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I hate 80hrs

Discussion in 'Surgery and Surgical Subspecialties' started by ESU_MD, Sep 4, 2006.

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  1. ESU_MD

    ESU_MD Old School

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    I am getting to the point where I think the "80hr workweek" is becoming a problem and making surgery residents less accountable. I don't think we should go back to q2 call, but its getting to the point in our program where things look like they can spiral out of control.

    I am tired of attendings telling me to "go home" What happened to the atta-boy for staying late and taking care of your patients?

    I am tired of junior residents signing out things they should stay and do- like the direct admission they have been waiting for all day, that finally shows up at 4:59pm. This is called DUMPING, or screwing over your colleagues just so you can leave on time and go to the movies!

    God forbid a junior stays late, then they think they can come in 10hrs later automatically- in other words using it as an excuse to miss morning rounds. which screws the team over. Or maybe they just want to miss rounds because they are scared to be pimped! take it like all of have took it since Halsted.

    Did I mention juniors scrubbing out of cases at 5pm to be relieved by the nite float?

    If I had more motivation I would organize a grassroot effort to at the very least make a statement AGAINST the workhour restriction. I understand that if we don't follow these rules our programs can be shut down, fined etc.. but it still doesnt make it right.

    We should not sit by idle and watch surgicical residency become restricted and watered down. Surgery is a way of life- not lifestyle like ER.

    As surgeons we are trained to be accountable for our actions.

    Does anyone else at least partially agree with any of this?

    ESU
  2. toxic-megacolon

    toxic-megacolon Toxic Member

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    I'm glad you're not my cheif.

    But on a serious note, although continuity of care is improved by longer work hours, at what time do resident mistakes/fatigue cancel out that benefit for the patients?
  3. Amy

    Amy Animal Lover

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    I don't think the problems you're listing have to do with the work hour restrictions... sounds more like lazy/unmotivated residents using the rules as an excuse. I would NEVER scrub out of a case because of the clock. Maybe you need to make it more clear to your junior what their responsibilities are, and what good patient care is. They can always leave a little early on days that are slow to keep their hours legal.
  4. boston

    boston Junior Member

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    I am with you bro. To the previous poster, I don't think the examples ESU gives are unreasonable expectations. A direct admit that comes in at 4:59 should be tucked in by the primary service, not the nightfloat team. Heck, even if sign out is 5pm and the pt arrives just after you finish sign out at 5:05, the primary service (who will be taking care of the pt) should take care of it. Sure, it's not written in the rules, but it's unwritten courtesy. Sometimes you can tag-team the end-of-the-day admission with the night float person.

    I have never ever heard of missing rounds because you stayed late the night before, unless the chief explicitly gives the ok. That just screws over the rest of your team. The way I look at it, we're all in this together -- divide up the pain equally.

    That's not to say the whole team should stick around when nothing is going on. When it's quiet, I take the opportunity to send my juniors home early. But if we're getting killed, I expect everyone to help out equally.

    80 hours is some arbitrary number -- I am not aware of any clinical evidence that it reduces medical error and morbidity. Why not 70 or 90? Personally, my impression is that more errors result from being unfamiliar with the pt than from fatigue. Don't get me wrong, it is a good idea to reduce resident fatigue and make more efficient use of our time in residency. I am all for that. But the 80 hours rule is an imperfect solution, though a step in the right direction -- as long as you don't apply blindly without regard to clinical circumstances.
  5. kaos

    kaos Web Crawler

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    Wow, I didn't know people actually did this and got away with it.
  6. Pilot Doc

    Pilot Doc SDN Angel Moderator Emeritus

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    Just shows the bizarre nature of the system. My program is very compliant, but the entire institution - from the GME office - has determined that the 10 hours off rule is merely a recommendation, because the requirement uses the word "should" instead of shall or must.
  7. thackl

    thackl 1K Member

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    Considering how much more competitive surgery has become since the 80hr wk, I would say most are liking it.
  8. dawg44

    dawg44 Senior Member

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    We haven't had a problem because anyone that acts like that won't be in our program very long. There is Karma in medicine too. Mentioning the 80 hour work week is a good way to never get to use the scalpel in our residency for a long long time.
  9. dawg44

    dawg44 Senior Member

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    That is the most shocking to me. One way to cure that is to let them know they probably won't need to scrub when the come back either.
  10. Winged Scapula

    Winged Scapula Cougariffic! Administrator Lifetime Donor

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    Wow...some pretty impressive acts you've listed there. That would have NEVER flown in my residency program.

