56 Hour Week Is Coming

[secretwave101]

Most of the notes I have seen from paperless systems suck.

I can't say for sure that 'paperless' is the answer. But I do know that the REDUNDANCY is what drives me nuts. It's expensive, both in terms of time and money...and leads to transcription errors, many of which aren't insignificant.

---

Members don't see this ad.

 

[3dtp]

Most of the notes I have seen from paperless systems suck. ICU patients with notes will have problems listed that have completely ressolved over a week ago, plans per consultants who have signed off, physical exams that don't match the patient, and are otherwise grossly incorrect. These systems are not that good, and teach lazy residents to be lazier. Just because the work gets done faster doesn't mean its done better.

This is a function of the author, not the system. If the system users don't enter the proper data, then the system will reproduce the improper data. QED.

Timeline:
ca 1500 BC: Egyptions invent paper. A new era is born. Village historians object saying writing things down will make memories soft and destroy civilization. Displaced Village historians become engineers use paper and pen to design refrigerator in the desert to make ice for Pharaohs without electricity or even knowing that it exists.

800 AD: Monks copied papal edicts by hand.
1500 AD: Moveable type printing press developed. Monks objected saying the printing press will destroy handwriting which will make the church soft and destroy civilization.
1540 AD: Reformation occured because it was too easy to print and circulate new ideas
Many unemployed monks now find new work as scholars and preachers.
The Renessance Era is Born - major advances in philosophy, medicine, science and the arts take place.

1950 AD: Photocopiers replace the last monks at the Vatican. Council of Cardinals cries out in agony at the passing of the old ways and predict the demise of civilization.

1951 AD: College of Cardinals become Attendings determened to find work for displaced monks hand copying documents and data. Find there is a shortage of monks, who have become engineers, so create residents and the match to fill positions due to the shortage of monks.

1970 AD: Computers begin to become pervasive. UNIX invented. Documents stored, printed and disseminated via electronic media (internet). World wide communications rapid, cheap and economical.
1975 AD: milnet/ARPAnet/Darpanet invented. Computers now talk to each other. forerunner of ethernet.
1990 AD: Powerful computers capable of advanced imaging/graphics/massive storage and internet communications become powerful and cheap and pervasive. Business adopts with massive cost savings.
1991 AD: Microsoft, fearing well working computers invents the "Blue Screen of Death" and programs computers to crash regularly. UNIX runs on.
2000 AD: Imaging and graphics sent round the world in seconds.

2000 AD: Cardinals (attendings) and Monks (residents) continue to keep faithful to the old ways and hand copy everything. Hospital administrators decry the shortage of monks and insist residents work 120 hours/week copying paperwork. Photocopiers deemed satanic and are off limits.

2001: AD: Attendings (cardinals), forced to modernize by the secular world install crappy emr/order entry systems and implement them badly so that when they fail they can show to the world that the old ways are better and hire more monks to copy things.

2003 AD: Limits placed on resident/monks forcing Attendings in charge of hospitals to create PA residencies to continue the old ways. PA-C councils object and are excommunicated for heresy.

2008 AD: EMR becomes more widely available and effective. Attendings (cardinals) cry that it is the demise of the time proven rigorous training and worry that the widespread use of computers will destroy civilization.

20xxAD: The power fails and all the computers go dark. The cardinals/attendings cry out with glee! We told you so! The sky has fallen.

.........But wait! Out of the darkness a light glows brightly. It is the battery backup keeping the EMR going. [energizer bunny [running UNIX] strolling around the unit....]

And Civilization continues.....


----
FreeBSD UNIX/KDE/OpenOffice.org -- Liberating the power of computers many users at a time....

 

[drfunktacular]

...bunch of awesome stuff...

 

[8744]

This is a function of the author, not the system. If the system users don't enter the proper data, then the system will reproduce the improper data. QED.

Timeline:
ca 1500 BC: Egyptions invent paper. A new era is born. Village historians object saying writing things down will make memories soft and destroy civilization. Displaced Village historians become engineers use paper and pen to design refrigerator in the desert to make ice for Pharaohs without electricity or even knowing that it exists.

800 AD: Monks copied papal edicts by hand.
1500 AD: Moveable type printing press developed. Monks objected saying the printing press will destroy handwriting which will make the church soft and destroy civilization.
1540 AD: Reformation occured because it was too easy to print and circulate new ideas
Many unemployed monks now find new work as scholars and preachers.
The Renessance Era is Born - major advances in philosophy, medicine, science and the arts take place.

1950 AD: Photocopiers replace the last monks at the Vatican. Council of Cardinals cries out in agony at the passing of the old ways and predict the demise of civilization.

1951 AD: College of Cardinals become Attendings determened to find work for displaced monks hand copying documents and data. Find there is a shortage of monks, who have become engineers, so create residents and the match to fill positions due to the shortage of monks.

1970 AD: Computers begin to become pervasive. UNIX invented. Documents stored, printed and disseminated via electronic media (internet). World wide communications rapid, cheap and economical.
1975 AD: milnet/ARPAnet/Darpanet invented. Computers now talk to each other. forerunner of ethernet.
1990 AD: Powerful computers capable of advanced imaging/graphics/massive storage and internet communications become powerful and cheap and pervasive. Business adopts with massive cost savings.
1991 AD: Microsoft, fearing well working computers invents the "Blue Screen of Death" and programs computers to crash regularly. UNIX runs on.
2000 AD: Imaging and graphics sent round the world in seconds.

2000 AD: Cardinals (attendings) and Monks (residents) continue to keep faithful to the old ways and hand copy everything. Hospital administrators decry the shortage of monks and insist residents work 120 hours/week copying paperwork. Photocopiers deemed satanic and are off limits.

2001: AD: Attendings (cardinals), forced to modernize by the secular world install crappy emr/order entry systems and implement them badly so that when they fail they can show to the world that the old ways are better and hire more monks to copy things.

2003 AD: Limits placed on resident/monks forcing Attendings in charge of hospitals to create PA residencies to continue the old ways. PA-C councils object and are excommunicated for heresy.

2008 AD: EMR becomes more widely available and effective. Attendings (cardinals) cry that it is the demise of the time proven rigorous training and worry that the widespread use of computers will destroy civilization.

20xxAD: The power fails and all the computers go dark. The cardinals/attendings cry out with glee! We told you so! The sky has fallen.

.........But wait! Out of the darkness a light glows brightly. It is the battery backup keeping the EMR going. [energizer bunny [running UNIX] strolling around the unit....]

And Civilization continues.....


----
FreeBSD UNIX/KDE/OpenOffice.org -- Liberating the power of computers many users at a time....

http://pandabearmd.com/blog/2007/09...d-in-which-i-say-something-nice-about-france/


http://pandabearmd.com/blog/2007/08...politely-where-the-sun-doesnt-shine/#comments

 

[sirus_virus]

Prove this to me. Show me definitive proof that patients suffer an increased rate of medical errors on the part of sleep-deprived residents under the 80-hour work week versus some other model involving fewer work hours.

What sort of proof will make you believe? Asking for proof that a physician working 30 hours straight will be more likely to make mistakes than a rested one is like asking me to show proof that finding your girlfriend in bed with your best friend is going to hurt. We really don't need data for that, we just kinda know. I could post some research that supports my argument, but I am sure the supporters of sleep deprivation are well armed with their own studies to counter it.

