New work hour rules? for residency!??!

Started by HMSBeagle
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HMSBeagle

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Hi. There is a thread in the surgery forum where they are discussing some new work hour rules for residents. Here is the link: http://forums.studentdoctor.net/showthread.php?t=497748
Basically the rumor is that work hours will be capped at 56 hours per week. It also says about the possibility of restricting work hours even for attending physicians. Is this true or a rumor? Has anyone heard about this? I don't think this is a wise decision because if it were true residency will be longer and I mean, 80 hours a week seems fair enough. I'm just very confused by this, so if anyone has any info please enlighten us.
Thanks!!!
 
HMSBeagle said:
Hi. There is a thread in the surgery forum where they are discussing some new work hour rules for residents. Here is the link: http://forums.studentdoctor.net/showthread.php?t=497748
Basically the rumor is that work hours will be capped at 56 hours per week. It also says about the possibility of restricting work hours even for attending physicians. Is this true or a rumor? Has anyone heard about this? I don't think this is a wise decision because if it were true residency will be longer and I mean, 80 hours a week seems fair enough. I'm just very confused by this, so if anyone has any info please enlighten us.
Thanks!!!
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Can you even get anything done in 56 hours per week?
 
This is ridiculous, but this is also the way you expect the field to be headed if we end up with socialized healthcare (this is a GREAT way to cut pay to physicians across the board). This is exactly what the govt wants, to circumvent doctors and to have a bunch of lawyers and accountants decide how medicine should be practiced in the US.

The problem with this policy is that if we end up with socialized healthcare with lower physician salaries, the number and quality of people entering medicine will drop significantly. Unlike in socialized countries such as Canada, Britain, France etc where lawyers and investment bankers dont make as much (or are taxed in such a high bracket it doesnt matter), in the US the kinds of students who get into medical school are the kinds that could easily become lawyers or i-bankers instead (see: drop in MD applicants during dotcom boom).

Also no one will want to specialize.

So if you extend training in number of years and decrease pay (which this is just a backhanded way of justifying) you are going to have even LESS doctors in the field. And considering the baby boomers are a decade away from major medical issues (if they havent already hit some), this is the worst possible thing you can do.

Can you imagine the waitlists? Fewer doctors are going to want to go into specialties (who wants to train for 12 years to only get paid 150k when you can go straight from college to Wall St and make 200k) and all these doctors can only work 56 hours? And medicare won't pay if you go over 56 hours? So what if you're an interventional cardiologist who's clocked at 55 hours and you get a STEMI page at 3AM... you are ethically bound to cath but youre not going to get paid? WTF

This is all starting to wreak of socialized healthcare-- reduced physician hours with consequent reduced pay, favoring a system of GPs of specialists, and long waitlists for patients.

We're trying to become like Europe as far as healthcare, yet our tax burden is nowhere near theirs... and everyone forgets Europe doesnt have nearly the same illegal immigration problems that the US does.
 
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I agree with both of you. Has anyone heard of this? Is this true? If so, who is behind this? Way to go and compromise patient care.
I just hope we don't adopt socialized health care, as it is going to wreck everyone everywhere including patients.
 
I don't necessarily disagree with anything that's been said, and I have no idea whether we're headed toward socialized medicine. (I also see no evidence that any of these new regulations are being considered by any body other than SDN posters.) Does anybody think, though, that there is at least some added value to the state of our brains when we have had adequate sleep vs inadequate sleep? Both in terms of medical errors and in terms of acquisition of new information and skills, I feel like more and more research demonstrates clearly that we are more impaired than we know most of the time. I'm not saying that I support a 56 hour work week or anything, and I realize it would be hard to achieve solid training and appropriate continuity of care under such restrictions, but I do think we should at least consider this aspect. Obviously shorter hours doesn't necessarily mean more sleep, but I think most people would agree that they get more sleep during 4th year med school than during intern year, so there's some correlation.
 
At the last APDIM meeting, the medicine RRC chair was asked about this. They responded that there was no such ongoing discussion to their knowledge, and no interest in decreasing workhours further.

Much of the push for this was over concerns for patient safety. Some focused studies had suggested that medical errors were decreased when duty hours were lowered. However, this study post implementation of the 80 hour rule failed to demonstrate any change in mortality.

I doubt we will see any further lowering of the 80 hour limit.
 
aProgDirector said:
At the last APDIM meeting, the medicine RRC chair was asked about this. They responded that there was no such ongoing discussion to their knowledge, and no interest in decreasing workhours further.

Much of the push for this was over concerns for patient safety. Some focused studies had suggested that medical errors were decreased when duty hours were lowered. However, this study post implementation of the 80 hour rule failed to demonstrate any change in mortality.

I doubt we will see any further lowering of the 80 hour limit.
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Just for the sake of argument (Id rather not see any further lowering either) how do you reconcile the study you posted with the similar VA study?

http://jama.ama-assn.org/cgi/content/full/298/9/984
 
Rasengan said:
Just for the sake of argument (Id rather not see any further lowering either) how do you reconcile the study you posted with the similar VA study?

http://jama.ama-assn.org/cgi/content/full/298/9/984
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Those papers were parallel studies by the same first author. Both address this issue of the discrepancy. To quote from the VA study:

Possible reasons for the differences in findings are detailed in that study, but briefly they include the markedly greater mean resident-to-bed ratios at VA teaching hospitals compared with non-VA teaching hospitals, potentially greater autonomy for residents at VA hospitals,47-48 differences in staffing models and clinical volume, differing balances between the effects of decreased fatigue41-43 and worsened continuity,45-46 and potentially different degrees of unmeasured confounders.
 
