56 Hour Week Is Coming

[sirus_virus]

If we decrease the 80 hour work week further, one of the following has to happen:

1. We decide that less training is OK, and leave everything else alone.
2. We increase the length of training to offset the decrease in hours.
3. We switch to a true "competency" based system -- i.e. your training is as long as it needs to be. In order to do this, we would need some very reliable metric of competency, else it leaves PD's in a truly horrific role (for everyone).
4. We average the hours out. In my program, there are busy months which tend to run 70-75hrs per week, and then there are Electives which are 7:30AM - 4-5PM no nights or weekends. If we were to switch to a 56 hour week, I'd probably have to move some additional work (i.e. weekend coverage) into the electives. I personally think this would be a tragedy.
5. We hire more people. Not going to happen, Medicare can't afford it.
6. We get "more efficient". Might happen in the long run.

I think the interesting question for debate (lost in some of the dialog above) is whether residents should work 24 hour shifts. We could switch to an 16 hour shift system that is still 80 hrs per week. Why should residents work 24 hours?

1. Cool stuff happens at night, and residents are at the forefront of that "cool stuff"
2. Residents get more autonomy at night, which is a good learning experience.
3. Working night shifts means missing out on day activities -- conferences, etc.
4. Working on a team (Resident/Interns/Medical student) taking call together is a huge bonding event. It gets lost in a shift based system. For example, on Internal Medicine rotations medical students usually admit a patient in the evening, then "digest" it, then present to the resident usually after 11PM once the team has capped. In a shift based system, this all gets rushed and you can't let the student go and learn at their own pace, since you need to get out at shift's end.
5. A shift based system is inherently less "coverage efficient" than a call based system. In my calculations, you usually end up about 15% short in trying to fill all the shifts with the same people in an overnight call schedule.

Why shouldn't residents work 24 hour shifts?

1. Many, many objective studies in various fields demonstrate that critical thinking skills, reaction times, and attention all deteriorate with both acute and chronic sleep deprivation.
2. Whether or not this translates to poor patient outcomes remains unclear. If so, the effect will be small. Regardless, there are studies showing the chances of a post call resident being involved in an MVA are much higher post call, clearly a bad outcome.
3. Some people think they can do fine post call. Honestly, I thought I was one of those people. Now, I am pretty sure it's not true, much like people who think they can drive "just fine" after having a few drinks. You just can't see it when you're the one "driving".

In a maximum 16 hour shift based system, residents will still work night shifts, so you would still get night exposure. In those surgical specialties where either 1) a certain procedure is very rare and you might miss it because of duty hours or 2) a procedure is so long that it would cause a violation, exceptions would be made. Presumably, both of these events are relatively rare.

Many of the above "pluses" of a 24 hour call based system can theoretically be designed into a shift based system, but there is an inherent risk that these good things will be lost, either through neglect, lack of resources, or competing priorities. Or, some may only be available in a 24 hour call system and really not work in a shift based system.

I am an IM PD so I really have no idea about running a surgical program. So, I have a question for Dr. Dre (or anyone who would like to chime in). Assuming that the hour limit stays at 80/week, could you realistically design your surgical residency to limit work to 16 hour shifts, or would that kill surgical training? Again, there could be rare exceptions for exceptional cases.

Good post. No need to reduce work load, lets just eliminate sleep deprivation. 16 hours sounds reasonable. 30 hours? not so much. BTW, dont worry about surgery residents, they seem to like their gig, and frankly I think they need to be excluded from the 80 hour limit too, so they can see more cases, which seems to be their major craving.

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[Blade28]

I feel that many of the workhour restrictions seem rather arbitrarily chosen with regards to procedure-heavy fields (like surgery). In other fields you can try to pare down rounding, become more "efficient" in ward/ICU tasks, cut down on conferences, etc. In surgery, you can't just "hurry up" your operations. You still want to perform the same number of cases as the previous residents so that you'll be equally competent when you're done with training and are ready to go out as an attending. You can't cut down on the number of cases or rush them simply to meet some arbitrarily-chosen time deadline.

Limiting ALL days, even "call" days, to 16 hours max, would fail miserably in a procedure-heavy field, IMHO.

 

[CambieMD]

One does not equal the other here. The time for focusing on book-learning is over when you hit residency. Use it as a supplement but that's not where the most important parts of your education come from.

Resident physicians become proficient by seeing patients and performing procedures. Why should a resident physician work less in training than he/she will work once the get out into the real world. This change will be more costly,also.