    Of course, the talk always is that the current crop of junior residents, who never knew life before the 80 hrs restriction, somehow lack a strong work ethic. I cannot agree with this across the board, as I've seen young residents complain bitterly if they were in the hospital overnight and not home by 8 am, and I've seen others (at the same level of training) who wouldn't leave even if you tried to force them.

    IMHO:

    1) it is unacceptable to sign out things like removing drains, chest tubes, placing lines, etc. unless there is a reason that it needs to be done late at night. If you are signing it out because it is now 5 pm (or whenever you typically do sign out [my residency never had a standard time]) and just didn't get around to the work, or the H&P on the direct admit, that's a problem and my residents would have heard about it from me.

    I know what its like to be dead tired and wait all day for the direct admit that was supposed to show at noon, but now its 6 pm and you just wanna go home, and guess who shows up on the floor? But as noted in posts above, its common courtesy. The nightfloat (if you have one) or cross coverage resident has plenty else to do and shouldn't be saddled with anything extra other than covering pages overnight (barring the unexpected).

    2) it is unacceptable to scrub out of a case; you start it, you finish it. If its a 13 hr disaster and you're post call...ok, then I'd make an exception, or else tell you to stay out of the room. But most cases, especially for the juniors, aren't these tour de forces and there's no excuse.

    3) I've never heard of people staying late and then coming in 10 hrs later...of course, it is the rule, but missing rounds was a no-go in my book.

    Most institutions TRY and follow the rules. And most residents are compliant and realize that the work has to be done and it should be divided fairly. However, when people start watching the clock REGULARLY (we're not talking about on your birthday, or when you have special plans), adhering to the rules without common sense for your fellow residents or patients, it really destroys the fabric of residency. These residents you mention wouldn't have lasted long in my program either...heck, I was berated by the Chief for complaining that I was kept until 1030 pm on my birthday as an intern (before the work hour restrictions), missing some special plans all the while doing nothing that was especially educational.
  11. RichL025

    RichL025 Senior Member

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    Yes, this IS the rule.

    And your (my) program can be de-credentialled for not following it.

    What _I_ hate about the 80-hr workweek is that it makes me compromise my integrity when filling out those questionaires.
  12. Pilot Doc

    Pilot Doc SDN Angel Moderator Emeritus

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    That's actually open to interpretation. From the ACGME:

    b. Duty hours must be limited to 80 hours per week, averaged over a
    four-week period, inclusive of all in-house call activities.

    c. Residents must be provided with 1 day in 7 free from all
    educational and clinical responsibilities, averaged over a 4-week
    period, inclusive of call. One day is defined as one continuous 24-
    hour period free from all clinical, educational, and administrative
    activities.

    d. Adequate time for rest and personal activities must be provided.
    This should consist of a 10 hour time period provided between all
    daily duty periods and after in-house call.

    Note the use of must and should. My program, which is a stickler for most things, has decided that the 10 hour limit is just a recommendation.
  13. Winged Scapula

    Winged Scapula Cougariffic! Administrator Lifetime Donor

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    You should not be compromising your integrity. While my program may have violated the rules or recommendations (which is what the 10 hrs really is), I never lied about my hours, nor was I asked to. Hence, they are getting site visited again. That bothers me, but I'm not the only one who was honest...there has to be a sea change, not only at the resident level (where they need to realize that sometimes the rules have to be broken; its a pattern of abuse that is the problem), but most importantly at the attending and administration level. Until steps are in place to compensate for the work that must be done without violating the residency work hour restrictions (ie, hiring NPs, PAs, using nurse assists in the OR, scheduling fewer cases when residents can't cover them etc.), these problems will continue to exist because the people in power allow them to.
  14. DrDawg