BTW, do you know how or where you can get medical error data in the U.S? Don't waste your time, you cant. The National Center for Patient Safety and Medicare are now working to make this data reportable and available to the public. When that happens, I might be able to show you the proof you need. The Europeans have their data and based on that, have made changes and are now enjoying fewer errors.

 

[DrDre311]

What sort of proof will make you believe? Asking for proof that a physician working 30 hours straight will be more likely to make mistakes than a rested one is like asking me to show proof that finding your girlfriend in bed with your best friend is going to hurt. We really don't need data for that, we just kinda know. I could post some research that supports my argument, but I am sure the supporters of sleep deprivation are well armed with their own studies to counter it.

BTW, do you know how or where you can get medical error data in the U.S? Don't waste your time, you cant. The National Center for Patient Safety and Medicare are now working to make this data reportable and available to the public. When that happens, I might be able to show you the proof you need. The Europeans have their data and based on that, have made changes and are now enjoying fewer errors.

My statement was purely rhetorical. I knew beforehand that you would not be able to provide evidence to back up your claim. Medicine is a field which rewards accuracy, not conjecture. Simply because something "makes sense" or seems intuitive does not make it so. Even if something goes with the prevailing opinion of the majority, it is not necessarily correct.

You made a unilateral statement that reducing the resident work hour requirement would reduce medical errors on the part of residents. There is no way that you can prove this without a study comparing medical errors attributable to resident fatigue (or even residents themselves) between two comparable medical education systems with differing work hour requirements. No such study exists, as far as I know. Also, I would like to see a study showing fewer resident-attributable medical errors as a consequence of reduced in work hours in Europe if you know where I can find one.

So, I am not saying whether or not a reduction in resident work hours will result in fewer errors--I don't know, because I can't prove it one way or the other. There is a tendency on this board for people to state opinion as inarguable fact, and such a practice is folly in an evidence-based profession. I'm basically playing devil's advocate as a way of cautioning you against making statements you can't back up.

 

[DrDre311]

(1) What sort of proof will make you believe? Asking for proof that a physician working 30 hours straight will be more likely to make mistakes than a rested one is like asking me to (2) show proof that finding your girlfriend in bed with your best friend is going to hurt. We really don't need data for that, we just kinda know. I could post some research that supports my argument, but I am sure the supporters of sleep deprivation are well armed with their own studies to counter it.

BTW, do you know how or where you can get medical error data in the U.S? Don't waste your time, you cant. The National Center for Patient Safety and Medicare are now working to make this data reportable and available to the public. When that happens, I might be able to show you the proof you need. (3) The Europeans have their data and based on that, have made changes and are now enjoying fewer errors.

(1) To make your statement a fact, rather than an opinion (which you are certainly free to hold) you would need: a study comparing medical errors definitively attributable to resident fatigue under the 80-hour restriction on residents in the U.S. graduate medical education system vs. medical errors definitively attributable to resident fatigue under a system comparable at baseline to the U.S. system, with fewer work hours. Until someone finds a way to produce such a study, you are stating opinion and not fact, and should preface your statements as such.

(2) Apples and oranges. I know how negative occurrences in romantic relationships affect me, and can use my prior personal experience to state confidently that I would not enjoy finding my girlfriend in bed with my best friend. Since you have no prior personal experience with reducing work hours and the relationship of such an action to reduced medical errors due to fatigue, you cannot say the same thing--you can only conjecture. Your comparison in this case is innacurate.

(3) Prove this to me. I haven't seen any data on the subject. Even if you can find such a study, can you be sure that the resident population/patient population is comparable to U.S. residents as a group at baseline? Can you be sure that the measured errors are due to fatigue? Is the reduction statistically significant? Can you be sure that the measured errors negatively impacted patient outcomes?

 

[3dtp]

(1) To make your statement a fact, rather than an opinion (which you are certainly free to hold) you would need: a study comparing medical errors definitively attributable to resident fatigue under the 80-hour restriction on residents in the U.S. graduate medical education system vs. medical errors definitively attributable to resident fatigue under a system comparable at baseline to the U.S. system, with fewer work hours. Until someone finds a way to produce such a study, you are stating opinion and not fact, and should preface your statements as such.

(3) Prove this to me. I haven't seen any data on the subject. Even if you can find such a study, can you be sure that the resident population/patient population is comparable to U.S. residents as a group at baseline? Can you be sure that the measured errors are due to fatigue? Is the reduction statistically significant? Can you be sure that the measured errors negatively impacted patient outcomes?

You are correct. There is no prospective randomized controlled study to prove conclusively according to our current "gold" standard with which we are presently so enamoured. However, the studies that demonstrate acute and acute on chronic sleep deprivation effects on judgement and decision making are legion.

To cite two of the more recent ones, one because the use of fMRI has given us specific insight into altered brain activity patterns and thus sheds some light on specific and quantifiable sleep deprivation alterations in brain function as in mayrelate to your demand.

This study done at Walter Reed by William Kilgore who has done a large number of studies on sleep deprivation and chemical stimulants to reverse the effects of sleep deprivation looks at 34 individuals in the states of a.) being well rested and b.) acute sleep deprivation at 49+ hours of wakefulness. Dr. Kilgore had subjects perform a gaming test known as the Iowa Gaming Test which looks at risk taking behavior and found that when the subjects were normally rested, they migrated toward advantageous low risk behavior and away from higher risk choices. In acute sleep deprived state, he noted that the subjects' behavior changed markedly toward higher risk choices. He also found that age was negatively correlated with increasing risk decision making in the setting of acute sleep deprivation. He states that this pattern of behavior is similar to that found in patients with frontal medial cortex lesions with the implication that cognitive functions known to be mediated by the ventromedial prefrontal cortex including decision making under conditions of uncertainty may be particularly vulnerable to sleep loss.WILLIAM D. S. KILLGORE, THOMAS J. BALKIN, NANCY J. WESENSTEN (2006) Impaired decision making following 49 h of sleep deprivation
Journal of Sleep Research 15 (1) , 7–13 doi:10.1111/j.1365-2869.2006.00487.x

Gee, that sort of sounds exactly like a resident and the working environment of a resident, doesn't it?

Second recent study worth noting, this one published in Nature. This was an interesting study done by the folks at UCSD in the late 1990s, published in Nature (Nature 403, 655-657 (10 February 2000) | doi:10.1038/35001068) Looked at 35 subjects otherwise healthy and did fMRI studies of sleep deprivation at 35 hours and found similar results. fMRI demonstrated substantial prefrontal cortex increases in activity and substantial reductions in temporal lobe activity. Subjective reports of sleepiness were directly correlated with increase PFC activity changes on fMRI.

So, clearly there are changes in brain activity following sleep deprivation. The question from this early functional study is: Do these changes reflect compensatory pathway alterations and if so, what overall effect do these compensated pathways have on a.) medical decision making, b.) risk taking behavior and c.) recall and learning?

I submit that until we know the answer to these question, in light of the Kilgore studies, that it would be foolhardy to risk patients lives on an unproven paradigm, namely allowing sleepy residents to make important medical decisions, in light of an overwhelming empirical data colletion that its not a good idea and now functional brain activity studies that demonstrate altered brain activity in the sleep deprived.