CambieMD

 

[DrDawg]

aProgDirector, many poster keep mentioning post call resident getting in more care accidents. You mention this in two of your pros for further reducing hours. Whenever I'm to tired to drive after a shift I sleep in the call room. After 2 to 4 hours I get up and go home.

As to your other question, I don't think anyone on here is a surgery PD. However, some may argue that the number of cases we need to do should increase. In addition to open surgery, lap surgery, and endoscopy (required numbers recently increased), we soon will have to learn NOTES. Many procedures that were common 15 years ago are rarely done, but may need to be preformed for complications. Further reductions in hours, at least in surgery, would appear to have a negative impact.

 

[Winged Scapula]

As to your other question, I don't think anyone on here is a surgery PD. However, some may argue that the number of cases we need to do should increase.

The number of cases has increased. The American Board of Surgery has, over the last year, increased the minimum number of cases required to be board eligible by 50%; of course most residents still exceed this minimum by a great deal but in some programs there may be difficulties in meeting these numbers, especially if hours in the hospital are decreased.

 

[orientedtoself]

most practicing physicians do not work eighty hours per week. some hard core individuals do, but on average, general surgeons work 60 hours per week and internists work 57 hours per week. see attached table from a jama article from 2003.

Resident physicians become proficient by seeing patients and performing procedures. Why should a resident physician work less in training than he/she will work once the get out into the real world. This change will be more costly,also.

CambieMD

 

[Blade28]

That's from 2003. In many fields (e.g. Surgery) attendings are now working more hours since their residents are working fewer hours (due to the 80-hour workweek).

ACGME and ACS surveys have consistently shown that attendings are picking up more of the workload that their residents used to do.

 

[deleted109597]

I feel that many of the workhour restrictions seem rather arbitrarily chosen with regards to procedure-heavy fields (like surgery). In other fields you can try to pare down rounding, become more "efficient" in ward/ICU tasks, cut down on conferences, etc. In surgery, you can't just "hurry up" your operations.

You know, that's true, but at the same time, when I had to show up at 330 am because the trauma census was so high that it took 3 hours to see them, so that we could pre-round with the chief at 630, conference at 7, cases all day, and no actual rounding (or teaching) with the attending because you couldn't leave a case to go round, then what is the point of me going in at 330? Did I learn anything that early? Did I change management of the patients that early?
This is why lots of surgery programs have NP/PAs now to do the floor work, because residency is time to learn to operate, not to learn to floor round.

 

[Blade28]

Definitely agree that we need to hire more midlevels to help out with some of the daily scut/paperwork. Some of it is necessary for teaching purposes, but when you're admitting and discharging 6-8 people a day? Lots of wasted time.

On our busy trauma months we have anywhere from 35-55 patients to see every morning...so painful.

 

[bcat85]

Paying your dues is a necessity for success in most things in life, not just medicine. It isn't something I need data to prove. If you don't believe me, then don't pay your dues.

To be honest, I'm not far enough into medical education to have an opinion either way... but saying residents should suffer because the doctors before him/her suffered is a pretty sadistic worldview. That would be like going to GM and saying "you know... it is ridiculous to let these workers use all these machines to build cars... they should do it by HAND like they did in the good ole' days!" c'mon

 

[Raidergate]

To be honest, I'm not far enough into medical education to have an opinion either way... but saying residents should suffer because the doctors before him/her suffered is a pretty sadistic worldview. That would be like going to GM and saying "you know... it is ridiculous to let these workers use all these machines to build cars... they should do it by HAND like they did in the good ole' days!" c'mon

You're going far with that attitude, let me tell you.

 

[bcat85]

You're going far with that attitude, let me tell you.

You're right man... not wanting to undergo chronic sleep deprivation is going to seriously hinder my ability to move up in the world. I'm not suggesting that I wouldn't do it if I had no other choice (because I certainly would), but I don't see the logic in torturing people because the people before you were tortured.

 

[DrDre311]

To be honest, I'm not far enough into medical education to have an opinion either way... but saying residents should suffer because the doctors before him/her suffered is a pretty sadistic worldview. That would be like going to GM and saying "you know... it is ridiculous to let these workers use all these machines to build cars... they should do it by HAND like they did in the good ole' days!" c'mon

I'm not advocating sleep deprivation, and unfortunately suffering (in addition to being subjective) is something that sometimes comes with the territory.

What I'm advocating is doing your job sans whining and paying attention to the people who came before you instead of throwing the baby out with the bathwater.