    DrDawg Member

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    None of that stuff happens at my program. We have an 88hr week. Sometimes we hit it, sometimes we don't. I don't think anyone tightly monitors their hours. (Although we are supposed to log them, that is just more time, and I would rather enter them all at once every month or so.) If things are quite in the morning, and you are post call go home. If not you help out. Someone will do it for you, at least they should. Sometimes your over sometimes your under. The only thing I like about the workhour restrictions is have 1 day off a week. And I would trade that for an extra week of vacation if I could.
  15. johankriek

    johankriek Removed

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    you aint kiddin' kimberli!! I did a surgical internship as a prelim and the abuse was rampant.. I was on call every third with no post call days off the whole entire year. the post call days were full days,,, like until 7 pm. it was brutal. made me hate everything and everybody... and people actually thought this was okay.. I knew something was wrong but i went along with it because everyone else did.. but looking back I wouldnt recommend it to anyone.. its a human rights violation is what it is..
  16. dawg44

    dawg44 Senior Member

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    I remember one month during my residency pre 80hr work weeks, I was on 17 times out of 31 days one month in the summer at a childrens hospital serving about a million people. At one point during that month I was on 7 days in a row. Yeah it was rough but by the time I was done with my rotation I was a fracture reduction machine. People can whine an complain about being worked too hard and learning doesn't have to be like the old days but there is absolutely no substitute for volume. That I am a firm believer in.
  17. toxic-megacolon

    toxic-megacolon Toxic Member

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    Wimp. Everyone knows you can't learn ANYTHING unless you are on call at least 15 days in a row...
  18. zinjanthropus

    zinjanthropus

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    blah blah blah
  19. dawg44

    dawg44 Senior Member

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    Looks like you are going to work as hard in your residency as you do on your posts.
  20. Apollyon

    Apollyon Screw the GST Lifetime Donor

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    OK, but you're wrong. I don't know where you get that impression.
  21. boston

    boston Junior Member

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    Thanks, that's helpful. Like I said, I don't pretend to have authoritative data (I doubt any exist), so I may be wrong. But I do get that impression, for example, from instances where the cross-cover fluid overloads a patient because they were not aware of the patient's cardiac history -- in other words, lack of familiarity. In contrast, I don't see as frequently the wrong medication or wrong dosage ordered and then given to the patient, or the chest tube placed on the wrong side because the resident was sleepy or too tired, in other words, fatigue. Anyway, this is just personal anecdote, subject to recall bias, small sample size, from a surgical residency setting (may not be generalizable), etc. I understand if you agree or disagree -- just trying to contribute to discussion.
  22. Winged Scapula

    Winged Scapula Cougariffic! Administrator Lifetime Donor

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    Likely because there are published reports that residents report most mistakes made come from inadequate supervision and lack of knowledge about the patients (ie, bad sign-out). Resident fatigue is also a factor, but in most studies, it is not the only one, nor is it the most common one listed by either residents or faculty.
  23. Apollyon

    Apollyon Screw the GST Lifetime Donor

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    I'm not usually so terse or brief in my posts, so I'm sorry - wasn't trying to antagonize.

    It's just the 'anecdote vs data' thing - although your clarification certainly is within bounds.
  24. boston

    boston Junior Member

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    that's precisely why I chose the words "personally, my impression is..." i never claimed veracity. perhaps i should have qualified it more by saying "based solely on my limited observations." anyway, sometimes it's necessary to begin a discussion with anecdotes when there is lack of tangible data or in cases where it would be difficult to implement a randomized controlled trial.
  25. Celiac Plexus

    Celiac Plexus Senior Member

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    I have to agree with dawg that there is no substitute for volume. Although I have had months where I exceeded the 80 hour mandate, it was during these times that I learned the most about patient care, and operative technique. Though I will qualify that remark by saying that my reading was severely reduced during these times, and I think this is a concern.

    My program, probably like most others, has difficulty making the 80 hrs work across the board. Some rotations just don't lend themselves to a clean 6pm sign out. But we don't dump on night float, and we never ever scrub out of cases to go home at a certain time.

    I dunno... I hear stories about programs making their residents scrub out, but somehow I just can't imagine an attending making a resident go home. That is just inconceivable to me.

