"Let First-Year Residents Work Longer Shifts, ACGME Proposes"

[SouthernSurgeon]

http://www.acgme.org/What-We-Do/Accreditation/Clinical-Experience-and-Education-formerly-Duty-Hours

I've been through a good portion of this...do you have a more specific link because I'm not finding it...

http://www.acgme.org/Portals/0/PDFs/Nasca-Community/NascaLetterToTheCommunity_11-4-16.pdf

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[Mad Jack]

but the guild couldn't get me arrested for plying my trade if I left the guild....I feel we're rabbit trailing here

It's tangential but important- under any system ever devised, medical training was basically a situation where you did what you were told when you were told for as long as you were told, and that was that. We've got it better than it has been since the Flexner report in literally every way, and we get a better deal than physicians have been handed pretty much anywhere outside of modern Europe (and they get their deal in exchange for much longer residencies and an uncertain path to becoming a consultant oftentimes). Working a few more hours in exchange for a few more days off is pretty great all around, and in the context of everything else, complaining about it is really splitting hairs.

 

[deleted480308]

.......Working a few more hours in exchange for a few more days off is pretty great all around, and in the context of everything else, complaining about it is really splitting hairs.

I would be more likely to agree if I didn't see them already pushing to increase the max hours beyond 80.

 

[TooMuchResearch]

The hospital could hire more staff instead of exploiting our cheap labor to profit?

Sure, but then they could just dump the residents for PA coverage.

 

[ProfMD]

I would be more likely to agree if I didn't see them already pushing to increase the max hours beyond 80.

Where do you see this? Most proposals discussed have been to limit hours further. The exception is the recent one to roll back the 16 hour restriction. Even this proposal does not involve changing the total hours per week.

 

[chipwhitley]

It's tangential but important- under any system ever devised, medical training was basically a situation where you did what you were told when you were told for as long as you were told, and that was that. We've got it better than it has been since the Flexner report in literally every way, and we get a better deal than physicians have been handed pretty much anywhere outside of modern Europe (and they get their deal in exchange for much longer residencies and an uncertain path to becoming a consultant oftentimes). Working a few more hours in exchange for a few more days off is pretty great all around, and in the context of everything else, complaining about it is really splitting hairs.

You can always find a ****tier situation that someone somewhere had, doesn't mean you have no right to complain. If that's the case, none of us, not even the poorest and most disadvantaged American has the right to complain because someone in the mumbai slum has it much worse than them.

 

[deleted480308]

Where do you see this? Most proposals discussed have been to limit hours further. The exception is the recent one to roll back the 16 hour restriction. Even this proposal does not involve changing the total hours per week.

we already have the ability to request exemptions for moving to 88hrs

 

[Mad Jack]

You can always find a ****tier situation that someone somewhere had, doesn't mean you have no right to complain. If that's the case, none of us, not even the poorest and most disadvantaged American has the right to complain because someone in the mumbai slum has it much worse than them.

I'm not saying don't complain. I'm saying feel free to, but understand why many of us are meeting the complaints with resounding shrugs.

 

[PL198]

What we should be worried about is balancing two issues:
1) Patient safety.
2) Resident education.

So far, there is no good evidence that limiting work hours has improved patient safety. There are serious concerns, particularly among surgical specialties, that residents are not getting appropriate training under the new rules.

and they think that an extra 8 hours at night is making or breaking if the surgeon is good at their field? give me a break.

maybe there's more to learn than ever before.

when the dinosaurs did their 100000000 hr in a row days or whatever bullcrap they tell, the hospital had half the volume it does now, patients were less complex and they were sleeping. working 24h as an intern now is nothing like it was in the past.

 

[Psai]

It's not about the number of hours. It's the change in mindset that matters. Before it was about doing what needed to be done no matter how long it took. Now it's about I'm in and out when the clock tells me to.

 

[chipwhitley]

It's not about the number of hours. It's the change in mindset that matters. Before it was about doing what needed to be done no matter how long it took. Now it's about I'm in and out when the clock tells me to.

Except that's not true. Even with the 16 hour limit, I regularly end up staying longer if I need more time to get my work done and my colleagues do too. The point is to not give programs the ability to abuse us. That's what these rules are supposed to be about.