Whether or not a massive restructuring of residency hours would or wouldn't work is a moot point because the structural change to the entire healthcare system and the accompanying increased manpower and finances such a change would require are so massive (to a bloated, inefficient system with so much inertia) that it borders on impossibility from a purely logistical standpoint.

 

[bcat85]

I'm not advocating sleep deprivation, and unfortunately suffering (in addition to being subjective) is something that sometimes comes with the territory.

What I'm advocating is doing your job sans whining and paying attention to the people who came before you instead of throwing the baby out with the bathwater.

Whether or not a massive restructuring of residency hours would or wouldn't work is a moot point because the structural change to the entire healthcare system and the accompanying increased manpower and finances such a change would require are so massive (to a bloated, inefficient system with so much inertia) that it borders on impossibility from a purely logistical standpoint.

I absolutely agree with that.

 

[toothless rufus]

So, the 56 hour limit is definitely going to happen? Will this effect third and fourth year med students?

 

[radonc]

So, the 56 hour limit is definitely going to happen? Will this effect third and fourth year med students?

No and No.

 

[jdh71]

The other thing you all have to realize is that times have changed since your crusty old-school attendings were residents. Nowadays, we routinely get patients who are so sick and carry so many competing comorbidities that they could not have been imagined forty years ago in the so-called Golden Age of medical training when residents knew their place and nobody ever made a mistake.

At least twice a night I get a patient with congestive heart failure, end-stage renal disease on hemodialyis, emphysema, coronary artery disease with a distant triple vessel bypass and four stents, atrial fibrillation with a pacer-defibrillator, diabetes, really bad peripheral vascular disease, alzheimer's, distant stroke with dysphagia and dysarthria, MRSA, bed sores, cancer of one flavor or another who has had resections, amputations, colostomies, feeding tubes, every organ out that can be removed and some that shouldn't, and who is on thirty different medications but who is nonetheless stable and whose family expects them to survive their hospital stay to squeeze a few more months out of that crappy thing called Their Life . . .

This is awesome. And so true. My father, who did his internship in '77, told me that back when he did his residency, all you really did was hang a bag of saline and hope for the best - Ha!

 

[jdh71]

True enough. If you're looking for a solid source on why physicians shouldn't work too hard, there's really no better place to start than an EM resident.

Yes...I think we forget that none of these diseases existed back then. Nobody smoked or drank, nobody was fat, everybody exercised and everything was easier on those jackass old school guys--they're just picking on us.

Gotta love the sarcasm. Sarcasm?! Nooooooooo?! What made you think that ?!

But it's the underlying attitude that is bull****, but then it's kind of easy to have a cavalier attitude about all of these co-morbidities and the work it takes to deal with them when these patients will merely get passed off to IM when you're done cutting, for "medical management" . . . hell some places just admit these patients to IM now, and surgery consults . . . probably better for everyone involved really

 

[jdh71]

As mentioned somewhere in this whole mess, it's not so much about total hours worked as much as it is about total hours work continuously. The literature is pretty clear about the decline in cognitive abilities beyond a certain time period, and no, you don't actually ever "get used to it" (even if that is what you have to tell yourself). Setting an upper limit to work hours does seem a bit short sighted, and as I can tell frustrating to my surgical colleagues, and as pointed out the lowering of work hours has not resulted in less adverse patient outcomes (although, to be quite honest the study has one HUGE confound . . . namely it assumes accurate and honest reporting and cataloging of work hours . . . because here's the rub: if residents were still actually working the traditional "100" but then reporting 80 or less, one would not expect different outcomes, would one? Hmmmm).

If you got rid of an 80 hour week cap and allowed for no more than 16 hours on at a time (unless of course there are allowable and excusable extenuating circumstances such as a long and or rare surgical procedure), assuming one day off in 7, you could actually work 96 hours per week - it wouldn't give you a ton of time to sleep, but would probably guarantee 6 hours per night (with an hour to eat and an hour to get up in the morning - which was about what I did during my surgical clerkship in med school between clinical duties, lectures, and reading. It wasn't a "fun" 6 weeks on general surgery, but I know that kind of work hours is at least feasible for that long, and I could have gone longer). Not much fun I admit, but I doubt every month would be like that.

 

[DrDre311]

Gotta love the sarcasm. Sarcasm?! Nooooooooo?! What made you think that ?!