    I think that these work hour limits are well-intentioned. I also think that they just don't work. I like the idea of doing less paperwork, but I don't like the idea of transferring responsibility for patient care back and forth 10-15 times a week between as many residents. It pretty much sucks in my experience.
  26. dawg44

    dawg44 Senior Member

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    What is it now? Something like 85% of ACGME programs are noncompliant. I don't think a magic wand will be waved everyone will be compliant any time soon.
  27. FACS

    FACS jolly good fellow

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    I'm happy with my work hours. I don't leave until I've finished all my work for the day and I won't cut corners just to sign out by 6pm. It's a pride thing with me. The more efficient I get, the closer I get to the official sign out time. Sure, I like to get out early but I couldn't live with myself if I compromized the quality of my work for a little bit of extra freetime. Doing right my the patients we serve is IMHO more important that sticking to a legal hour limit.

    Most of the catagoricals here are very happy with their hours. The people I hear grumbling are the prelims. And it's usually prelims who I see rushing out at six, leaving a ton of daytime crap for the nightfloat to deal with. So they don't really want to be there in the first place. Tough. They chose specialties that demand a year or two of GS. If they weren't willing to do that in good faith then they have no business taking the path they chose.

    Leaving at the "required time" and dumping on the night float is NOT acceptable.

    Fortunately no one here comes in late the next day if they go over in the evening. WTF. If I saw someone doing that I'd damn well give them a good tongue-lashing.

    BTW I'd encourage anyone on nightfloat to simply refuse to take daytime chores at signout. Dumping continues as long as it's enabled.
  28. dawg44

    dawg44 Senior Member

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    You will be very successful. That is the type of attitude that gets you into a highend residency and keeps you there. And that's exactly the kind of attitude our residents have. People forget that we are taking care of people here and the clock has nothing to do with that. It's the shift work mentality and pervasive laziness that comes with it that I'm railing against.
  29. Faebinder

    Faebinder Slow Wave Smurf

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    Indeed when I was young... I used to walk to the classes in our med school...in the thorns and snow..... barefooted... uphill... both ways...
  30. imalwayshungry

    imalwayshungry

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    I do! I hate it how they always tell you to go home!!! I mean, on one hand they tell you to be a good student and 'be the first person there and the last person to leave'. I think that some attendings still appreciate it... once i stayed in the OR until 830 two nights in a row and the attending gave me a fabulous evaluation... I think he appreciated the fact that I wanted to finish the case even though my resident told me I could go home if I wanted. But it's just frustrating - you try to demonstrate that you have a committment to patient care and that patient care comes first... but then they try to stress how important it is to go home. i just dont get it. it makes things confusing, becuase you want to do a good job and impress the residents, but then at the same time, if you DO stay, sometimes they think you're a weirdo (what psycho would want to STAY at the hospital longer than they had to?)... it makes it confusing.

    And I agree, I'm so sick of people going into surgery becuase of this 80 hour thing. I know people who have switched from fields like psych or peds into surgery... they all say that they like procedures but they dont want to work that hard...I dont agree with the way things used to be, but some of us would still do it if we had to work 120 hours a week, and the field is becoming more competitve only to welcome people who WOULD NEVER do that... I cant imagine how passionate one can be about their field if they are only doing it because now you dont have to work so hard to do it.

    I'm also sick of hearing residents complain about how much work they have to do. My residents complain about seeing patients - I'm like, um you're a doctor you fool, that's your JOB. like, they hate evaluating patients... which i understand - surgeons like to be in the OR... but the patient has to GET to the OR first... i personally get excited when someone comes to the ER if for no other reason than it means that i may get to see something cool and/or go to the operating room.


    ok, enough of my useless nonsense.
  31. Pir8DeacDoc

    Pir8DeacDoc Cerumen Extractor

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    It sounds like you're a medical student. We'll see how your attitude is when you've been at this for more than a 2 month rotation. It's easy to be on your game for a month or two at a time, what really wears you down is the month after month without any "clinic" month where you come in at 8 and leave at 5 without any call. I hope you have the same attitude when your time comes. Good luck to you!
  32. imalwayshungry

    imalwayshungry

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    i've been on surgery rotations straight since april (no clinic months). i think thats more than 2 months.

  33. Winged Scapula

    Winged Scapula Cougariffic! Administrator Lifetime Donor

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    I think perhaps the point that Pir8DeacDoc was making is that you never really know how something is until you've done it and there's a difference between being a student and being a physician with the responsibilities that entails.