 

[ProfMD]

we already have the ability to request exemptions for moving to 88hrs

It's been that way since the first work hour restrictions started in 2003. Certainly not indicative of a new trend.

and they think that an extra 8 hours at night is making or breaking if the surgeon is good at their field? give me a break.

maybe there's more to learn than ever before.

when the dinosaurs did their 100000000 hr in a row days or whatever bullcrap they tell, the hospital had half the volume it does now, patients were less complex and they were sleeping. working 24h as an intern now is nothing like it was in the past.

8 hours several days a week spread over a year. Plus, as others have said, if interns are not working at night, then upper levels are. That means those upper levels don't work during the day and miss out of operating opportunities.

Also, intern year is when surgeons learn a lot of perioperative management. Then more senior years are for learning how to operate.

Also, it is the mindset in the trainees that this engenders. I see the shift work mentality all the time where some residents feel no responsibility for the patient when it gets close to the end of a shift.

Also, I think 80 hours is plenty. I do not think further restrictions are appropriate unless data comes out that suggests further restrictions may be beneficial.

 

[neusu]

Interesting arguments all around.

Several things stuck out to me. As an MD, we typically bear the burden and sacrifice to take the 28-/36- hour call, nights, weekends; during training and after. Is it safe? The studies seem to suggest so. Is it reasonable? Most of us argue it is not. The current focus is on the 16-hour limit for interns, but I would not be surprised if a study on the 80-hour limit comes up in the near future, as well.

Our colleagues in ancillary staff and midlevel support have no such sentiment to work such long hours, at undesirable times, on weekends and holidays. They went in to it for the life-style. Not surprisingly, they have ingrained themselves as professional workers, paid on an hourly rate, with overtime, and other benefits.

With respect to the decision making about this controversy regarding residents, we can trot out all of the data and emotional arguments on all sides. This comes down to money, plain and simple. Residents are cheaper, more effective labor, and their salary is fixed regardless of the number of hours they are required to work. I am all but certain, somewhere high up in the ACGME and/or associated specialty organizations the powers at be have done an actuarial analysis and determined the risk of a major adverse event, cost associated with such an event, and compared it to the revenue saved by having residents work more. Likewise, the relative risk of increasing burnout, rate of resident attrition and or suicide.

It seems the writing is on the wall, the open comment stage of this revision is a mere formality.

 

[SurfingDoctor]

Further restriction would only work if you extend the length of training. The current work hours are pushing it as far as the effectiveness in training in my opinion. I'm sure there is a balance. I remember doing 36 hours and it was terrible and my mine was in the fog. As an attending I regularly do 24 hours and am tried but can function well. Having seen the pre and post 16 hours I don't think patient safety has been improved. However I think the quality of second year residents has diminished.

 

[saveourpens]

Any thoughts?

http://www.medscape.com/viewarticle/871432

"First-year residents would no longer be limited to 16-hour shifts during the 2017-2018 academic year under a controversial proposal released today by the Accreditation Council for Graduate Medical Education (ACGME).

Instead, individual residency programs could assign first-year trainees to shifts as long as 28 hours, the current limit for all other residents. The 28-hour maximum includes 4 transitional hours that's designed in part to help residents manage patient-care handoffs.

The plan to revise training requirements does not change other rules designed to protect all residents from overwork. The maximum number of hours that they can log each week remains at 80. All residents must have at least 1 day in 7 free from both clinical experience and education. And in-house call can't be more than every third night. All these limits are based on 4-week averages.

The ACGME capped the shifts of first-year residents at 16 hours in 2011 as a part of an ongoing effort to make trainee schedules more humane and avoid clinical errors caused by sleep deprivation. Some medical educators and medical societies claim, however, that this particular reform has worsened the learning experience of first-year residents as well as continuity of patient care.

ACGME CEO Thomas Nasca, MD, told Medscape Medical News that the problem arises largely from first-year residents not being on the same schedule as supervising residents and others on their "home" educational team. On a 16-hour clock, first-year residents can end up working under relative strangers, said Dr Nasca. "The lack of synchronization is very disruptive."

The solution, he said, is putting everyone on the same clock.

And it's a safe solution for residents and patients alike, according to the ACGME. The group touts a study published in the New England Journal of Medicine in February showing that longer shifts and less rest in between for surgical residents did not affect the rate of serious complications or surgical fatalities. Residents working longer shifts were no more dissatisfied with their overall well-being than those whose shifts were capped in accordance with AGME standards. They indicated that their educational experience improved, but at the expense of personal time. The study, called Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST), encompassed 117 general surgery residency programs in 151 hospitals.