Next study. chronic and acuted on chronic sleep deprivation in obstructive sleep apnea patients. A study which matched health subjects with OSA subjects given 8 hours in bed baseline and then sleep deprived for 40 hours. This study, although it has flaws, again, using a variety of psychomotor tests appears to demonstrate that acute sleep deprivation is a key cause of reduced performance. (J.Sleep Research, in press, June 2008:
Comparing the neurocognitive effects of 40 h sustained wakefulness in patients with untreated OSA and healthy controls
doi:10.1111/j.1365-2869.2008.00665.x

So, opinion based on the available evidence is grounded in well established data is about as close to objective truth as you can get, absent placing people at high risk. Contrarily, everything is an opinion. Newton had an opinion that F=ma, which we later found out needed refining and Schroedinger came up with quantum theory. Yet, I dare to bet not a single one of us will argue with the law of gravity to any significant degree.

I think a significant time waster preventing residents from copying lab values from computer screen to index card to progress note is the need to take a dump. Every resident should be placed on opiates to reduce the need to sit down for a few minutes, given immodium and only allowed MGCitrate on their days off. There's plenty of excess colon capacity to store things up for a week or so, as our patients can attest and it is only mildly uncomfortable for the first 4-6 days. If we combine this with food restrictions, we might get an additional 3 days out of them and at 10 minutes/day, that'san hour a week of increased lab copying. Anybody agree?

 

[sirus_virus]

(1) To make your statement a fact, rather than an opinion (which you are certainly free to hold) you would need: a study comparing medical errors definitively attributable to resident fatigue under the 80-hour restriction on residents in the U.S. graduate medical education system vs. medical errors definitively attributable to resident fatigue under a system comparable at baseline to the U.S. system, with fewer work hours. Until someone finds a way to produce such a study, you are stating opinion and not fact, and should preface your statements as such.

(2) Apples and oranges. I know how negative occurrences in romantic relationships affect me, and can use my prior personal experience to state confidently that I would not enjoy finding my girlfriend in bed with my best friend. Since you have no prior personal experience with reducing work hours and the relationship of such an action to reduced medical errors due to fatigue, you cannot say the same thing--you can only conjecture. Your comparison in this case is innacurate.

(3) Prove this to me. I haven't seen any data on the subject. Even if you can find such a study, can you be sure that the resident population/patient population is comparable to U.S. residents as a group at baseline? Can you be sure that the measured errors are due to fatigue? Is the reduction statistically significant? Can you be sure that the measured errors negatively impacted patient outcomes?

Do you see why I would not waste my time providing you with such a study? You already have your counter argument ready. Remember how all these years they told you getting enough sleep will help you do better on tests, well every patient encounter is a test question of it's own, and you also need quite a bit of cognition to take care of them. The problem I have with the people that ask for data to proof this is that it appears they need enough people to die before it makes sense to correct the problem. Do you know that one death or one injury due to sleep deprivation is enough grounds to make changes? It becomes more apparent if it were a family member or you on the receiving end.

 

[AwesomO]

Finally, if it is lazy to not want to come in at six when the hospital could buy some ten-year-old IBM PS2s and streamline things enough to let us come in at seven instead, well, I guess I am lazy.

Whats sad is there isn't a single job in the hospital besides being a resident that this wouldn't be common sense to, even the attendings. But if your a resident and suggest such a thing it's "Stop being lazy!"

 

[DrDre311]

Do you see why I would not waste my time providing you with such a study? You already have your counter argument ready. Remember how all these years they told you getting enough sleep will help you do better on tests, well every patient encounter is a test question of it's own, and you also need quite a bit of cognition to take care of them. The problem I have with the people that ask for data to proof this is that it appears they need enough people to die before it makes sense to correct the problem. Do you know that one death or one injury due to sleep deprivation is enough grounds to make changes? It becomes more apparent if it were a family member or you on the receiving end.

You're missing the point. I said before that I wasn't coming down on either side of the issue. It just isn't a good idea to say things you can't back up. I'm not asking for deaths, I'm asking for proof in the form of recorded medical errors definitively attributable to resident fatigue. I'm not even telling you that your opinion is wrong (because I have no way of knowing), I'm telling you that you shouldn't state it as fact.

 

[mig26x]

I will take the 80 hour week any day vs a 56 hr week and one more year. Loans are starting to become a pain in the a$$!!!

 

[DrDre311]

You are correct. There is no prospective randomized controlled study to prove conclusively according to our current "gold" standard with which we are presently so enamoured. However, the studies that demonstrate acute and acute on chronic sleep deprivation effects on judgement and decision making are legion.

To cite two of the more recent ones, one because the use of fMRI has given us specific insight into altered brain activity patterns and thus sheds some light on specific and quantifiable sleep deprivation alterations in brain function as in mayrelate to your demand.

This study done at Walter Reed by William Kilgore who has done a large number of studies on sleep deprivation and chemical stimulants to reverse the effects of sleep deprivation looks at 34 individuals in the states of a.) being well rested and b.) acute sleep deprivation at 49+ hours of wakefulness. Dr. Kilgore had subjects perform a gaming test known as the Iowa Gaming Test which looks at risk taking behavior and found that when the subjects were normally rested, they migrated toward advantageous low risk behavior and away from higher risk choices. In acute sleep deprived state, he noted that the subjects' behavior changed markedly toward higher risk choices. He also found that age was negatively correlated with increasing risk decision making in the setting of acute sleep deprivation. He states that this pattern of behavior is similar to that found in patients with frontal medial cortex lesions with the implication that cognitive functions known to be mediated by the ventromedial prefrontal cortex including decision making under conditions of uncertainty may be particularly vulnerable to sleep loss.WILLIAM D. S. KILLGORE, THOMAS J. BALKIN, NANCY J. WESENSTEN (2006) Impaired decision making following 49 h of sleep deprivation
Journal of Sleep Research 15 (1) , 7–13 doi:10.1111/j.1365-2869.2006.00487.x

(1) Gee, that sort of sounds exactly like a resident and the working environment of a resident, doesn't it?

Second recent study worth noting, this one published in Nature. This was an interesting study done by the folks at UCSD in the late 1990s, published in Nature (Nature 403, 655-657 (10 February 2000) | doi:10.1038/35001068) Looked at 35 subjects otherwise healthy and did fMRI studies of sleep deprivation at 35 hours and found similar results. fMRI demonstrated substantial prefrontal cortex increases in activity and substantial reductions in temporal lobe activity. Subjective reports of sleepiness were directly correlated with increase PFC activity changes on fMRI.

(2) So, clearly there are changes in brain activity following sleep deprivation. The question from this early functional study is: Do these changes reflect compensatory pathway alterations and if so, what overall effect do these compensated pathways have on a.) medical decision making, b.) risk taking behavior and c.) recall and learning?

I submit that until we know the answer to these question, in light of the Kilgore studies, that it would be foolhardy to risk patients lives on an unproven paradigm, namely allowing sleepy residents to make important medical decisions, in light of an overwhelming empirical data colletion that its not a good idea and now functional brain activity studies that demonstrate altered brain activity in the sleep deprived.