    Your hours might be the same, but the responsibility for the patients, the constant stress from that responsibility and the not infrequent brow-beating from attendings, senior residents and even allied health care workers and patients, gets to you. It CAN make some people bitter and hate to see patients, even when you realize that clinic and ER visits are the source of a lot of OR action.

    No one is meaning to belittle your experiences but perhaps read the posts above from some surgical residents and attendings who say they loved the field as a student but its a whole different game doing it as a resident or attending.
  34. SLUser11

    SLUser11 CRS

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    You said that alot nicer than I would have.

    I mean, the poster even pointed out that his post was "useless nonsense."

    I can't stand the overly-enthusiastic-saying-what-I-think-they-want-me-to-say guy. I remember at a pre-interview social last year, some super-nervous "please like me!" girl made a remark like, "Yeah, all because of that STUPID 80 hour rule." Beyond my best judgment, I had to lay into her a little bit for that.
  35. Tenesma

    Tenesma Senior Member

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    I remember when they made the transition to the 80 hour work week - it felt for the first few months like a VACATION... isn't that weird? I had all this extra time to sleep, wash-up, read, relax, party... and it was funny to see all the newbies start complaining about how hard the 80 hour work week was... gosh if they only knew what it used to be like...
  36. Jonassen

    Jonassen Too pale

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    But from reading posters like dawg44 and FACS, it seems to pay off. :confused:
  37. SLUser11

    SLUser11 CRS

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    It pays off at places that I don't want to be at....with the people that I don't want to train with. BUT, that's just me.
  38. imalwayshungry

    imalwayshungry

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    first my residents complain about not having enough cases.
    then a patient shows up (who just may need an operation) and they complain about that the second they hear about it - not even having seen the patient or looked at any of the information about why they're in the ED.

    that's pretty illogical to me.

    especially when you see the residents who DONT do that, it makes the ones that do seem ridiculous.


  39. Pir8DeacDoc

    Pir8DeacDoc Cerumen Extractor

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    Thanks for clarifying my post. I would say that definitely the tension that comes with ultimate patient responsibility and making decisions is a lot harder than just watching or writing the occasional H&P.

    I guess what caught me is the same thing that caught a few others, no need to be overzealous and critique residents. It's a really tough job that I must admit I didn't have adequate respect for until I became one myself.
  40. Winged Scapula

    Winged Scapula Cougariffic! Administrator Lifetime Donor

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    Well, without belaboring the point, for most of us, its a lot less fun seeing a patient in the ER (who probably WON'T need an operation or at the very least, will require a lot of work to get to the OR) than just showing up in the OR and doing the case. Many of us don't care much for the H&P/DDx part of the job...but it is part of the job.

    Again, its pretty illogical to us for you to criticize something of which you have little real world experience.
  41. imalwayshungry

    imalwayshungry

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    the fact remains that residents and attendings are our role models. hence, it's not a good thing to complain about taking care of patients (isnt that the point of being a doctor/surgeon after all? you dont just operate and make someone else take care of your patients). it creates an environment in which the students observe patient care as being a chore. it's the exact thing they teach us NOT to do in medical school. and it only propogates the notion that surgeons only want to cut and have no interest in patient care.
    if you want to complain about having to see a bull**** consult, that's fine. just dont do it in front of your students all the time all day long, because students actually LISTEN to their residents and use them as examples of how they should be themselves.

    most of the residents that i've worked with, if they heard a med student complain about having to see a patient, they would criticize him for it, thinking that he didnt care for the learning opportunity or was just simply lazy. imagine if a student complained every single day all day long about how they had to preround, do a pre-op H&P, check up on their patients multiple times a day and said that they just want to go to the OR all day long and never see a patient that wasnt under anesthesia - you would smack them! but that attitude is learned from somewhere. it eventually seems to be the norm or a natural reflex to be pissed off when you have to see a patient.

    and it's not just surgery. i've seen it on almost every rotation i've done - even the ones where the residents definitely dont work as hard as surgery residents - they still complain. it's rare to find a resident who is truly a great role model.

    it's not that students dont appreciate how hard residents work, but at the same time, they'd kill to have your job and are working their butts off to get it, and then they hear you complain about it; it's awfully discouraging.

    i haven't heard that many surgery residents at my main institution complain like this. but the one i'm at now, which is just affiliated with our school, is full of residents who sit around and complain about patients all day long - today one of them even complained about having to go to the OR (even though she was going to get to do the whole case). after working with the residents at my home institution (who are fantastic role models), it's frustrating to hear these other residents complain constantly about how they hate their jobs and hate the patients.

    that's all i'm saying. complain all you want (lord knows that med students do it too) just keep in mind that the med students are going to model their behavior after yours... and while med school isnt the "real world", the attitudes developed in med school will most likely be carried into residency. and after all, they're going to be your interns pretty soon.