"A Dangerous Step Backward"

Not everyone buys these findings and the arguments for relaxing the 16-hour rule for first-year residents. Both the American Medical Student Association and the Committee of Interns and Residents, a union representing 14,000 physicians, oppose the AGCME proposal. The consumer watchdog group Public Citizen calls it "a dangerous step backward."

"Study after study shows that sleep-deprived residents are a danger to themselves, their patients, and the public," said Michael Carome, MD, director of Public Citizen's Health Research Group, in a news release. "It's disheartening to see the ACGME cave to pressure from organized medicine and let their misguided wishes trump public health."

Public Citizen says it has public opinion on its side. A recent poll commissioned by the group showed that 86% of Americans oppose lifting the 16-hour cap on the shifts of rookie residents.

Public Citizen also looks askance at the FIRST trial, funded in part by the ACGME. It accuses the study of neglecting to obtain informed consent from trainees and patients. To Dr Carome, the study conveniently arrived at the conclusions that its authors set out to reach.

For his part, Dr Nasca said the ACGME made a good-faith effort to arrive at a consensus decision by listening to specialty societies, certifying boards, patient safety organizations, and residents. And rather than ignoring the well-being of first-year trainees, he said, the plan would step up efforts to prevent burnout and depression. It calls on residency programs, for example, to ensure that trainees can make appointments with a physician or a mental health professional, even during their working hours. And faculty and residents must be trained to identify symptoms of burnout, depression, and substance abuse.

The ACGME proposal will go to the group's board of directors for a final decision after a 45-day comment period. More information on the proposal is available for download from the ACGME."

Man **** this. Does anyone care about caring for the provider? We're not machines here.

"Worsened learning experience and continuity of patient care"? Sounds like your typical academic medicine drivel. Cheap hospital labor even further exploited.

 

[Mad Jack]

Further restriction would only work if you extend the length of training. The current work hours are pushing it as far as the effectiveness in training in my opinion. I'm sure there is a balance. I remember doing 36 hours and it was terrible and my mine was in the fog. As an attending I regularly do 24 hours and am tried but can function well. Having seen the pre and post 16 hours I don't think patient safety has been improved. However I think the quality of second year residents has diminished.

While I don't disagree, I wonder if it's more field-dependent than cut and dry. Surgical fields certainly have a more hours= better doctors argument. But is doing 30 hour shifts going to make a person a better psychiatrist, physiatrist, hospitalist, outpatient IM/FP PCP, etc? Do you need to clock 36 hours of work with overnight call to be a decent anesthesiologist, radiologist, or outpatient neurologist? I really don't know the answer, but perhaps it lies more in the culture that medicine attracted prior to duty hour limits than it does to the limits themselves. How many of these kids would still be signing up in the days of 120+ hour a week residencies?

 

[SouthernSurgeon]

Further restriction would only work if you extend the length of training. The current work hours are pushing it as far as the effectiveness in training in my opinion. I'm sure there is a balance. I remember doing 36 hours and it was terrible and my mine was in the fog. As an attending I regularly do 24 hours and am tried but can function well. Having seen the pre and post 16 hours I don't think patient safety has been improved. However I think the quality of second year residents has diminished.

Yes and no.

Training as it stands is not efficient. As I've said I am overall very satisfied with my training, but it's been studied across specialties - for general surgery residents they spend something like 9% of their work hours actually operating. Internal medicine residents spend less than 10% of their time interacting with patients.

In an ideal world you'd design a more efficient training system that flipped those ratios and decreased the busywork and downtime, and had you progress by competency rather than using hours worked as a rough surrogate for ensuring competency. But that's hard to do for many, many reasons, and the obvious barrier has been mentioned many times in this thread - money.

 

[Mad Jack]

Man **** this. Does anyone care about caring for the provider? We're not machines here.

"Worsened learning experience and continuity of patient care"? Sounds like your typical academic medicine drivel. Cheap hospital labor even further exploited.

Functioning under duress is a learned skill. Some fields need it- surgery, for instance, where you might very well have 24 hour shifts with call and might be responsible for some of your patients until discharge, day or night, for days on end.

 

[Mad Jack]

Yes and no.

Training as it stands is not efficient. As I've said I am overall very satisfied with my training, but it's been studied across specialties - for general surgery residents they spend something like 9% of their work hours actually operating. Internal medicine residents spend less than 10% of their time interacting with patients.

