Is the "80 hour work week" for medical residents really true or just a rumor?

[SouthernSurgeon]

While browsing through Uncle Harvey and Orthogate, I've noticed that ppl on those sites tend to criticize the levels of autonomy at big-name academic programs (with some exceptions of course). Is their any validity to this criticism or are ppl just knocking the big-shot programs because they didn't match there? Obviously, this isn't relevant to me at the moment, but it has generated curiosity.
Thanks again for your feedback!

Hard for me to know - as I said it's really hard for an outsider to know what goes on unless you talk to the people training there (and trust them not to BS you).

I do think people tend to get a lot of pleasure/schadenfreude from knocking the traditional big-boys in surgical training.

And there is a common meme of "community programs actually let you operate...big name programs just scut you out" - I don't generally put a lot of stock in this line of thinking as I believe I'm getting really good training at my academic center.

My friends at "mans best hospital" and the like all seem happy with their training? And my program has hired attendings from MGH, MD anderson, and MSK since I've been here - they come in able to do big cases from day one and seem skilled from the residents' perspectives.

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[ChiDO]

There are vast differences in operative training. The problem is it is really hard as an outsider to know what you are getting. The things that matter, to me, for operative training are:

1) Volume. You just have to have enough experience, and volume is something non-negotiable to me. If residents are struggling to get the minimum case requirements, it's a big red flag. I will probably finish with 1200-1300 cases at the current rate (even with my...let's just say...less than perfect...logging habits).

Is that total, or per year ? (guessing total). I'll have that many cases at the end of my PGY3 year at least at my program. Think I'm at ~900 total already, so probably 1400 by this year.

 

[SouthernSurgeon]

Is that total, or per year ? (guessing total). I'll have that many cases at the end of my PGY3 year at least at my program. Think I'm at ~900 total already, so probably 1400 by this year.

You're in orthopedics.

General surgery resident case volume is much lower.

Programs actually get dinged by the ACGME/ABS if case volumes are too high - since it implies the residents aren't learning enough about patient care and disease management (or at least so the thinking goes).

For general surgery - minimum case requirement for graduation is 750. General SDN consensus is to worry about a program where you graduate with less than 1000. 1300 is generally considered high.

 

[mimelim]

You're in orthopedics.

General surgery resident case volume is much lower.

Programs actually get dinged by the ACGME/ABS if case volumes are too high - since it implies the residents aren't learning enough about patient care and disease management (or at least so the thinking goes).

For general surgery - minimum case requirement for graduation is 750. General SDN consensus is to worry about a program where you graduate with less than 1000. 1300 is generally considered high.

I only log cases that I do in my opinion 50% or more of the case. I still have to watch out for being too high. We've already gotten in trouble for that. In contrast to some of our neighboring programs where they have to figure out how to have two residents log the same case under different things in order to get their numbers.

 

[Cyberdyne 101]

I only log cases that I do in my opinion 50% or more of the case. I still have to watch out for being too high. We've already gotten in trouble for that. In contrast to some of our neighboring programs where they have to figure out how to have two residents log the same case under different things in order to get their numbers.

Should these programs reduce the number of residents they train per year?
Fwiw, I heard that the Northwestern ortho program reduced the number of residents for their newest class in order to improve training.

 

[mimelim]

Should these programs reduce the number of residents they train per year?
Fwiw, I heard that the Northwestern ortho program reduced the number of residents for their newest class in order to improve training.

Yes. Or close.

 

[Cyberdyne 101]

Yes. Or close.

The info you and others have provided on this thread has been great. Thank you!

 

[premedbrah]

Anesthesiologist I shadowed today told me to apply for a residency in a highly populated area in order to work 130 hour weeks. His logic was getting as much clinical experience as possible. I was like wait what..? But he was dead serious lol...

(Already talking about residency with me and I'm pre med lol)

 

[Ace Khalifa]

Anesthesiologist I shadowed today told me to apply for a residency in a highly populated area in order to work 130 hour weeks. His logic was getting as much clinical experience as possible. I was like wait what..? But he was dead serious lol...

(Already talking about residency with me and I'm pre med lol)

......you would literally be working the equivalent of one 18 hour shift for each of the 7 days of the week. No matter how you arrange those 130 hours, that's way too much.

 

[mimelim]

Anesthesiologist I shadowed today told me to apply for a residency in a highly populated area in order to work 130 hour weeks. His logic was getting as much clinical experience as possible. I was like wait what..? But he was dead serious lol...