    ''
  42. tooshorttoolong

    tooshorttoolong scissor hoarder

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    Seriously??? Did you just scold residents who are currently working rediculous hours in harrowing situations with tons of pressure and no thanks for little pay? And who take time out of their day to include you in what they are doing so that you can learn? I don't even know where to start with you.
  43. solstice118

    solstice118 Member

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    Just the other day after coming off of a 30 hr call I had a med student say,

    "You get to go home? That's not fair. I was on call too last night... and I have to stay and round. No fair."

    Umm.... no. I had to set her straight.

    Just because you wake up at 5:30 am and help with patient care (which is huge don't get me wrong) doesn't mean you get to tell us you worked as hard as we did. I had two 40 hr days when I was a med student (On call and then went to a 10-12 hr whipples both times after). I was tired... but being directly responsible and being paged 10-20 X times an hour and being yelled at for doing something that you were told to do by one your seniors who are standing right there when you are getting yelled at for doing the thing they told you to do, ER consults that are not about pt care but about getting a poor soul out of their ER... Nearly ALL THE TIME... is a little more wearing than having to know 6 common etiologies of fistulas. So residents... bitch away at bull**** consults and medicine/er transfers... It's therapeutic and we do it too (transfers that is). and med students please understand that

    30 Med student hours do not equal 30 intern/resident hours... it's just different...
  44. boston

    boston Junior Member

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    Seriously, your post comes off as a bit naive and arrogant. I sort of sort of understand your point, but you should be wary of criticizing others without having been in their shoes. It is kind of analogous to telling a cancer patient, "oh quit crying and deal with it, it aint so bad... " Like you, as a student, I was as hardcore and enthusiastic about surgery as anyone. But, the difference is, I didn't feel the need to advertise it.

    you know, if you really feel that way, you could choose the high road and understand where they are coming from. your residents and attendings are human beings - no one is perfect. you could choose take a step back and consciously say to yourself, well i understand where that human behavior arises from and i won't let that influence my idealism. if you did that, that's something i would applaud you for. after all, in a hospital setting, you'll see lots of staff including doctors, nurses, techs, etc. misbehaving, treating each other rudely. just because everyone else is doing it, doesn't mean you have to.

    if you have this insight, then you could choose to overcome this "natural reflex"

    i try not to complain and vent at work. i do, however, vent to my friends outside of work. do you know why? because i understand that the fact that all of my seniors and attendings have gone through it all before and probably have had it much worse than i have. that's why i try to never complain while i am at the hospital, but especially to someone senior to me. likewise, that's why medical students shouldn't complain to their residents. i can also tell you i worked damn hard as a student on my surgery rotation and sub-i's. but i am far more tired and stressed hour-for-hour in residency. you can't even compare, because it's a whole different ballgame.

    do you think it's likely that they are uniformly all lazy whiners, or do you think that it's more likely that they are exhibiting the normal human response to an otherwise stressful situation?

    sure it would be great if we were all angels and never complained. but i want you to save this post and read it again when you are a pgy-3 in surgery. then ask yourself, if during the past 3 years you were able to hold yourself to such high standards and never utter a complaint.
  45. gunit07

    gunit07 Member

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    it seems like you actually agree with this poster...
    i think what s/he is trying to say is that: residents do work their asses off, but SOME of the ones s/he has seen complain way too much. (not all, not even most, but SOME)

    also, all this talk about not criticizing someone until you've walked in their shoes is just silly - haven't we all criticized the president? paris hilton? maurice claret? our professors? few of us have walked in their shoes. (hell, we all complain about nurses, but honestly, i have NO clue what their jobs are like seeing as how i've never had to do it myself)

    also this poster admitted that med students complain a lot too - clearly s/he understands that everyone does; i think that s/he is just tired of hearing residents complain about having to see patients while they are on duty. that's all.