But it's the underlying attitude that is bull****, but then it's kind of easy to have a cavalier attitude about all of these co-morbidities and the work it takes to deal with them when these patients will merely get passed off to IM when you're done cutting, for "medical management" . . . hell some places just admit these patients to IM now, and surgery consults . . . probably better for everyone involved really

This just doesn't happen where I am, and it didn't happen when I was a med student either. We consult medicine only for complex issues not related to an operation. If any surgical service admits the patient and the patient needs an operation, they're ours unless a new, unrelated, complex medical issue arises after surgery and even then we consult medicine instead of turfing the patient--no one cuts and then dumps the patient.

If you take the time to read the intervening posts between the ones you quoted and your post, everything you've just said has been postulated, debated, and debated again ad nauseam.

 

[jdh71]

This just doesn't happen where I am, and it didn't happen when I was a med student either. We consult medicine only for complex issues not related to an operation. If any surgical service admits the patient and the patient needs an operation, they're ours unless a new, unrelated, complex medical issue arises after surgery and even then we consult medicine instead of turfing the patient--no one cuts and then dumps the patient.

Well, that is a nice change, is it not?

If you take the time to read the intervening posts between the ones you quoted and your post, everything you've just said has been postulated, debated, and debated again ad nauseam.

I'm sure, if you say so, it has, but I actually did not have the time to do so I posted anyway. The internet is F-ing magic like that

 

[DrDre311]

Well, that is a nice change, is it not?



I'm sure, if you say so, it has, but I actually am too lazy to think about what I'm saying before I do it so I posted anyway. The internet is F-ing magic like that

It isn't a change. You're propagating a specialty-specific stereotype which means you haven't been around a lot of surgery or surgeons.

You want to consult me to rule out compartment syndrome on every infiltrated peripheral line, or for pressure sores on all your unit patients that you neglected to take the proper precautions on? Fine, that's my job. I don't feel bad about asking cardiology to take a look at a patient with a complex arrhythmia or asking medicine to help out with progressive systemic sclerosis if I may need to operate on that patient. Big difference between that and dumping some old gomer who's several weeks/months postop but can't go home because of placement issues--unfortunately I can't do that.

 

[jdh71]

It isn't a change. You're propagating a specialty-specific stereotype which means you haven't been around a lot of surgery or surgeons.

You want to consult me to rule out compartment syndrome on every infiltrated peripheral line, or for pressure sores on all your unit patients that you neglected to take the proper precautions on? Fine, that's my job. I don't feel bad about asking cardiology to take a look at a patient with a complex arrhythmia or asking medicine to help out with progressive systemic sclerosis if I may need to operate on that patient. Big difference between that and dumping some old gomer who's several weeks/months postop but can't go home because of placement issues--unfortunately I can't do that.

Wait. What? Are you actually all buttsore by my comment?

 

[Faebinder]

This just doesn't happen where I am, and it didn't happen when I was a med student either. We consult medicine only for complex issues not related to an operation. If any surgical service admits the patient and the patient needs an operation, they're ours unless a new, unrelated, complex medical issue arises after surgery and even then we consult medicine instead of turfing the patient--no one cuts and then dumps the patient.

If you take the time to read the intervening posts between the ones you quoted and your post, everything you've just said has been postulated, debated, and debated again ad nauseam.

It happened where I was at least once per 2 weeks on the subspecialties (Vascular/Colorectal, etc). Trauma is the ones that usually dont let their patient get admitted to other services and them as consults, for obvious reasons. The idea is that surgeons dont get paid for rounding on patients postop for 90 days... so it's better to have a team to do it. Also many insurance companies demanded from the programs in my previous university to admit to a certain hospitalist for them basically to keep an eye on costs and minimize them.

 

[DrDre311]

Wait. What? Are you actually all buttsore by my comment?

I do take care of a lot of butt sores, but I don't sit down enough to actually get one.

 

[jdh71]

I do take care of a lot of butt sores, but I don't sit down enough to actually get one.

good

 

[Tired]

You want to consult me to rule out compartment syndrome on every infiltrated peripheral line, or for pressure sores on all your unit patients that you neglected to take the proper precautions on? Fine, that's my job. I don't feel bad about asking cardiology to take a look at a patient with a complex arrhythmia or asking medicine to help out with progressive systemic sclerosis if I may need to operate on that patient. Big difference between that and dumping some old gomer who's several weeks/months postop but can't go home because of placement issues--unfortunately I can't do that.

There's a pretty big double standard when it comes to consults in my hospital. Like everyone else, we will complain to each other about the lame consults. But (by directive of our senior attendings) we never express frustration or reluctance to the consulting teams.