Next study. chronic and acuted on chronic sleep deprivation in obstructive sleep apnea patients. A study which matched health subjects with OSA subjects given 8 hours in bed baseline and then sleep deprived for 40 hours. This study, although it has flaws, again, using a variety of psychomotor tests appears to demonstrate that acute sleep deprivation is a key cause of reduced performance. (J.Sleep Research, in press, June 2008:
Comparing the neurocognitive effects of 40 h sustained wakefulness in patients with untreated OSA and healthy controls
doi:10.1111/j.1365-2869.2008.00665.x

So, opinion based on the available evidence is grounded in well established data is about as close to objective truth as you can get, absent placing people at high risk. Contrarily, everything is an opinion. Newton had an opinion that F=ma, which we later found out needed refining and Schroedinger came up with quantum theory. Yet, I dare to bet not a single one of us will argue with the law of gravity to any significant degree.

I think a significant time waster preventing residents from copying lab values from computer screen to index card to progress note is the need to take a dump. Every resident should be placed on opiates to reduce the need to sit down for a few minutes, given immodium and only allowed MGCitrate on their days off. There's plenty of excess colon capacity to store things up for a week or so, as our patients can attest and it is only mildly uncomfortable for the first 4-6 days. If we combine this with food restrictions, we might get an additional 3 days out of them and at 10 minutes/day, that'san hour a week of increased lab copying. Anybody agree?

(1) No, it doesn't.

(2) I'm familiar with these studies. The problem is that the sample sizes are very small, and how can you be sure they'd be comparable at baseline to the general population of residents (external validity)?

Also, the issue isn't really the same. Residency doesn't frequently involve being awake for 49 straight hours and THEN being asked to make critical medical decisions (hence 80/30) although there are cases when it does. But the real issue with people who don't like the hours is chronic sleep deprivation over a period of months/years, for which you have no data. Plus, how can you account for tolerance to sleep deprivation? It's something you learn to deal with as a student and resident.

5 hours of sleep per night is a good night for me and I like my job, so I haven't found residency to be all that strenuous. However, instead of using my n=1 personal experience and saying "80 hours is dumb! Why can't you sissies just do your jobs!" or something equally asinine, I recognize that: I am not like all other residents (i.e., my personal experience is not generalizable); and I have seen data showing that (before the 80 hour week) residents tended to mangle themselves in their cars on the way home (but no evidence for increased medical errors!).

I'm not coming down on either side of the issue, but I say again: simply because something seems like it should be so does not make it so. So, just because 34 people exhibit increased risk-taking after being kept awake for more than 49 hours does not mean that implementing a 56 hour work week (pretty similar numbers, hmmm?) will reduce medical errors definitively attributable to resident fatigue.

The studies you have provided are not designed nor statistically powered to answer the question we are debating. All you have shown me is that a small sample of people exhibited increased risk-taking, a change in fMRI, or reduced performance on psychomotor exams following extreme acute sleep deprivation (under conditions not generally encountered by residents)--not specifically that residents working long hours make more errors. That is an assumption; it might be a good one, or it might not. You can't assume that the results of these small studies transmute themselves to the errors made by the entire population of medical/surgical residents in the U.S.

And Newton's "opinions" about gravity and other aspects of physics had a great deal of data to back them up (unlike proponents of a 56 hour week). However, Newton was proved wrong under some extreme conditions requiring the invention of quantum mechanics. I don't argue with gravity because I experience its effects continuously. I am not kept awake for 50 hours continuously, nor do I work under a 56 hour system, so I don't make arguments involving either condition.

 

[BlondeDocteur]

(1)
And Newton's "opinions" about gravity and other aspects of physics had a great deal of data to back them up (unlike proponents of a 56 hour week). However, Newton was proved wrong under some extreme conditions requiring the invention of quantum mechanics.

Well, my observations of the orbit of the planet Mercury definitely support a 56-hr week.

 

[secretwave101]

I will take the 80 hour week any day vs a 56 hr week and one more year. Loans are starting to become a pain in the a$$!!!

Totally agree. It's an expensive year when you calculate lost doctor wages (around 100k) plus another year of interest (variable, but freaky for most of us).

Plus, if I only worked 56 hours a week...I'd moonlight as much as possible (to try to offset the above)...and end up working around 80 hours anyway. Probably 90.

 

[StealthNerd]

So, wow. I need to jump in here on this "prove to me that sleep-deprived residents make more mistakes" thing. The argument that since no study has been conducted comparing numbers of patients killed by rested vs. fatigued physicians means there's no proof that they do, is f*cking ridiculous. That's like saying smoking doesn't cause cancer. Sure, there's hundreds of known carcinogens in cigarettes. But we can't PROVE that they cause cancer. Are they linked? Yep. Strong correlation? No doubt. But to actually prove it, we'd need to set up an experiment where we killed the subjects. People tend to frown on that. ... so back to the original point. There's been a ton of research to prove that humans function much worse both in terms of physical reaction time as well as cognitive thought when they are sleep deprived. No, I'm sorry, I don't have any such studies in front of me to cite. But I'm sure you can Google them. In fact, if I remember correctly, at least one study proved that people who have been awake for 24 hours, or who got less than 6 hours per night for a week straight, are as impaired as a person who is legally drunk. Now that's bad. So bad, in fact, that New Jersey passed a law making it illegal to drive if you haven't slept in the last 24 hours. So think about that. You're a doctor in Jersey, who is so freaking impaired you can't legally drive... but you can make life and death decisions and actually do interventions for patients?

O, btw, here's a link and a blurb to get you started:

From www.DrowsyDriving.org

The New Jersey State Senate passed the bill, known as "Maggie's Law", on June 23, 2003. The law establishes fatigued driving as recklessness under the existing vehicular homicide statute (N.J.S.2C:11-5). This legislation overwhelming passed both chambers of the state legislature and represents the first bill in the nation to specifically address the issue of driving while fatigued. The bill defines "fatigue" as being without sleep for a period in excess of 24 consecutive hours.

Most people are aware that drunk drivers are a danger to themselves and others on the road. Sleepy drivers are as much of a danger, and sleep deprivation can cause impairment equal to drugs or alcohol. Two recent Australian studies demonstrate that being awake for 18 hours produces impairment equal to a blood alcohol concentration (BAC) of 0.05% and 0.1% after 24 hours; 0.08% is considered legally drunk.

So yeah, let's not go back and forth on whether or not a fatigued person functions just as well as a rested person. Cause that's just ridiculous.

You're welcome.

S

 

[DrDre311]

So, wow. I need to jump in here on this "prove to me that sleep-deprived residents make more mistakes" thing. The argument that since no study has been conducted comparing numbers of patients killed by rested vs. fatigued physicians means there's no proof that they do, is f*cking ridiculous. That's like saying smoking doesn't cause cancer. Sure, there's hundreds of known carcinogens in cigarettes. But we can't PROVE that they cause cancer. Are they linked? Yep. Strong correlation? No doubt. But to actually prove it, we'd need to set up an experiment where we killed the subjects. People tend to frown on that. ... so back to the original point. There's been a ton of research to prove that humans function much worse both in terms of physical reaction time as well as cognitive thought when they are sleep deprived. No, I'm sorry, I don't have any such studies in front of me to cite. But I'm sure you can Google them. In fact, if I remember correctly, at least one study proved that people who have been awake for 24 hours, or who got less than 6 hours per night for a week straight, are as impaired as a person who is legally drunk. Now that's bad. So bad, in fact, that New Jersey passed a law making it illegal to drive if you haven't slept in the last 24 hours. So think about that. You're a doctor in Jersey, who is so freaking impaired you can't legally drive... but you can make life and death decisions and actually do interventions for patients?