In an ideal world you'd design a more efficient training system that flipped those ratios and decreased the busywork and downtime, and had you progress by competency rather than using hours worked as a rough surrogate for ensuring competency. But that's hard to do for many, many reasons, and the obvious barrier has been mentioned many times in this thread - money.

We could substantially reduce the BS by getting rid of a lot of the paperwork, charting, and other bureaucratic BS, but the suits and bureaucrats would never let better training and higher output get in the way of systemic inefficiency.

 

[SurfingDoctor]

While I don't disagree, I wonder if it's more field-dependent than cut and dry. Surgical fields certainly have a more hours= better doctors argument. But is doing 30 hour shifts going to make a person a better psychiatrist, physiatrist, hospitalist, outpatient IM/FP PCP, etc? Do you need to clock 36 hours of work with overnight call to be a decent anesthesiologist, radiologist, or outpatient neurologist? I really don't know the answer, but perhaps it lies more in the culture that medicine attracted prior to duty hour limits than it does to the limits themselves. How many of these kids would still be signing up in the days of 120+ hour a week residencies?

Maybe it is speciality specific I don't know. I do know that if a patient gets sick, but you are done at 16 hours and miss the hands on the experience of watching and treating the evolution of pathophysiology, you lost a learning experience. And the next time you encounter that pathophysiology, you are less prepared. Once this happens on a frequent enough basis, you loss general medical training experiences. The only way to make up for lost experiences is to extend training, like the European system; less work hours = longer duration of training. Personally I would be fine with either if that's what trainees really want.

 

[chipwhitley]

Functioning under duress is a learned skill. Some fields need it- surgery, for instance, where you might very well have 24 hour shifts with call and might be responsible for some of your patients until discharge, day or night, for days on end.

Surgery is a whole different animal, those who go into it know (hopefully) what they're getting into. The rest of us shouldn't be subjected to that if we don't need it. No family doc is working a 24 hour shift in the clinic.

 

[Mad Jack]

Surgery is a whole different animal, those who go into it know (hopefully) what they're getting into. The rest of us shouldn't be subjected to that if we don't need it. No family doc is working a 24 hour shift in the clinic.

But there's plenty of family docs working in ERs and as hospitalists that benefit greatly from the pathology and continuity they saw during those long shifts on the wards.

 

[QualityProcess]

less work hours = longer duration of training.

several of my "old-school" attendings have suggested this. 6 months to a year, depending on specialty?

 

[SurfingDoctor]

several of my "old-school" attendings have suggested this. 6 months to a year, depending on specialty?

Probably, but I really don't know. Most residencies in the U.K. are 1 to 2 years longer in the duration compared to their US counterparts.

 

[cbrons]

Man **** this. Does anyone care about caring for the provider?

Yes, they do care for "Providers" which is why DNPs and PAs get paid 4x as much and do not work anywhere close to 80 hours or have anywhere near the same liability.

So the word you probably meant to use was "resident".

 

[PL198]

Probably, but I really don't know. Most residencies in the U.K. are 1 to 2 years longer in the duration compared to their US counterparts.

and aren't the hours they work capped at 60? so if you looked at their total hours and the US hours from the year or two shorter residencies here they'd be similar.

 

[PL198]

wait I just found this. If this is what they have in UK and residencies are only 1-2 years longer, they're getting much less training than US docs even with longer residencies.

• a maximum work week of 48 hours
  
  
• a minimum rest period of 11 consecutive hours per 24-hour duty
  
  
• a minimum rest period of 24 hours per 7-day duty, or 48 hours of rest per 14-day duty
  
  
• a minimum of 4 weeks of paid annual leave
  
  
• a maximum of 8 hours’ work in any 24 hours for workers in stressful positions
  
  
• a minimum 20-minute rest period per 6 hours worked

 

[Mad Jack]

Yes, they do care for "Providers" which is why DNPs and PAs get paid 4x as much and do not work anywhere close to 80 hours or have anywhere near the same liability.

So the word you probably meant to use was "resident".

They get paid about twice as much around here. Work about three fifths the hours of the residents though.

 

[Mad Jack]

wait I just found this. If this is what they have in UK and residencies are only 1-2 years longer, they're getting much less training than US docs even with longer residencies.