Medicine and Cardiology, on the other hand, frequently bitch and moan at us directly when we ask for help.

Some of my favorite highlights from this year:

- Cards consult for chest pain with elevated troponins --> "I'm sick of these bullsh*t consults, you know damn well it's just cardiac strain. I have better things to do than bedside ECHOs on every one of your stupid ICU patients."

- Preop consult for woman in 80s with afib and HR 110s --> "We're not seeing this patient, she's totally stable on her current meds. If she decompensates after surgery, call us then."

- Postop CT consult for BP 180/90 on 30yo patient previously on 5-drug regimen. "Any competent doctor should be able to manage hypertension."

 

[DrDre311]

There's a pretty big double standard when it comes to consults in my hospital. Like everyone else, we will complain to each other about the lame consults. But (by directive of our senior attendings) we never express frustration or reluctance to the consulting teams.

Medicine and Cardiology, on the other hand, frequently bitch and moan at us directly when we ask for help.

Some of my favorite highlights from this year:

- Cards consult for chest pain with elevated troponins --> "I'm sick of these bullsh*t consults, you know damn well it's just cardiac strain. I have better things to do than bedside ECHOs on every one of your stupid ICU patients."

- Preop consult for woman in 80s with afib and HR 110s --> "We're not seeing this patient, she's totally stable on her current meds. If she decompensates after surgery, call us then."

- Postop CT consult for BP 180/90 on 30yo patient previously on 5-drug regimen. "Any competent doctor should be able to manage hypertension."

That double standard exists at every hospital I've ever worked/rotated at. It's been my experience that medicine residents get pissed off about every admission/consult for their service, warranted or not.

 

[Apollyon]

That double standard exists at every hospital I've ever worked/rotated at. It's been my experience that medicine residents get pissed off about every admission/consult for their service, warranted or not.

A common Duke über-brainy response to ANY admission was "this patient isn't right for internal medicine". Huh?

 

[Tired]

A common Duke über-brainy response to ANY admission was "this patient isn't right for internal medicine". Huh?

Sounds like a good dodge technique to use with the ER.

We usually use, "Admit the patient to medicine, and if they need us they can consult us."

 

[bcat85]

So, the 56 hour limit is definitely going to happen? Will this effect third and fourth year med students?

What about those of us who are in our 1st and 2nd years of medical school?

Wait. What? Are you actually all buttsore by my comment?

That's superfunny

 

[midwesterner]

Originally Posted by Panda Bear
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.

Wow, both so beautifully said. There needs to be more opinions like that among those making the rules, and not just some board that seems to think the ability to sleep every night is some optional and luxurious thing. I'm seriously thinking about not going to med school because of these hours (because I've had sleep issues before and was miserable), yet I think I'd be a great doctor without any troubles once practicing (both parents are docs with schedules that allow uninterrupted nightly sleep). The first two years don't scare me at all because I can juggle my own time fine, but I don't want someone dictating to me that I can't sleep every 4th night.

Number of hours are less important to me than a full night's sleep. I have no problems doing an extra year or even two of residency if that's deemed necessary, though for FP I think that's overkill, especially as NPs are having a very similar scope of practice. I think that would improve, not hinder, my ability to learn as a resident and my ability to care for patients. Doctors tell patients about the dangers of sleep deprivation yet deny it applies to them? It's even more than sleep too: it's also about a balanced life- time to exercise, eat well, spend time with family and friends, and etc. Or are we not human anymore?

I think the superhuman mentality that residents can do without all that is also what makes doctors arrogant, because they're just so much tougher than everybody else and they endured/triumphed over so much, so they feel like they've earned it. So maybe selecting for only those people is actually a disservice to medicine, especially in specialties that would benefit from a better bedside manner. Maybe it's time to at least ALLOW future doctors to practice what they will preach and live a healthy lifestyle if they want one and want to choose a specialty that leaves room for one.

I would have no problems with letting people moonlight or even do a fast-track residency with as many hours as they can handle. Everybody's different and can handle different things. It might be that the people who are really adamant about working 80-100+ hours really are physically and mentally able to handle that and don't have any concerns/desire to be with their family. This doesn't make them innately more qualified to be a doctor, but could mean they could become one quicker or make more money while doing it. That's fair.

Once priorities are established, then implementation can be discussed around that. As is, it doesn't seem the ACGME has really agreed that resident sleep is a top priority, so they're not so motivated to work through challenges it raises.