    i haven't read every single post thoroughly, but i don't think s/he ever mentioned that med students work harder than residents or even equal to that (that's just be grounds for a psych consult :p). (unlike the med student mentioned in a previous post who said that it's not fair that the resident go to go home and she had to stay and round - that's pretty ridiculous, i think we'd all agree on that)

    though I have to admit that as i have gone through my (very few) years of education, i have found that the things that i stress over have changed... and now when i see a fresh med3 stressing over writing a progress note, it seems silly, but i remember back in the day when I too stressed over such silly things as well... just becuase those things dont stress me NOW, does not mean that the severity of the stress is not high for the med3 who is stressed about it. everyone at every level has thier own stresseors. a little kid stresses about learning how to poop in the toilet after all.

    and i think that this poster would probably agree with you and appreciate you seeing as how you said you try not to complain at work, but you do to your friends. i think that's the whole point of his/her post. i dont think the point is not to complain EVER (clearly, s/he is complaining about people complaining, so s/he is also guilty of complaining), but it's just the setting in which the complaining is done.

    anyways, it's clear that s/he is just working with some crappy residents right now who s/he does not admire... which seems to be in direct contrast to the surgery residents s/he has worked with in the past.

    either way, i think it's a good idea to keep the complaining down to a minimum regardless of who you are/where you work/etc WHILE you are at work... come home and complain on this forum, that's why it's here;)

    okee? let's be friends now:cool:


  46. boston

    boston Junior Member

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    fair enough -- maybe i was being a little too harsh. i did agree with the poster that perpetually complaining about getting new consults in front of the med student is not the best thing to do. in general, i think it helps team morale to keep an upbeat attitude in spite of whatever difficulties arise. but, i stand by what i said.

    perhaps i failed to make my point more clearly. my point was that complaining about consults is not always wrong. there's a distinction between appropriate and inappropriate consults. for instance, sometimes you'll find that people may dump a consult on you to save themselves the work of initiating a proper workup, so that you can do their work for them.

    a more concrete example: a medicine resident consults surgery for "dialysis access." As the consultant, i ask for more of a story, i ask "what's the indication?" the medicine resident sounds a little confused and replies, "renal failure." i am expecting he wants me to put in a bedside quenton for an acidotic, hyperkalemic, fluid overloaded, or uremic patient. actually no, this patient just has slowly worsening progressive renal failure and is pre-dialysis. he just needs an outpatient appointment to be hooked up for an av fistula or graft in the near future, not an urgent inpatient consult.

    in this situation, it's not wrong to complain about inappropriate consults because it wastes your time and energy that could be better spent taking care of patients who actually need your care.

    also, i never said you shouldn't criticize anybody else. my point was that one should be "wary" or careful about making blanket criticisms without a more complete perspective.

    bottom line, the tone of the original post to which i was responding seemed to me a little patronizing. to the original poster, my apologies if i over-interpreted the tone of your post.
  47. Winged Scapula

    Winged Scapula Cougariffic! Administrator Lifetime Donor

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    I don't think I or anyone else meant to imply that we didn't see the need or importance of seeing patients outside of the OR or just plain taking care of them without operating. This is a point I've tried to explain time and time again to those who think surgery is JUST operating. It might be the most fun, but it is only a part of the picture.

    Boston has a good spin on the issue and our take on it. Yes, it is usually inappropriate to complain, demoralize, etc. in front of the students - we do realize that many of you look up to residents and seek guidance from them. But we/they are only human and sometimes the exhaustion, frustration and rote repetition just get to you. And sometimes residents are just jack&*&* and they've always been that way. We all know the medical school and residency screening process doesn't weed out the arrogant, mean or inconsiderate SOBs.

    When you hear a complaint about a consult, especially when the resident hasn't even seen the patient, you might wonder why - as Boston noted, sometimes there are ridiculous or inappropriate consults or even more often, consults which are called by a person who knows NOTHING about the patient. I have actually been called to see a surgical consult by anither physician who did not know the patient's name, medical record number or even the specific room number. I'm as patient as the next guy, but I don't really have time to search the 6th floor for someone with a partial small bowel obstruction ("Excuse me ma'am...have you farted lately? Yes? Ok, sorry, wrong room!").