• a maximum work week of 48 hours
  
  
• a minimum rest period of 11 consecutive hours per 24-hour duty
  
  
• a minimum rest period of 24 hours per 7-day duty, or 48 hours of rest per 14-day duty
  
  
• a minimum of 4 weeks of paid annual leave
  
  
• a maximum of 8 hours’ work in any 24 hours for workers in stressful positions
  
  
• a minimum 20-minute rest period per 6 hours worked

****ing lol, maximum 8 hours for anyone in a "stressful position?"

 

[Foot Fetish]

What is the ACGME's endgame here? Hypothetically, if there was no public outcry and they could pass any changes they wanted, what would a residents' work week look like? I feel like it would amount to indentured servitude with residents basically living in the hospital.

 

[SurfingDoctor]

wait I just found this. If this is what they have in UK and residencies are only 1-2 years longer, they're getting much less training than US docs even with longer residencies.

• a maximum work week of 48 hours
  
  
• a minimum rest period of 11 consecutive hours per 24-hour duty
  
  
• a minimum rest period of 24 hours per 7-day duty, or 48 hours of rest per 14-day duty
  
  
• a minimum of 4 weeks of paid annual leave
  
  
• a maximum of 8 hours’ work in any 24 hours for workers in stressful positions
  
  
• a minimum 20-minute rest period per 6 hours worked

I think this is just general practice though. 2 years as a foundation doctor (ie prelim year) plus 3 years as a registrar (ie resident) just for general practice, 4 if you specialize. For additional specialist training as a consultant (ie fellow) that is an additional 3 to 4 years. Essentially, it is nearly a decade in graduate level training and that is the minimum level of training (typical is about 9 years). If you don't show competency, the training is extended.

 

[SurfingDoctor]

lol anyone who's been paying attention the last few years should NOT be envious of the British system.

I don't think anyone was suggesting to be envious of that medical training system (though in my limited experience with people have trained under that system, they are quite good doctors). It merely is a simple math, work less hours = longer training period.

 

[SurfingDoctor]

What is the ACGME's endgame here? Hypothetically, if there was no public outcry and they could pass any changes they wanted, what would a residents' work week look like? I feel like it would amount to indentured servitude with residents basically living in the hospital.

That is why they are called "residents". I remember seeing the resident dormitory at one of my previous institutes. In fact there was a painted line in the dormitory lobby where you were not allowed to leave unless you have permission. Obviously it will never go back to that, but just some perspective.

 

[chipwhitley]

But there's plenty of family docs working in ERs and as hospitalists that benefit greatly from the pathology and continuity they saw during those long shifts on the wards.

I guess the great pathology only starts to show up in hours 17-28? Somehow the pathology and continuity gained from working twice the normal workday and several hours longer than the attendings isn't enough already? Maybe if we got to be well rested, we'd actually learn more from what we see when we're at the hospital and actually remember it decades later as opposed to being a zombie and going through the motions at the 28th hour.

 

[IlDestriero]

My ICU days were 530-6 prerounding, 24 hrs on (7-7), and then rounding and a lecture. So ~6am-noon the next day.
Sucked, yet we all survived.
Their big decrease the workload initiative at the time was to make the lecture elective. You always hit 80 hrs in the ICU months. But that's the nature of the beast. You have to preround, and it takes time. Then rounding and bedside teaching. You can make that an hour instead of 2-3, but you lose a lot of education.


--
Il Destriero

 

[cbrons]

@SouthernSurgeon reddit famous

https://www.reddit.com/r/medicalsch...hernsurgeon_why_the_16hour_work_limit_is_bad/

 

[Mr Roboto]

Threads like this make me want to drop out

 

[Promethean]

My ICU days were 530-6 prerounding, 24 hrs on (7-7), and then rounding and a lecture. So ~6am-noon the next day.
Sucked, yet we all survived.
Their big decrease the workload initiative at the time was to make the lecture elective. You always hit 80 hrs in the ICU months. But that's the nature of the beast. You have to preround, and it takes time. Then rounding and bedside teaching. You can make that an hour instead of 2-3, but you lose a lot of education.


--
Il Destriero

No, you didn't. That is the point. Everyone who did survive can say that, and go unchallenged because those who didn't survive aren't here to speak up.

 

[Psai]

Wtf

We all know you're loving it

 

[PL198]

I think this is just general practice though. 2 years as a foundation doctor (ie prelim year) plus 3 years as a registrar (ie resident) just for general practice, 4 if you specialize. For additional specialist training as a consultant (ie fellow) that is an additional 3 to 4 years. Essentially, it is nearly a decade in graduate level training and that is the minimum level of training (typical is about 9 years). If you don't show competency, the training is extended.

