post call is transfered to night float. Actually this sytem should gain the hospital man hours, since under a traditional system several of thehours that counted towards the 80 hour cap were at least theoretically supposed to be spent asleep during the call night. Under a night float system every one of those 80 hours is spent awake and working. And of course even in systems where you never slept you at least don't lose any manhours.

Except that interns can't do night float without direct supervision, in the form of a senior resident or attending in the building.

If the only upper level on a service was taking call under the old system then clearly the system could function without the upper level resident, since he was post-call one day in four and needed to be out of the hospital by noon. This means they either it was an elective service where they didn't schedule cases for the afternoons of post call days, in which case you switch to not scheduling cases for the week of night float, or it was a service where the attending took the upperlevel cases without a resident on the days the resident was post call, in which case the attending just does that for the entire week of night float rather than doing it every fourth day of the call system. Again, the number of days in the hospital doesn't change.

Total number of hours is not the entire picture. A resident can easily schedule himself to not be post-call on the primary operating days for their attending. Plus, most of our cases are done by 2-3pm, and many are done by noon, so a senior resident could have been doing them up until July 2011. Surgeons don't just randomly operate on any day of the week - they almost always have block time, and specific types of cases are scheduled on different days (e.g., outpatient day, big inpatient case day), and it would be bad for everyone involved to be sending the intern into a Whipple.

And when I disagree then I suspect that you'll advise me to wait until I'm an attending, and then a program director. I'm sorry but we've all worked in the same system and with the same call and night float schedules. Seniority might give me some perspective about how the two systems feel relative to one another, as L2D had mentioned, but the actual logistics of this is a simple math problem.

You haven't worked either one as a resident, especially not as a surgery resident, which is exactly where we're telling you that this poses the biggest problem.

Originally Posted by southernIM

Except you continue to ignore the details of this math problem. It's not just trading night float vs call. It's night float + the 16 hr limitation (meaning the night float person cant stay late past their shift and contribute more work) + the 8hr/10hr rules (further restricting the ability to stay past the end of a shift) + the 6 day in a row limit (restricting flexibility for days off, eliminating golden weekends) + the direct supervision rule (increasing requirements for in house call for senior residents).

+ vacation + circumstances specific to a given elective....

Total number of hours is not the entire picture. A resident can easily schedule
himself to not be post-call on the primary operating days for their attending.

Out of curiosity, how does this work if you're not on a q7 call schedule? If the attending only operates on a certain day of the week how can you always avoid hitting that day while taking q3, q4, or q5 call?

Originally Posted by Perrotfish

Out of curiosity, how does this work if you're not on a q7 call schedule? If the attending only operates on a certain day of the week how can you always avoid hitting that day while taking q3, q4, or q5 call?

Call doesn't have to be at the same interval every time (two Q3, one Q4, and two Q5 average out to Q4), and even if it is, you can stagger it so that you're only post-call on a bad day once or twice, instead of five or six times.

Originally Posted by TheProwler

Call doesn't have to be at the same interval every time (two Q3, one Q4, and two Q5 average out to Q4), and even if it is, you can stagger it so that you're only post-call on a bad day once or twice, instead of five or six times.

And of course this is assuming that the program and the resident don't violate post call regulations and the senior resident doesn't stay post call to do cases.

Originally Posted by Winged Scapula

And of course this is assuming that the program and the resident don't violate post call regulations and the senior resident doesn't stay post call to do cases.

Which would never happen....

Originally Posted by Perrotfish

You still lose at least half of your man-hours for that day. This doesn't change under a night float system, the only difference is that rather than losing the entire team for part of the day you lose part of the team for the entire day. You have about the same number of man hours to do the work and advance the patients' care.

I think I see where the confusion lies.

You are correct, the number of person-hours in the hospital is about the same whether you use a q4 system, or three teams with night float. In fact, when I switched our system to a pure night float (which I did in advance of the ACGME regs, simply because I thought it was the right thing to do (but also because I could see the writing on the wall)), the residents were all certain that they would be working many less hours with night float -- and they were wrong. The hours are exactly the same -- in number.

But, the night float can't carry a team of patients. So, no matter how you slice it, the new 3 team + NF is capped at less patients overall.

Now, you wonder how we really took care of patients on the post call day, right? I mean, if managing a full team of patients takes a full day, then how do you manage a team of patients in half a day? Well, the answer is:

1. The post call team doesn't get any new patients, so it's faster to manage the patients you have rather than deal with new patients.
2. It was not uncommon to start post call rounds at 4AM. That way, just when all the other teams are coming in to start, you've actually finished rounds and get to work.
3. Patients admitted after midnight don't need a progress note post call -- one note per calendar day, only a brief update if things have changed.
4. All educational stuff post call was optional -- no morning report, conferences, etc (some programs do require residents to come to MR post call, another reason to start post call rounds at 4AM).
5. It was "all hands on deck" -- the resident and interns just worked like crazy until the work was done.

Did it suck? Yep. Like when you were on at the VA (with an open ICU) and an ICU admission arrived at 4AM.

And did you sometimes leave a sick patient who then would need to be managed by the on call intern while they were trying to deal with their new patients? Yep, and that sucked too.

I want to be clear here: I fully support the abolishment of 24 hour shifts (with the exception of those roles where you're likely to sleep all night). I'm just pointing out that when you do so, you create inefficiencies that need to be addressed.

Again, you have the same number of man hours per Intern per month, except now instead of having one Intern post call you have one Intern on night float. The scut that that Intern did post call is transfered to night float. Actually this sytem should gain the hospital man hours, since under a traditional system several of thehours that counted towards the 80 hour cap were at least theoretically supposed to be spent asleep during the call night. Under a night float system every one of those 80 hours is spent awake and working. And of course even in systems where you never slept you at least don't lose any manhours.