O, btw, here's a link and a blurb to get you started:

From www.DrowsyDriving.org

The New Jersey State Senate passed the bill, known as "Maggie's Law", on June 23, 2003. The law establishes fatigued driving as recklessness under the existing vehicular homicide statute (N.J.S.2C:11-5). This legislation overwhelming passed both chambers of the state legislature and represents the first bill in the nation to specifically address the issue of driving while fatigued. The bill defines "fatigue" as being without sleep for a period in excess of 24 consecutive hours.

Most people are aware that drunk drivers are a danger to themselves and others on the road. Sleepy drivers are as much of a danger, and sleep deprivation can cause impairment equal to drugs or alcohol. Two recent Australian studies demonstrate that being awake for 18 hours produces impairment equal to a blood alcohol concentration (BAC) of 0.05% and 0.1% after 24 hours; 0.08% is considered legally drunk.

So yeah, let's not go back and forth on whether or not a fatigued person functions just as well as a rested person. Cause that's just ridiculous.

You're welcome.

S

I'm tempted not to even bother with this one...

Well, I'll keep it brief. Cigarette smoking is well-established as a cause of lung cancer. Although you are correct that it would be unethical to set up a double-blind, randomized, placebo-controlled trial involving smoking and lung cancer, there are a MULTITUDE of well-designed case-control studies, cohort studies, etc. establishing cigarette smoking as a causative factor in many, many different types of cancer. It's proof enough for the CDC, and it's proof enough for me. It is not an arguable point. However, no data exist to suggest with any strength that medical errors would be reduced by a 56 hour work week.

Again, your comparison is flawed because you assume that only a blinded, randomized, controlled prospective trial can prove something. If you can think of a way to do a case-control or cohort study or whatever with enough statistical strength to prove, or even strongly suggest, that medical errors attributable to resident fatigue would be reduced with a 56 hour work week relative to the current 80-hour model that would be great. But, you can't, Sirus can't, and nobody else can. So, it remains your opinion and not a fact. Also, you're forgetting (or didn't read my post) that I'm not actually stating that a 56 hour week would not reduce medical errors (because I cannot know that based on currently available data). I'm just advocating being able to put your money where your mouth is.

Also, everybody knows about Maggie's Law--you're not posting anything that hasn't been posted before on this board. And nobody's saying that people don't experience functional impairment from being tired. We're all aware that sleep-deprived residents are more likely to mangle themselves in cars. But, as intuitive as it may seem, there is no basis for your leap from automobile accidents to medical errors caused by resident fatigue. You are making an assumption which may or may not be true.

There's an epidemic of people on this board who like to state wrongheaded opinions as fact, get pissy about others' posts without bothering to read them, and who have very little understanding of statistics (on which we rely professionally)--despite being tested on them repeatedly in medical school.

 

[mig26x]

There was a study published one year ago in AMA were it showed that sleep deprived residents are more prone to needle stick injuries than, and to me that's pretty scary!!!

 

[core0]

Here is the study that started the argument over the 56 hour week:
http://www.ahrq.gov/news/press/pr2004/16hrintpr.htm

Dr. Barger at Harvard is probably the one doing the most work on this right now:
http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0030487

David Carpenter, PA-C

 

[DrDre311]

Here is the study that started the argument over the 56 hour week:
http://www.ahrq.gov/news/press/pr2004/16hrintpr.htm

Dr. Barger at Harvard is probably the one doing the most work on this right now:
http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0030487

David Carpenter, PA-C

David, thanks for posting that. I am familiar with Barger's work as well, and (hate to be a naysayer) that study is just a survey with each intern acting as his/her own control! There's no way you can get rid of bias in that study design.

And I have read the NEJM studies upon which the AHRQ report is based--they are limited to a small number of interns at one institution (in the case of the study involving attentional failures--measured by episodes of eye-rolling) and to 2 10-bed ICU's (in the case of the study involving serious medical errors). What about different ICU's with different personnel, or the floors, or OR's, or clinic? What about a different hospital, or a different residency program within the hospital? Even in the medical error study, patient stay and length of outcome did not vary from the traditional schedule to the intervention schedule. Furthermore, under both the traditional and intervention schedules in the study, interns averaged more sleep per night (along the lines of 6.5 to 7.5 or so) than I have since I was a teenager. Also, the authors state that the observers quantifying medical errors were not blinded as to what schedule the interns were working. And what about interrater difference as to whether an error was serious, or attributable to fatigue?

Not to mention the fact that all the studies in question are only limited to interns! What about all the people who are not interns--upper levels, pharmacists, attendings, etc. (the ones who intercept intern medical errors of any cause, not just fatigue)--what do we know about how work hours affect their errors/judgment?

There are serious problems with the external validity of this study.
In the words of the authors:

"It is important to emphasize that not all interventions that reduce interns' work hours will increase interns' sleep or improve patients' safety...Furthermore, any systemic intervention that reduces work hours necessarily increases either providers' workload (i.e., the number of patients covered by a provider at any time) or the number of handoffs in care between medical personnel on shorter work shifts. Either can lead to increased rates of errors and adverse events...Our study has several limitations...We studied two ICUs in a single hospital, and our results may not be generalizable to other settings. In addition, although our study was very large as compared with prior observational safety studies...the study was not powered to detect differences in the rates of preventable adverse events. Larger-scale, multicenter trials are needed to investigate this aspect."

I repeat that I am not saying that widespread implementation of a 56 hour work week would not reduce medical errors. I am saying that there is insufficient evidence, including the posted studies, to say one way or the other.

Those studies raise interesting questions--in fact, they pose more questions than answers. Again, people who blindly state that a 56 hour work week for all U.S. residents would definitely reduce medical errors do not have sufficient evidence to back that claim up.

I have made this point ad nauseam and any further input on my part will be me agreeing with myself.

 

[exPCM]

Does anyone really think that people function as well when they have been up for 24-30 straight hours versus being well rested?

Items to consider:
1) Residents spend 35% of their time on activities with little or no educational value:
http://www.iom.edu/Object.File/Master/54/597/Bellini Presentation.pdf

2) A primary reason that resident work hour restrictions have been opposed is financial IMHO:
http://www.iom.edu/Object.File/Master/52/259/Liekweg Presentation.pdf

 

[3dtp]

Does anyone really think that people function as well when they have been up for 24-30 straight hours versus being well rested?

Items to consider:
1) Residents spend 35% of their time on activities with little or no educational value:
http://www.iom.edu/Object.File/Master/54/597/Bellini Presentation.pdf

2) A primary reason that resident work hour restrictions have been opposed is financial IMHO:
http://www.iom.edu/Object.File/Master/52/259/Liekweg Presentation.pdf

Sadly, the answer to this appears to continue to be yes. And no amount of objective evidence will convince them. Consider this: Our air traffic system is the safest in the world and is arguably one of the safest mass transportation systems ever designed. Part of what makes it safe is limits on commercial pilots (FAR Part 135.267) which limits flight and duty times of air crew flying for hire. Why? Because in the 1930s we learned that well rested pilots make better in-flight decisions than exhausted pilots and accident rates went down.