I don't think those times are impressive though in terms of actual training. I mean if you did the 48 vs 80 math they would probably be about equal vs the US system. In a field where I'm gonna train for 7 years I can't imagine doubling that even if I work half as much. brb 40th birthday time to be an attending

 

[CTFellowMD]

IMHO there are two separate arguments that tend to get conflated:
-Argument one is whether the overall duty hours (80 hrs/wk) are too strenuous
-Argument two is over the particular 16 hr limit i.e. elimination of 24 hour call


1. Days off....
2. Covering days off.....
3. Work compression.....
4. Sleep cycles. ....

Everything SouthernSurgeon said.

I was an intern during the 80 hr cap, but prior to the 16hr limit. My intern schedule was routinely 12-13/hr shifts M-F, and 2 weekends a month where I worked a 28hr shift. That allowed for 2 golden (sat+sun off) weekends/month. Night float was similar. Were the long weekends painful? Extremely. Doable? Definitely. Did the subsequent weekends off more than make up for them? 100%.

I was administrative chief resident after the 16/hr cap for interns. It was my responsibility to redo the schedule. I tried every iteration possible to try to get the interns some full weekends off. At my hospital, it was impossible. We only had so many bodies to fill a set amount of hours. I tried weird rotating start and end times, alternating 16hr and 12hr shifts, cross covering additional teams. The only way to make it work would have been to combine two additional services on the weekend under one intern. We all agreed (interns and faculty included) that the workload would have been too much. Interns ended up working 6 days a week, all year (M-F 13/hrs a day, and one 12hr weekend shift each weekend).

I would take the 28hr shifts twice a month over the 16 hr cap in a heartbeat. 1 day off is not enough to decompress. You need the occasional full weekend.

For those saying....
1) Hire more interns -- you clearly have no idea how hard it is to increase the resident cap through ACGME, especially in a surgical program. Where are the extra cases going to come from when they become senior residents? So just hire prelims? What non-existent spots to they goto after their prelim year?

2) Hire more PAs and NPs -- did that. Unfortunately, midlevels are in high demand right now. How long do you think they will stay at your hospital if you only are having them do intern level work so the interns could have a break? They are also significantly more expensive -- 2 PAs at ~30% higher salary PER person to cover each intern. What kind of midlevels do you think you're gonna get for that kind of work? New grads, who will take a fair amount of oversight and training to get them up to speed, and then quit as soon as a better job comes along.

3) The cost isn't our problem -- well, unfortunately it is. The boat on doctors running hospitals has sailed. Administrators are going to look for the lowest cost option to achieve a level of appropriate patient care. Unless you have a net-even solution to decrease intern work load, no one is going to listen to you whine.

 

[SouthernSurgeon]

I was administrative chief resident after the 16/hr cap for interns. It was my responsibility to redo the schedule. I tried every iteration possible to try to get the interns some full weekends off. At my hospital, it was impossible. We only had so many bodies to fill a set amount of hours. I tried weird rotating start and end times, alternating 16hr and 12hr shifts, cross covering additional teams. The only way to make it work would have been to combine two additional services on the weekend under one intern. We all agreed (interns and faculty included) that the workload would have been too much. Interns ended up working 6 days a week, all year (M-F 13/hrs a day, and one 12hr weekend shift each weekend).

This is I think an important point.

At my program the residents were also heavily involved in trying to redo the schedules. One of my classmates came up with the final iteration that we used. We did everything we could to try and find the best possible option in terms of time off and days off. The program director signed off on it but it was our decision how to do it. It's not like the program was out there trying to screw us over - we made the changes ourselves and it was the best possible option we could think of for our particular program's needs. Every residency I know of did the same after 2011 - residents made the schedules to meet the new rules.

2) Hire more PAs and NPs -- did that. Unfortunately, midlevels are in high demand right now. How long do you think they will stay at your hospital if you only are having them do intern level work so the interns could have a break? They are also significantly more expensive -- 2 PAs at ~30% higher salary PER person to cover each intern. What kind of midlevels do you think you're gonna get for that kind of work? New grads, who will take a fair amount of oversight and training to get them up to speed, and then quit as soon as a better job comes along.