(Already talking about residency with me and I'm pre med lol)

You would have a hard time finding an anesthesia program that worked half of that per week. (sample size 3 programs)

 

[Instatewaiter]

I'm extremely hesitant to wade into this ****show of a thread, but as someone who feels like they don't know enough about the practical aspects of medicine and medical

1b) I also understand that surgery residencies are unusually long, and surgery is not something I'd be interested in pursuing (I don't have the dexterity for it). How much of the attitude being presented is specific to a surgical residency? At the moment, I'm leaning towards an allergy/immunology residency, although I'm aware of the fact that I know too little to say for certain what I want.

Allergy Immunology is a somewhat competitive fellowship off of internal medicine. You have to finish 3 years of IM residency and IM residency can vary from very cush to very not cush.

 

[Instatewaiter]

Except you're wrong. Academics may work long hours, but they did that to themselves by going into academics. You can find positions paying over 200k working less than 80 hours a week. I could post pages of IM hospitalist gigs that are 7 on/7 off with 12 hour shifts that pay 200k+ a year. FP you'd be hard pressed to even find a way to work 80 hours a week, given the schedules of most offices and patient preferences. EM, it just doesn't happen. Psych, PM&R, derm, and the like, 80 hours a week is certainly not normal lol. Just because you and your wife's lives suck doesn't mean you couldn't go online right now and find a gig working elsewhere that gave you less hours per week if you were willing to leave academia.

If you think that a primary care doc's work hours only include office hours you are very, very sorely mistaken, especially these days. With all the paperwork, FMLA forms, school forms and the like there are many hours each day after office hours doing paperwork that the other specialists push toward the primary care doc.

It's one of the reasons I flet from primary care

 

[Winged Scapula]

If you think that a primary care doc's work hours only include office hours you are very, very sorely mistaken, especially these days. With all the paperwork, FMLA forms, school forms and the like there are many hours each day after office hours doing paperwork that the other specialists push toward the primary care doc.

It's one of the reasons I flet from primary care

Really? I can push those forms off to the PCP?

And here I am completing the FMLA etc forms myself.

 

[dkr34]

Read "The House of God" by Samuel Shem. That'll give you an idea of residents' crazy schedules.

 

[Dare2Dream]

After you pass 12 hours you just kind of stop caring. It's like you get kind of numb to it. The difference between 8 and 12 is huge, 8 and 16 massive, but between 12 and 24? My whole day's already gone, why not. Hell is 80 hour weeks split over 12 hour shifts.

That is a great point. Going home to sleep only to come back in the morning vs. staying the night and having the next day to yourself is more attractive but staying up for 24 hours straight without sleep still sounds atrocious.

 

[Dare2Dream]

And with regards to cross cover, there is nothing more terrifying that getting a stat page to a room, and walking in to a jaundiced, tachypneic patient on BiPAP and CRRT who is tachy and hypotensive. I have no idea what the hell is happening with this patient after getting my crap signout. Are they septic? Are they in liver failure? What are they post-op from? No idea. Dangerous, dangerous, dangerous.

Understand the concern but why is the handoff done so poorly? If we're stuck with this system, then it can surely be done in a better way so as not to jeopardize peoples' lives.

 

[Siggy]

[snip]So hard and fast rules don't always work.

Then there's the issue of self reporting. [snip]

I think that self reporting fixes the issue of "Well, we want to trade shifts and we'll still average 1 shift/wk off, but I'll be pulling 8 shifts in a row because my partner needs to switch because of family obligations." The problem without hard and fast rules is that there are too many residency programs who would play loose with the rules and essentially ignore them.

 

[Dare2Dream]

Except you're wrong. Academics may work long hours, but they did that to themselves by going into academics. You can find positions paying over 200k working less than 80 hours a week. I could post pages of IM hospitalist gigs that are 7 on/7 off with 12 hour shifts that pay 200k+ a year. FP you'd be hard pressed to even find a way to work 80 hours a week, given the schedules of most offices and patient preferences. EM, it just doesn't happen. Psych, PM&R, derm, and the like, 80 hours a week is certainly not normal lol. Just because you and your wife's lives suck doesn't mean you couldn't go online right now and find a gig working elsewhere that gave you less hours per week if you were willing to leave academia.