You are correct here -- you can get more "hours" since now the NF doesn't really need to sleep. But, as mentioned above, since the NF can't carry a census, it remains more "patient census inefficient" while perhaps being more "hour efficient". However, you haven't addressed the transitions, which tend to create more inefficiencies (i.e. switching someone from nights to days and back again creates more holes in the schedule)

Good luck to all the happy, healthy, well-adjusted future residents who slept through their eight year residency. You will have a blast as an attending when you find no restrictions on your work hours and no sympathetic ears to your whining.

You know what my group would say to the idealistic young anesthesiologist who wants a job with us but feels that 24 hours of call is bad for patients and their own personal mental health?

"NEXT."

I take in-house call 18-24 hours about once a week. On sunday, I maybe sat down for a total of 90 minutes during 24 hours. Did it suck? Definitely. Is it going to change anytime soon? Not unless the number of anesthesiologists who like getting paid 1/3 their salary magically triples. It isn't just about continuity of care; it's also about supply and demand. I work in a specialty with virtually no continuity of care, but there still needs to be someone covering for every specialty every hour of every day. Some have fewer calls/emergencies and may take even longer call shifts.
Our general surgeons tend to do their weekend calls (in-house, covering GS and trauma in a level 2 trauma center) in 48-72 hour chunks to minimize the number of weekends they have to work. They don't get a lot of sleep. Guess what? They still have a full surgical schedule on Monday!
I know people in other specialties that take home call a week at a time. They may be in every night doing crap at all hours as well as working full days. Why do they do it? Because there needs to be coverage.

Bottom line is, you can be as vocal and picky as you want when you're a student. Don't go to a residency with call. Sleep instead of learn. But don't expect a hospital/private group/academic department with patients to take care of/call to cover to have much patience for your idealism. They pay you to work and get the job done. If you don't want to do it, fine. You may find your job prospects pretty slim in a world where it's all about dollars and cents.

Leaving aside the whole issue of what is best for residents' health and education, one of the things that students need to understand about residency (and being a physician in general) is that you are not just hanging out playing doctor any more like you were as a student. You *are* a doctor, and you're expected to act like one. If you aren't present in the hospital, other people (colleagues as well as patients) are going to be negatively affected. Someone has to do the work that makes patient care happen, and as a resident in a teaching program, that someone is you. If that means you get less sleep sometimes, then you get less sleep sometimes. If that means you come in sicker than some of your patients sometimes, then you come in sicker than some of your patients sometimes. This is the reality of the culture of medicine. If you're not willing to make this kind of sacrifice for your colleagues and patients, you should seriously re-think whether medicine is the right career for you. Because no one wants to work with a resident who is more worried about being sleep deprived than being a team player.

For those who keep harping on the fact that sleep deprivation is akin to being drunk, I'd also point out that people do adjust to being chronically sleep-deprived, just as they adjust to being alcoholics. A BAL of 0.2 might well put a teetotaler like me into a coma, but people who are hard-core drinkers come in with BALs higher than that and act totally sober.

Maybe these are the reasons that the newer generation of docs is leaning more towards shift work. Just because it was done a certain way in the past doesn't necessarily mean it is the only or best way to do it.

Plus by the time we figure out half the crap in medicine as students we have 170k+ in loans on our heads that aren't easy to make disappear.

I don't think a DUI's criteria is based on how sober you can act.

As time passes physicians are moving more and more to shift work. These training guidelines are probably just pushing us there faster.

Originally Posted by Roguelyn

As time passes physicians are moving more and more to shift work. These training guidelines are probably just pushing us there faster.

The message, that evidently is not getting through to students, is that the training guidelines and move towards shift work is, frankly, not working.

Already, several surgical groups have considered abandoning the guidelines altogether, and, if need be, the ACGME.

You may desire shift work and 36 hour weeks, but that does not happen in medicine. Period.

Originally Posted by neusu

The message, that evidently is not getting through to students, is that the training guidelines and move towards shift work is, frankly, not working.

Already, several surgical groups have considered abandoning the guidelines altogether, and, if need be, the ACGME.

You may desire shift work and 36 hour weeks, but that does not happen in medicine. Period.

Laborists, hospitalists, ER, trauma surgery....I wouldn't necessarily say shift work is not working. 36 hours a week you could still pull in over 100k as a family physician. The attitude that sucks for medicine is change is bad.

Why must it be we desire 36 hr work weeks? Why must we always take things from one extreme to another? It's just about wanting a nicer work/life balance. Shouldn't have picked medicine...There are ugly strippers and hookers that don't want to be kissed on the lips...people choose things doesn't mean it's wrong of them to want some slight changes in a suboptimal training system. If it was such a great system before the changes came then all physicians trained before the changes would have been great and nobody would have made mistakes...we made em then we make em now...crap happens.

Originally Posted by neusu

The message, that evidently is not getting through to students, is that the training guidelines and move towards shift work is, frankly, not working.

Already, several surgical groups have considered abandoning the guidelines altogether, and, if need be, the ACGME.

You may desire shift work and 36 hour weeks, but that does not happen in medicine. Period.

I was talking to one of the ER docs yesterday, and he says that he has to work 145 hours/month. That's only 34 hours/week in a 30 day month. Most of the other guys work fewer clinical shifts, because they have some administrative duties as well.

Originally Posted by SeekerOfTheTree

I don't think a DUI's criteria is based on how sober you can act.

You'll never get pulled over for being drunk if nobody notices anything awry. The drunk guy who drives better than the sober guy isn't going to get pulled over, and nobody is the wiser.