I always find it kind of funny. As I mentioned before - we have hired more PAs. My department barely had any when I was an intern. And now we have a buttload. They are a genuine help to the interns and (not to sound all walking uphill both ways in the snow old man...) the floor work is easier now than it was when I was an intern. It has made our residency more humane. And what has been the result? Now the interns just complain that the PAs get paid more than they do.

 

[Psai]

This is I think an important point.

At my program the residents were also heavily involved in trying to redo the schedules. One of my classmates came up with the final iteration that we used. We did everything we could to try and find the best possible option in terms of time off and days off. The program director signed off on it but it was our decision how to do it. It's not like the program was out there trying to screw us over - we made the changes ourselves and it was the best possible option we could think of for our particular program's needs. Every residency I know of did the same after 2011 - residents made the schedules to meet the new rules.



I always find it kind of funny. As I mentioned before - we have hired more PAs. My department barely had any when I was an intern. And now we have a buttload. They are a genuine help to the interns and (not to sound all walking uphill both ways in the snow old man...) the floor work is easier now than it was when I was an intern. It has made our residency more humane. And what has been the result? Now the interns just complain that the PAs get paid more than they do.

Well you only know what you go through. Can't tell what it's like when you haven't been through it.

The solution is simple. Give all the PAs paid leave for a month and watch your interns struggle.

 

[chipwhitley]

If interns and residents are so vital to keeping a hospital afloat and midlevels are too expensive to hire, how exactly do hospitals without a residency program survive?

 

[VA Hopeful Dr]

Through a completely different calculus.

Academic hospitals could survive, it would just require radical change and removing the academic (i.e. research and training) missions.

That, and I know of very few non-academic level one trauma centers

 

[ProfMD]

If interns and residents are so vital to keeping a hospital afloat and midlevels are too expensive to hire, how exactly do hospitals without a residency program survive?

Academic hospitals, by and large, are less efficient. As @SouthernSurgeon mentioned, they have an academic mission (teaching and research) that cuts into productivity and costs money. In addition, as @VA Hopeful Dr mentioned, academic centers take care of a different population that often has more acute needs, like the trauma patient. These are patients who also tend to have little or no insurance.

Non-academic hospitals survive in part by hiring armies of physician extenders, but also by selecting which patients they care for (less complex, well-insured). Academic centers end up taking care of the more expensive, less well-insured patients. Of course, there are examples on both sides of hospitals that don't fit these molds, but on average this is the way it works.

 

[sazerac]

If interns and residents are so vital to keeping a hospital afloat and midlevels are too expensive to hire, how exactly do hospitals without a residency program survive?

Some of my interviews have been at programs that recently made the transition- the hospital functioned just fine for years without a residency program, and they added a residency in the last five years or so.

Definitely a different vibe at a hospital where they have residents because they want them, instead of needing them to keep the doors open.

 

[chipwhitley]

Academic hospitals, by and large, are less efficient. As @SouthernSurgeon mentioned, they have an academic mission (teaching and research) that cuts into productivity and costs money. In addition, as @VA Hopeful Dr mentioned, academic centers take care of a different population that often has more acute needs, like the trauma patient. These are patients who also tend to have little or no insurance.

Non-academic hospitals survive in part by hiring armies of physician extenders, but also by selecting which patients they care for (less complex, well-insured). Academic centers end up taking care of the more expensive, less well-insured patients. Of course, there are examples on both sides of hospitals that don't fit these molds, but on average this is the way it works.

How do non-academic hospitals select patients? I thought hospitals were required to treat any patient who comes to the ED regardless of insurance.

 

[ProfMD]

How do non-academic hospitals select patients? I thought hospitals were required to treat any patient who comes to the ED regardless of insurance.

Only for life or limb threatening emergencies. Once the patient is stabilized, they can kick them out. Transfers of underinsured patients from private to academic because they are "too sick" happens all the time. Also, EMTALA violations happen routinely in some private hospitals.

The big money is in elective procedures, though. Here there is definitely a lot of cherry picking going on.

 

[Psai]

Only for life or limb threatening emergencies. Once the patient is stabilized, they can kick them out. Transfers of underinsured patients from private to academic because they are "too sick" happens all the time. Also, EMTALA violations happen routinely in some private hospitals.

The big money is in elective procedures, though. Here there is definitely a lot of cherry picking going on.

So true, I'm pretty tired of dealing with trainwrecks that get sent over by mt st elsewhere