Can you elaborate on the bolded? Is 7 on/ 7 off days, meaning you work a week and are off the next? That sounds unreal. What kind of IM specialities are were talking about?

 

[Law2Doc]

I think that self reporting fixes the issue of "Well, we want to trade shifts and we'll still average 1 shift/wk off, but I'll be pulling 8 shifts in a row because my partner needs to switch because of family obligations." The problem without hard and fast rules is that there are too many residency programs who would play loose with the rules and essentially ignore them.

Yes but many of us don't really need that 1 day off in 7 as much as we need that extended three or four day weekend 3 months from now. So the 90% of people in reasonable residencies who play by the rules get punished because there are 10% that MAYBE, in theory, won't behave unless such a rule is in place (and this is totally speculation -- my bet is those programs are going to do what they want regardless of whatever rule is in place). I'm always against the notion of punishing the majority for the small chance of protecting the minority. And i dont like hard and fast rules that dont make sense just because of the notion the minority would otherwise abuse the system because frankly those few same people will still find ways to abuse the system. So this is really just the AcGME saying they are too lazy to find the trouble spots so lets just make a rule that everyone has to follow so it will be more obvious to identify who isn't. Or it's based on a misguided idea of what's "better" for residents or patients. Either way the premise is all wrong.

As far as lifestyle for residents, I agree with the people who said that 30 hour shifts were more lifestyle friendly than night float. I've lived through both, and you are less tired and have more free time with the longer shifts. You arent incompetent after 30 hours of work. Im not sure id do a long commute home, because sitting in traffic is deadly -- without the adrenaline flowing you won't stay awake -- but finishing up your night of patient care was certainly doable, your mind stays on high alert for the extent of your shift. I didnt see people making bad mistakes in the morning -- the biggest mistakes happened early -- right after handoffs when you didnt know the patients yet. and no study since the change has borne out that the reduction of hour improved patient safety, so residencies really should schedule things as they work best for residents, not the Zion family.

Think about it -- how quickly do you get to your 80 hour "cap" when doing 30 hour shifts. Heck if it were up to me I would have done two 40 hour shifts a week and had an extra day off. That would have been a lifestyle friendly schedule.

 

[TooMuchResearch]

Understand the concern but why is the handoff done so poorly? If we're stuck with this system, then it can surely be done in a better way so as not to jeopardize peoples' lives.

Because really good sign outs on 20+ inpatients takes a very, very long time. And even if one received such a sign out, one would not remember it for so many patients. If there are 1-2 sick ones who will likely need attention overnight, it can be okay. If the sign out is on a unit full of sickies, there can be issues.

 

[TooMuchResearch]

Because really good sign outs on 20+ inpatients takes a very, very long time. And even if one received such a sign out, one would not remember it for so many patients. If there are 1-2 sick ones who will likely need attention overnight, it can be okay. If the sign out is on a unit full of sickies, there can be issues.

Keep in mind night float is mostly there to admit new patients and keep the current ones alive until the day team fixes their presenting ailments the following day. They don't need to know everything about Mrs. Jones if the key things about her are that she doesn't do well with opioids, follow-up on her potassium, and we started her on Zyprexa.

 

[mimelim]

Because really good sign outs on 20+ inpatients takes a very, very long time. And even if one received such a sign out, one would not remember it for so many patients. If there are 1-2 sick ones who will likely need attention overnight, it can be okay. If the sign out is on a unit full of sickies, there can be issues.

Lol 20+ patients...

CVICU, 40+ patients or general surgery night float 120+ patients

 

[Mad Jack]

Can you elaborate on the bolded? Is 7 on/ 7 off days, meaning you work a week and are off the next? That sounds unreal. What kind of IM specialities are were talking about?

You work seven days, 12 hours per day usually, then have seven days off. It's usually general hospitalists on the wards that do this sort of schedule but I've seen it a every rare now and again in other specialties.

 

[Mad Jack]

Understand the concern but why is the handoff done so poorly? If we're stuck with this system, then it can surely be done in a better way so as not to jeopardize peoples' lives.

Giving a good sign out after 16+ hours of work on every single one of your dozens of patients can be difficult. You kind of have to prioritize who gets the spotlight. Unfortunately, patients often don't play along and the ones you skimmed might end up crashing.

 

[DrBowtie]

Lol 20+ patients...

CVICU, 40+ patients or general surgery night float 120+ patients

Are you guys primary team on all 120?