Rules: Single Pilot: 8 hours Two Pilots: 10 hours
Rest: 10 hours between duty.
Exception exceeding 8/10 hour rule by < 30 min 11 hours rest
exceeding 8/10 hour rule by 31-60 min 12 hours rest
exceeding 8/10 hour rule by > 1 hour 16 hours rest.

The FAA wisely realized that it could extend the work day where there was redundancy and cross checking between pilots. A similar redundancy in medicine that keeps many errors from becoming manifest.

And the FAA knows, as do we in medicine, that occasionally stuff happens and schedules aren't kept. So these rules do not limit pilots to 8 or 10 hours in a given day. So, if a trip is legal for me to accept, I can fly and even if I end up flying 12 hours on a trip due to traffic/weather/mechanical/the catering truck is late, the FAA allows it. But there are consequences to the company: My mandatory crew rest time increases and that can play havoc with the next day's flight schedule. Companies have a strong financial/reputation incentive to keep the schedules honest.

What I do during rest time is my business, but at that point I am not company property. I can sleep, eat, pay bills or fly my own personal airplane for fun, but the company cannot make me work and the FAA will issue a "civil penalty" to me and my company if I do or they try.

Anecdote: NTSB Accident Report:
Pilot: 15000 hours total time, 2000 hours in aircraft make/model.
A/C: Beech B55 Baron
Weather: widespread low ceilings/visibilities, but all stations reporting above minimums at the origin of the trip.
Severity: 1 fatal, aircraft destroyed.

Events: Pilot went on duty at 1400 on a 7 leg Part 135 trip . His final leg was from DPA (Dupage County, Illinois) to DBQ (Dubuque, IA). The prior legs were uneventful. Prior to departure, at 0453 (local time) or after the pilot had been on duty more than 14 hours, the pilot obtained a weather update at DBQ which indicated the weather was well below minimums, and elected to depart DPA anyway. The aircraft crashed on approach to destination. Visibility at DBQ was ceiling 100 foot and 1/4 miles. The minimum ceiling was 800 or 900 feet and 1/2 mile visibility (I don't have the chart handy so this is a guess, but it'll be close to that.)

NTSB's investigation revealed no mechanical defect with the aircraft or its systems. Their conclusion as to the cause of the accident was pilot error due to poor preflight planning and lack of judgement as a direct and proximate result of fatigue. Contributing factors were pilot complacency. The flight was legal since all delays were due to weather related traffic congestion.

Some of you will say that aviation is apples to oranges, but apples are round, sweet and fruit. So are oranges.

The decision making cascades can be similar between the two and the consequences of a wrong decision just as devastating. (Those of you type-rated in something and have >1000 hours night/IMC logged, feel free to disagree). I know the pilot's quandary, I've done it myself once or twice. I survived and am here to tell about it. Would I do it again? I'd like to think not. But there are similarities between the occasionally grueling hours of flying freight and internship. The difference is that in medicine we only place one person at a time at risk, and not up to 300.

Some in medicine would have us believe that there is only one way to arrive at objective truth: a randomized controlled blinded prospective study. This is patent nonsense. It is true that such a study can arrive at an objective truth and test statistically the outcomes of two different courses of action in a specific setting. They assert that absent that in exact circumstances, then the collective weight of information coupled with rational interpretation of same is merely opinion. I disagree. DrDre311gave his philosophy (based on an anecdote of 1) on the need for a good night's sleep. He/she is articulate, clearly very bright and has done well with relatively fewer hours of sleep. But, we will never know how much more of an achiever DrDre311 might have been if he had, in fact, had a full restorative nights sleep each and every night. Again, n=1.

Anecdotal evidence of 1 is just that. A story of a particular time and place. Gather a few anecdotes and pretty soon you may have a pattern of similar stories.

Over many years and thousands of anecdotes, all telling you the same or very similar things, and you have a preponderance of the evidence. And that is as close to generalized objective fact as we can get.

No one did a randomized identical twin study where one twin was raised in a tobacco free environment and the other in smoky bars and encouraged to start smoking at age 9. But eventually, smoking related illness anecdotes caused people to pay attention. RJR and PM were claiming as recently as the mid 1990s that there was no "objective evidence" that smoking causes cancer, copd and a myriad of other illnesses. But the weight of decades of anecdotal evidence led to the inevitable conclusion of the CDC that smoking is bad for you. I accept their conclusions. We do not need to set up a study that gets people killed to demonstrate this.

Likewise, I accept the conclusions of the FAA and the NTSB and the Air Force, at the same level as I accept the CDC's conclusion that smoking is bad for people's health. Sleep deprivation is very bad for you and those around you, based on decades of accumulated anecdotal evidence and now coupled with numerous studies.

To come to any other conclusion and discount the accumulated evidence before our eyes ( and this is my opinion) is sheer folly.

 

[3dtp]

Those studies raise interesting questions--in fact, they pose more questions than answers. Again, people who blindly state that a 56 hour work week for all U.S. residents would definitely reduce medical errors do not have sufficient evidence to back that claim up.

I do not think that a 56 hour week would make any signficant difference for reasons I have already stated above. I am opposed in general to weekly work hour limits, including both the 80 and the suggested 56 hours limits. There are bona fide reasons why these may be problematic.

I am most certainly opposed to excessive, sustained and chronic time on duty absent sufficient rest. There is no need for it. Other than a hospital's bottom line. As I advocated above, a mandated reasonable daily rest period would solve most of the problems and would not appreciably interfere with legitimate educational processes and would not lead to a need to extend residencies.

 

[drfunktacular]

Did anyone watch 60 Minutes yesterday? They had a long segment about the science of sleep deprivation: http://www.cbsnews.com/stories/2008/03/14/60minutes/main3939721.shtml

I found it interesting that none of the physicians they interviewed commented on the success of their hospitals being built upon the back of resident sleep deprivation (which they acknowledge causes decreased mental functioning and increased propensity to error). They also repeatedly contradict the classic justification that residents need to be underslept so they can "train" themselves to function better on less sleep--all of these researchers say their work shows the opposite is the case.

 

[8744]

Did anyone watch 60 Minutes yesterday? They had a long segment about the science of sleep deprivation: http://www.cbsnews.com/stories/2008/03/14/60minutes/main3939721.shtml

I found it interesting that none of the physicians they interviewed commented on the success of their hospitals being built upon the back of resident sleep deprivation (which they acknowledge causes decreased mental functioning and increased propensity to error). They also repeatedly contradict the classic justification that residents need to be underslept so they can "train" themselves to function better on less sleep--all of these researchers say their work shows the opposite is the case.

Oh man. This is another pet peeve of mine. There is no point training residents to function with less sleep because most physicians, the majority, don't practice medicine like we do in residency. I don't, for example, know of any primary care attending who comes into the department at night to see patients when they are on call. Instead, they give some phone orders to the nurse and go back to sleep. And if you do pick a job after residency that deprives you of sleep, that's a personal choice, nothing more.

As for getting used to being tired, I did two intern years and about 150 nights of call. I probably got meaningful sleep on less than twenty of those nights and it sucked just as hard the last night as it did the first.

 

[montessori2md]

That is why, for the rare few who actually want to work more in medicine and who are as vociferous as you so as to make it seem like a lot of people want that too, extra training time should be available in the form of moonlighting.