    And this is not the only time its happened...I'll give the nurses or receptionist a break when they are asked to call a consult without any information (they should know better and ask for it from the physician asking them to call, but sometimes they don't), but its insulting to me to hear from another physician (its often the intern) who wants me to urgently see their patient but doesn't care about the patient or respect me enough to provide some basic information. I've been there - I know what its like to be asked by a senior resident to do something you don't really understand. But at least have the courtesy to admit that, or to ask your senior for more information, and have some identifying characteristics for the consultant. Think about your consults - if the patient needs an outpatient procedure (ie, like the AV fistula in boston's example), do you need the surgical resident to see the patient at 0200? No? Then why are you calling them at that time? Medical students may not realize how often their residents get these kind of calls, or how often the other service may be rude when you question the need for the consult. It is not enough to call the surgical resident for abdominal pain consult without any work-up and it is darn near unfuriating if you call the consult and you've NEVER seen the patient.

    This is NOT just a surgical issue - it happens on every service, to every specialty. And its not just consults. Patients and allied health care workers can ask you to do strange stuff, at all hours. Or maybe the behavior isn't all that strange but when you're overworked, the ridiculousness of some consults or of some patient or allied health staff requests are absolutely maddening. The nice guy who loves to talk about random stuff is delightful to talk to on a slow afternoon, but quickly becomes a chore to round on in the am when you can't get out of his room to see the other patients because he wants to tell you about the minutiae of the day or his diabetic feet.

    I try not to complain in front of students but found myself doing it just yesterday - granted we were talking about how much we hated some of our Chiefs when we were interns and the hours in the old days, but I"m sure she still found in demoralizing. I'll try better...I promise.
  48. boston

    boston Junior Member

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    well said. another thing to keep in mind is that, unlike most other specialties, if surgery is consulted, you're obligated to evaluate the patient promptly (i.e. not later in the day). it doesn't matter what the primary service says, ("oh don't worry, it's 5pm, the patient is stable, you can see it tomorrow...") i usually just reply, "ok, just call me tomorrow then -- if you give me a name and mr#, i'll have to see it now."

    how do you know that cellulitis consult is not nec fasc? you don't, until you lay eyes on the patient. maybe I am neurotic, but unseen consults feel like time-bombs to me -- until i see them and know what it's about, i take whatever i hear over the phone with a grain of salt.

    my personal favorite is the 2am consult for debridement of sacral decubs in the bedbound demented nursing home patient (stable floor pt who is not septic). not that they don't need it, but i sure don't feel like i'm doing them much of a favor, in terms of quality of life.
  49. Winged Scapula

    Winged Scapula Cougariffic! Administrator Lifetime Donor

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    I'm not sure if its the difference in training or just our midset that surgical consults need to be seen asap, but I too was trained that ANY consult is seen within 30 minutes, if not sooner.

    Now, that may not be the Chief or attending seeing the patient but unless there was an emergency (like the hospital burning down), this time frame was expected and SOMEONE from the team with an MD/DO saw the patient within that time and came back with a plan for the patient if they didn't know what it was right away. In my experience, many other consultant services would send their student to see a consult and the "real" doctors wouldn't get around the writing a note or calling us for hours, or even days. That I find insulting and infuriating. Not that medical students aren't a good source of information and I have no problem with them writing notes, but when their notes are the only ones in the chart and they contain errors in information, its a problem. When I call a Cards consult I want a Cardiologist to see my patient and I'm sure they expect the same in return.

    I wouldn't be able to sleep if a consult came in and I ignored it until the next day; as boston pointed out, you never know what might be lying in wait for you. If it really is benign, don't call me and tell me to see it tomorrow - if that's the case, call me tomorrow, otherwise I feel (and am expected) obligated to see it today. The reverse is true as well - "your lack of planning does not constitute an emergency on my part" - ie, don't call me for a stat surgical consult on a patient who could be seen as an outpatient or has been festering in the hospital for days and is just now being discharged but I have to see him right now to evaluate for something surgical.

    There are many reasons residents are bitter and while its not right to allow students to be disillusioned by this, the reasons are often valid.

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