 

[mimelim]

Are you guys primary team on all 120?

I am in Vascular, so I am not. But they are primary on maybe 70% of them if I had to ballpark it.

 

[Law2Doc]

Keep in mind night float is mostly there to admit new patients and keep the current ones alive until the day team fixes their presenting ailments the following day. They don't need to know everything about Mrs. Jones if the key things about her are that she doesn't do well with opioids, follow-up on her potassium, and we started her on Zyprexa.

Um no -- the opposite is more often true. The patients that are inevitably the most trouble are the ones the team says "nothing to worry about" - we will handle it in the morning. You end up needing to know more information than you are given overnight. Patients who seem totally stable during the day like to crash in the middle of the night. As an intern I never had a night where I didn't need to prescribe meds, deal with unmentioned uncontrollable hypertension, intractable vomiting or constant pain not relieved by meds, maybe call a consult, Sometimes run codes. That's the role of the night person -- addressing all the overnight details. And detail is the key word -- you really need to know what going on with the patient, because the night nurses might not, and you are the only doctor there. The consult or others helping with the code or (even more commonly) the attending who checks in in the middle of the night doesn't want to hear that you know squat about the patient. It's well and nice if patients are tucked in and you have an easy night, but that's not as common as you seem to be suggesting. So yeah, the more things I can get on sign out the better I can manage the patient overnight. And that Of course has to be balanced with the time it takes to get the day person out of there in a timely basis. It's not just a Babysitting job.

 

[Siggy]

Are you guys primary team on all 120?

Primary? No. However when you add up all 9 ward teams, the night float interns cover over 100 patients over night... while also assisting with admissions... while also seeing and writing notes on their own team's patients.

 

[jl lin]

Primary? No. However when you add up all 9 ward teams, the night float interns cover over 100 patients over night... while also assisting with admissions... while also seeing and writing notes on their own team's patients.

This cannot be the safest and most effective approach. I mean, how could it be? This is one reason why I am in awe of surgery. The amount of necessary stamina is incredible.

 

[mimelim]

This cannot be the safest and most effective approach. I mean, how could it be? This is one reason why I am in awe of surgery. The amount of necessary stamina is incredible.

Which is why night float is not a good idea, but it is mandatory with the work hour restrictions. Hence why it is fairly clear to most, if not all residents that go through this system recognize that the work hour restrictions hurt patients.

 

[jl lin]

Which is why night float is not a good idea, but it is mandatory with the work hour restrictions. Hence why it is fairly clear to most, if not all residents that go through this system recognize that the work hour restrictions hurt patients.

And these issues have been addressed but have fallen on deaf ears? Seems like it is think tank time. Funny though, this doesn't seem to fully go down this way in the children's hospitals I have worked. But docs come right in, OR/ECMO teams come in at the drop of a hat. Regardless of who is on, attendings get called by fellows right away. A bit of a different world than when I did all adult SICUs.

 

[moop]

And these issues have been addressed but have fallen on deaf ears? Seems like it is think tank time. Funny though, this doesn't seem to fully go down this way in the children's hospitals I have worked. But docs come right in, OR/ECMO teams come in at the drop of a hat. Regardless of who is on, attendings get called by fellows right away. A bit of a different world than when I did all adult SICUs.

Do you figuratively mean "think tank," or do you actually mean places like KFF, RWJF, CMWF?

 

[jl lin]

Do you figuratively mean "think tank," or do you actually mean places like KFF, RWJF, CMWF?

Figuratively. . .but also, now that you mention it, why not with the others as well? Let them be a part of the solution and not the problem. Problem-solve until you get this thing right. It's ridiculous that patient outcomes should suffer--um, that's on the counterproductive side. Not sure exactly where to begin; b/c I also think that when you overwork and shiftwork the crap out of people, it invariably jeopardizes their performance as well. What's the compromise? What's the balance? Heck if I know right now. But if the issue was given enough priority attention, things might improve. Change, however, takes time. It's usually very, ultra-slow motion. I think this is what causes humans the most trouble--the reality that a good number of things cannot instantly change.

Regardless, carrying that kind of patient load with all the other stuff and new admits is beyond insanity. Plus, we have to remember that when patients actually do get admitted to the hospital today, it often is because they are patients that are pretty sick, or with serious underlying comorbid concerns, or the are just plain critical.