For rare cases, consult. Seeing 2 or 3 more rare cases by working 30 extra hours a week is not worth the cost or patient morbidity associated with medical errors. In fact an attending who is more "scared" of a rare diagnosis and orders a consult as a result will likely serve a patient better than one who arrogantly assumes they know how to manage it because they've seen a whole case (while SLEEPY! reduced stage 3/4 sleep -> less memory!) during residency.

Healthcare efficiency should not be underestimated. It is basically another word for cost (time is money, etc). Cost is what raises insurance premiums and promotes the level of uninsured individuals that exist in this country. It is what delays or prevents necessary patient care. It is what is rising steadily towards and past 20% of GDP, a ridiculous figure and trend that will be unsustainable. In fact one statistic suggests that 31% of healthcare cost is associated with excessive administration, and that successfully reducing such a cost would be enough to cover the majority of the uninsured population. http://content.nejm.org/cgi/content/short/349/8/768. (I do not support the conclusion that we should switch to a canadian healthcare system but the point is made nonetheless).

The quality of healthcare suffers as a result of inefficiency to a MUCH greater extent than it does due to "lack of training." In this example, it is because of inefficiency that residents have to work such long hours and as a result make mistakes. It is because of inefficiency that people that can't find the flow sheet say "screw it." It is one of the reasons ER's are so overwhelmed and critical patient care is delayed. It contributes to sloppy hand-writing and incorrect medication dosages. The list continues endlessly. Doctors work very hard; it is the system in which they work that results in poorer quality, not the doctors themselves. It is not training that is the problem, but the system we are trained into. Measures such as this that FORCE change from the bottom up (rather than encourage change from the top down) are necessary.

Calling for a consult instead of trying to handle it all yourself is supposedly one of the better ways to improve efficiency (Redefining Healthcare, I'm reading it now, butting in as a pre-med).

Very irked that it is politically impossible to address healthcare as the century old behemoth that it is, even (and especially) among healthcare professionals.

We have EMR at my hospital and dictation and handwritten charts. Go over to radiology, ma'am, we'll give you your MRI on a cd, but it will take all day to get your chart to appear on the right floor. It will take 2 hours to assign you a room, because, even though there are 30 beds clean and unassigned, they aren't blinking red on the computer screen yet, and I'm not "allowed" to call the unit secretary and ask her to change it. It's giving me a strong distaste for medicine, which seems to be similar to being a court recorder.

 

[DrDawg]

With your fear being that people will be lazy I'm guessing your a surgical resident? Not trying to bust your balls, I've just noticed the same thing with my friends in surgery.

Yes I'm a surgical resident, and no offense taken. More than anything I can't stand lazy people. EMR's are coming, and ultimately it will be nice to be able to read everyones notes. I just doubt that it will increase effiency, improve patient care, or save money, but I guess we all wil be doing that experiment shortly.

 

[Long Dong]

Go figure it's always the surgeons calling everyone else lazy for wanting to work less and getting some sleep. Not everyone loves living in the hospital and having no life outside of work.

 

[Tired]

Go figure it's always the surgeons calling everyone else lazy for wanting to work less and getting some sleep. Not everyone loves living in the hospital and having no life outside of work.

I could deal with the lazy specialties a lot better if, when I called the consult, they would just man up and say, "You know what? I'm more interested in getting home to watch Gossip Girl than I am in helping out this patient."

 

[elwademd]

I could deal with the lazy specialties a lot better if, when I called the consult, they would just man up and say, "You know what? I'm more interested in getting home to watch Gossip Girl than I am in helping out this patient."

i take ofense, i gotta get home for flavor of love or ufc ultimate fighter, not gossip girl!

 

[Yasargil]

Now that does not make any sense! People, I'm talkin' bout Chewbacca. Does that make any sense?

Where have I heard that line before!

 

[DrDawg]

Go figure it's always the surgeons calling everyone else lazy for wanting to work less and getting some sleep. Not everyone loves living in the hospital and having no life outside of work.

My orginal post, which was several post back, said that EMR's enable lazy residents to be lazier. Notes become essentially cut and paste with no thought as to if the information is still relavent, and often it's not. Although they maybe somewhat faster, I don't think they will result in a change in the quality of care, and isn't that the goal? I may be proven wrong. We will see.

I am all for working less, so long as all the work gets done, and done well. Till then I will just have Tivo Lost, football, and Red Sox games.

 

[cimorene]

The solution to excess work is this (IMHO): set up an efficient system that gets the work done without the stupid unnecessary admin work. Having worked in multiple other fields, I find medicine to be the most absolutely inefficient of all. For example, cut out pre-rounding and repeat rounding with different levels of staff, unless you are actually going to do some kind of quality bedside teaching. Set up efficient admit and discharge paperwork that does not require crap like the resident having to hand-write the pt's discharge med list. Have admin people available to chase down charts from OSH. Get EMRs that actually work and do not add unnecessary time to the MD's day. Allow the option of typing in your note instead of dictating. Have flawless IT systems and staff that work all the time. Set up standards for calling consults that specify what you need to know, do, and order before calling the consult.

I think that a 56 hour work week is definitely reasonable if healthcare efficiency is vastly improved, as stated by this previous poster. There is just way too much burden on a physicians shoulders these days. There is NO reason why every single thing that happens to a patient must go through as a physicians order. As an intern, there are hours of each day where I have to write orders for ancillary services to let them do their expertise.

For instance, nutritionists are always checking if patients are on the correct diet, type of G-tube feeding formula etc. Do I care whether a patient is on Jevity or Promote tube feed at 60 or 80cc/hour? Not really. I only care if I have to have them NPO or something. But whenever the nutritionists want to alter something, they gotta find me, and have me write the order. Most of the time I just write down exactly what they want and sign it. Maybe this isn't a lot of time in and of itself, but hundreds of interruptions like this a day occur when I'm say, thinking about how to manage a patient who is in CHF, ESRD on dialysis, and is also septic but needs surgery. Or maybe I was looking at a critical lab value and after the distraction I've forgotten all about it.

Also, insurance companies as well are insane about the things that need a doctor's prescription. Like a shower stool? A cane? If a patient came to a doctor's office and said they need something like that, no doctor is going to say no. So why does insurance require a doctor's signature? It's insanity.

I dont' know if I agree with reducing the weekly hours, but decreasing the workload. Inpatients these days are sicker than ever, due to the quality of medicine increasing. In the old days, you would say, admit every case of pneumonia. Now, so much can be handled outpatient that a lot inpatients have 5-10 problems. My hospital has a high nursing home population so, each patient would have like 10 "stable" problems and a couple active ones. but of course the "stable" problems would include renal failure, A-fib on coumadin, and terrible diabetes. So of course each patient like this had 500 details a day to followup on which include massive social work issues. As an intern, handled 8-10 of these patients a day. Who has time to cousel patients and families on their disease? Who wants to go home and read after a day like that?

I'm almost positive that everyone would rather have a patient workload they could do thoroughly and well, vs "churning" them out as fast as possible, hoping that something big didn't slip by.

And of course, one of the things I think is majorly wrong about residency is that it doesn't mimic the attending's life enough. There is a huge emphasis on inpatient care in most residency programs but very little outpatient. Whereas most attendings spend a lot more time outpatient and very little time inpatient. Also, we tend to ignore insurance issues and billing as residents, but these are huge concerns in real life and actually do drive a lot of patient care.