I was a baby, but I remember the days when patients were admitted just to be a bit on the safe side--not to be a lot of the safe side. That is to say, people were admitted that could have been managed well from home, but they put them in the hospital anyway. Often today if you get admitted to the hospital--with some exceptions of course--especially in certain pediatric situations--you have to be deemed risky enough to not be dispo'd to home. Point being, it's not like a lot of those 100+ patients are easy-peasy patients. The potential to overlook or miss something is greater for most folks admitted to the hospital anymore. Add on surgical patients with their own share of risks, wow, this is not good.

 

[moop]

Figuratively. . .but also, now that you mention it, why not with the others as well? Let them be a part of the solution and not the problem.

I don't get understand. How are the Robert Wood Johnson Foundation, Kaiser Family Foundation, and the Commonwealth Fund, which are research institutions focused on health policy, part of the problem?

 

[jl lin]

I don't get understand. How are the Robert Wood Johnson Foundation, Kaiser Family Foundation, and the Commonwealth Fund, which are research institutions focused on health policy, part of the problem?

I don't know if they did or exactly how they would. But foundations with some money might be enticed to throw their hats in the ring--b/c quality of treatment does affect health policy. Hell, it seems like it's a big enough issue for health-related organizations to contribute into the inquiry somehow. I'm not a grant-writer though. LOL.

I just think the situation seems pretty serious, and it explains why so many patients' families have sounded out in great frustration (noted this much when my loved ones have been in the hospital) over the care their loved ones have gotten, especially when the regular team is not around. Again, in recent years, I have been working in the pediatric arena. It's a bit of different world in these hospitals compared with say more generalized hospitals and those that have primarily adult patients.

 

[TooMuchResearch]

Figuratively. . .but also, now that you mention it, why not with the others as well? Let them be a part of the solution and not the problem. Problem-solve until you get this thing right. It's ridiculous that patient outcomes should suffer--um, that's on the counterproductive side. Not sure exactly where to begin; b/c I also think that when you overwork and shiftwork the crap out of people, it invariably jeopardizes their performance as well. What's the compromise? What's the balance? Heck if I know right now. But if the issue was given enough priority attention, things might improve. Change, however, takes time. It's usually very, ultra-slow motion. I think this is what causes humans the most trouble--the reality that a good number of things cannot instantly change.

Regardless, carrying that kind of patient load with all the other stuff and new admits is beyond insanity. Plus, we have to remember that when patients actually do get admitted to the hospital today, it often is because they are patients that are pretty sick, or with serious underlying comorbid concerns, or the are just plain critical.

I was a baby, but I remember the days when patients were admitted just to be a bit on the safe side--not to be a lot of the safe side. That is to say, people were admitted that could have been managed well from home, but they put them in the hospital anyway. Often today if you get admitted to the hospital--with some exceptions of course--especially in certain pediatric situations--you have to be deemed risky enough to not be dispo'd to home. Point being, it's not like a lot of those 100+ patients are easy-peasy patients. The potential to overlook or miss something is greater for most folks admitted to the hospital anymore. Add on surgical patients with their own share of risks, wow, this is not good.

Lots of admitted patients are still relatively easy. The three I admitted tonight (number four was observation so I won't count it) were all easy. Algorithmic treatment. Manage any complications that arise. Likely d/c home within 2-3 days.

Yes, I admit sick, complex patients but they go to smaller services with adequate coverage.

Either our system is lucky enough to not see the problems associated with night float, or some people are really blowing things out of proportion.

Our day teams don't sign out many follow-up items, unlike other posters here.

Not all patients are always trying to die all of the time. Sometimes, only some of them are only trying to die some of the time.

 

[jl lin]

Yes. In the ICUs, we sure get our share of those that are trying to die. A few VIPs now and again. A few watch and see. I'm just blown away by the sheer numbers that have been given here.

Specialized areas have tighter controls. And like I said, the peds hospitals, well, it's a lot different, it seems. There is much less autonomy for both doctors and nurses compared with adult critical care. But it's reasonable, and you accept it. Family-centered care also means a lot of the time parents are there to watch and hover, and I am cool with this too. The big, general medical centers can be wild though.

Good to know not all places are like this, but the concensus here seems to indicate that it's a big enough problem, which is scary.

 

[Sartorius111]

Pre-med afraid of resident hours is almost pathognomonic for future PA.

I'm afraid of resident hours...

But I'm excited about being afraid.