This rant turned out longer than I planned. Anyway, in short I think: Healthcare needs to become way more efficient. Reduce workload (which doesn't necessarily mean reducing hours) to increase resident sanity and patient safety. Stop forcing the physician to be the central clearinghouse for mountains of inanity. Shorten residency/med school by increasing efficiency which will also increase physicians and reduce healthcare costs.

 

[elwademd]

Also, insurance companies as well are insane about the things that need a doctor's prescription. Like a shower stool? A cane? If a patient came to a doctor's office and said they need something like that, no doctor is going to say no. So why does insurance require a doctor's signature? It's insanity.

your patient needs the prescription so that the shower stool/cane is cheaper/free than without the prescription. whether or not that's a good use of financial resources is in some ways a separate issue, and depends on the perspective.

and yes, in the outpatient setting, its the same way (needing a prescription of durable medical goods, which are covered under medicare).

 

[radonc]

I like the idea but not the lengthening of the residency. Its not like the extra year is needed to make up for the hours reduced. You are doing pretty much the same damn thing for 3 years in IM no need for a 4th

seems like 10 years ago, people put in 100 hrs/week...now its going down to 56? maybe IM should be 5 years, not 3....

 

[radonc]

if you guys want a 40-50 hours work week during residency, go into derm or radonc (if you can get in).

 

[tr]

I could deal with the lazy specialties a lot better if, when I called the consult, they would just man up and say, "You know what? I'm more interested in getting home to watch Gossip Girl than I am in helping out this patient."

Amen. I am so sick of the blocking. I called the Hand fellow last night for this dude who had sliced through two fingers with a food processor, and the fellow was trying to convince me - without seeing the patient or the Xray - that the patient didn't need a hand surgeon and the ER should be able to sew him up just fine.

 

[3dtp]

Came across this while looking for something else. Has some interesting comments on EMR./efficiencies and paradigms of future working conditions.

http://www.aps-spr.org/Public_Policy/2006_Docs/pedsacadsoc0406.pdf

I was particularly impressed with a statistic on slide 31. It lists the amount of time "attending a patient" in each of the major specialties.

 

[8744]

I used to really get hot about the topic of sleep deprivation but now that it has been almost a year since I have done call (and will never do it again) I have cooled down a little. But I have to say that as to whether or not sleep deprivation is more harmful to patients than increased handoffs...I just don't care. I want to sleep every night (or day, I mean) and to do otherwise is both painful and harmful to our health and the patients are just going to have to live with a little bit of increased risk.

Screw 'em. If we go down the road that the patient's welfare trumps every other consideration we would never leave the hospital but instead hole up in some ratty call room, surviving on stale coffee and occasional cat-naps, perpetually on tenter-hooks about every little detail of the patient which we are too altruistic to let anybody else handle.

"Patient Care" is a blunt instrument used to shame residents into accepting working conditions that would be considered war crimes in most of the civilized world.

 

[AwesomO]

i take ofense, i gotta get home for flavor of love or ufc ultimate fighter, not gossip girl!

You're not helping your case

 

[Faebinder]

Amen. I am so sick of the blocking. I called the Hand fellow last night for this dude who had sliced through two fingers with a food processor, and the fellow was trying to convince me - without seeing the patient or the Xray - that the patient didn't need a hand surgeon and the ER should be able to sew him up just fine.

I rotated with a hand surgeon for 4 weeks during plastic surgery... I dont blame them at all. Those hand surgeries at midnight are usually:

1) 4-6 hours long, very intense and you usually end up using the microscope to look at the arteries you are suturing. If you have scheduled surgeries the next days.. they are shot!

2) Pay very little.. especially that many workers are illegal with no insurance. Despite the very low reimburisement, the lawsuit level is still high. And of course if you were working all night on this surgery that means your scheduled surgeries either will be cancelled or run very late. You're losing $$$ big time.

3) Many times the outcome remains dismal.

 

[Faebinder]

Side comment, if residency years were to increase and more time off is given, people can always moonlight to compensate. It's up to the person to do it. They will know how much they can and cannot do.

 

[NotAProgDirector]

Amen. I am so sick of the blocking. I called the Hand fellow last night for this dude who had sliced through two fingers with a food processor, and the fellow was trying to convince me - without seeing the patient or the Xray - that the patient didn't need a hand surgeon and the ER should be able to sew him up just fine.

Side comment: I want to know how someone cut their fingers off with a food processor. Mine won't run unless you have the top locked on, all protectors in place, etc. I guess you could push the food down the chute with your hands, but boy that would be dumb.

 

[Winged Scapula]

Side comment:

tr is a psych resident so who knows what her patients are up to or sticking their fingers into.

I'd love to know where she is, so if it were <ahem> a bit less urban than other places I could make some snide remarks about hillbillys modifying their food processors (or even worse, that a hillbilly food processor is your snaggletoothed cousin)! "You know you're a redneck when..."

 

[dpmd]

Aprogdirector, your faith in humanity is cute. People have been know to disable all sorts of protective mechanisms in industrial and home tools in the interest of saving a little time in operation.

 

[Winged Scapula]

Your faith in humanity is cute. People have been know to disable all sorts of protective mechanisms in industrial and home tools in the interest of saving a little time in operation.

I am guilty of that...I always break the "protective" sheaths off needles because I find them more cumbersome to use.

Remind me of that when I stick myself one of these days.

 

[dpmd]

I am guilty of that...I always break the "protective" sheaths off needles because I find them more cumbersome to use.

Remind me of that when I stick myself one of these days.

I do that too, usually when I need a little more length since the kind they have here shorten the usable length by a centimeter or two

 

[maxbaner]

There was a neat segment about sleep on 60 minutes a few days back check it out..

Part 1:
http://www.cbsnews.com/sections/i_v...nel=/sections/60minutes/videoplayer3415.shtml

Part 2:

http://www.cbsnews.com/sections/i_v...nel=/sections/60minutes/videoplayer3415.shtml

 

[DrDre311]

Side comment: I want to know how someone cut their fingers off with a food processor. Mine won't run unless you have the top locked on, all protectors in place, etc. I guess you could push the food down the chute with your hands, but boy that would be dumb.

You'd be shocked how many people manage to mangle their hands with seemingly innocuous objects. Most plastics/ortho types hate hand call for this reason.

 

[StealthNerd]

I used to really get hot about the topic of sleep deprivation but now that it has been almost a year since I have done call (and will never do it again) I have cooled down a little. But I have to say that as to whether or not sleep deprivation is more harmful to patients than increased handoffs...I just don't care. I want to sleep every night (or day, I mean) and to do otherwise is both painful and harmful to our health and the patients are just going to have to live with a little bit of increased risk.

Screw 'em. If we go down the road that the patient's welfare trumps every other consideration we would never leave the hospital but instead hole up in some ratty call room, surviving on stale coffee and occasional cat-naps, perpetually on tenter-hooks about every little detail of the patient which we are too altruistic to let anybody else handle.

"Patient Care" is a blunt instrument used to shame residents into accepting working conditions that would be considered war crimes in most of the civilized world.

And Panda strikes again! As far as I'm concerned, this is the coup de grâce point that ends the sleep deprivation argument. The concern for the welfare of the patients ends where the safety, health, and welfare of the physician begins.