0382938 said:
Those papers were parallel studies by the same first author. Both address this issue of the discrepancy. To quote from the VA study:

Possible reasons for the differences in findings are detailed in that study, but briefly they include the markedly greater mean resident-to-bed ratios at VA teaching hospitals compared with non-VA teaching hospitals, potentially greater autonomy for residents at VA hospitals,47-48 differences in staffing models and clinical volume, differing balances between the effects of decreased fatigue41-43 and worsened continuity,45-46 and potentially different degrees of unmeasured confounders.
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Well I was asking a leading question :laugh:

I felt the study that aPD posted didnt do a good job of dilineating between teaching and non-teaching services (the latter of which are especially prominent at non-county centers). I do feel that the VA study is a better indicator simply because (as you stated above) there are more resident beds and more resident autonomy.

I think just as interesting would be a study looking at county hospitals affiliated with academic medical centers. But I do feel the VA study better addresses the question of resident fatigue and outcomes, as it seems as if the VA study involves centers that are more "resident intense" than the more generalized study.
 
It seems, like anything in life we have to find that happy medium, or barring that . . . compromise. 80hrs per week is just about right IMHO. If you start pushing things beyond that, I think you really do run the risk of not letting your resident's get enough sleep and/or out of the hospital time. With that said, at any teaching institution there is so much work that NEEDS to be done, and above and beyond that, much of residency is learning through doing. For instance, I remember learnig about pancreatitis in my first two years of medical school, but it was actually when I was the student on a pancreatitis case that things started to really come together. The same with residency. We need as much time in the hospital as is safely possible if we are to become what we want to be. 80hrs seems to be the happy medium.
 
Christopher Landrigan, who was involved with some of the literature on this topic (including this paper)
gave grand rounds at NIH last year and addressed some of these issues. His conclusion is that the current system is unsafe. He also addresses the issues of information lost at signout and the comparison with other industries and with the medical profession in other countries. If anybody has the patience to listen, I'd be interested to hear your responses.

(I haven't done residency yet and don't yet have a well-formed opinion on the matter.)
 
Check the thread in the surgery forum. Supposedly there are rumors about also limiting attending work hours. For example, you need 8 hours of rest before being able to come to work, etc, like truck drivers.
 
I'm curious who they propose would come in on emergent cases for surgery, or who would pay all the nursing over time required for postponing the elective surgeries so they attendings are gone the full 8 hours.

You either going to have 4 times as many physicians as the projected shortfall, or they'd be shoving midlevels in to fill the gaps.
 
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0382938 said:
Christopher Landrigan, who was involved with some of the literature on this topic (including this paper)
gave grand rounds at NIH last year and addressed some of these issues. His conclusion is that the current system is unsafe. He also addresses the issues of information lost at signout and the comparison with other industries and with the medical profession in other countries. If anybody has the patience to listen, I'd be interested to hear your responses.

(I haven't done residency yet and don't yet have a well-formed opinion on the matter.)
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That grandrounds was freakin awesome. Thanks for posting it.

I have to say after hearing that . . . further change is probably needed. I'd have a hard time stomaching 56 hours per week, like the Europeans, but one of the studies he did with the interns in the ICU had them working like 65 hours per week. I was also fascinated to find out that a structured hand-off system virtually eliminated any medical errors associated with the hand-off itself. If this could be done, and from data he showed from studies that have done this in practice, in a practical fashion, I don't see how it will be much longer before the changes come.
 
Do you think that attending physician's work hours can be limited? What is the possibility of this happening and if so what could be a reasonable hour cap?
 
HMSBeagle said:
Do you think that attending physician's work hours can be limited? What is the possibility of this happening and if so what could be a reasonable hour cap?
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I would say that most physicians when done with training, will work reasonable hours, mostly because they will want to. But . . . perhaps you are alluding to attending physicians in teaching institutions and should there hours be limited? I would have to say that, after listening to the talk, particularly the points on acute sleep deprivation and chronic sleep deprivation, that some sort of restriction on work hours is sane. What that would be needs to be better defined through more investigation. Other industries limit on duty hours, such are airline pilots, long-haul truckers, and nuclear engineers. So I think a reasonable and equitable solution can be found with more investigation. But it is pretty clear that mistakes go up with increasing number of on duty hours. So how does this apply to an attending who is not actually "in house" for the whole time would make it a different and unusual situation.

No real god answers yet, but enough data to suggest it needs to be seriously looked at.
 
I predict that overnight call is doomed. I'm not sure if it will be 1) mandate from congress, 2) mandate from ACGME, or 3) high profile death / major monetary litigation.

All programs will switch to a night float only system. Duty hours will likely stay at 80, maybe shifted to 70. Shifts will be limited to 12-16 hours max.

It's unclear how programs will do this. Switching from an overnight call system to a shift based system is about 20% less efficient -- i.e. you need 20% more people to do all the work. This means that 1) they hire new people to do this extra work; 2) residents from non-call rotations are pulled to cover some shifts.

Of note, if duty hours are shifted to 70, then six 12 hour shifts (which is what's often needed to cover an inpatient service) doesn't fit any more.
 
aProgDirector said:
I predict that overnight call is doomed. I'm not sure if it will be 1) mandate from congress, 2) mandate from ACGME, or 3) high profile death / major monetary litigation.

All programs will switch to a night float only system. Duty hours will likely stay at 80, maybe shifted to 70. Shifts will be limited to 12-16 hours max.

It's unclear how programs will do this. Switching from an overnight call system to a shift based system is about 20% less efficient -- i.e. you need 20% more people to do all the work. This means that 1) they hire new people to do this extra work; 2) residents from non-call rotations are pulled to cover some shifts.

Of note, if duty hours are shifted to 70, then six 12 hour shifts (which is what's often needed to cover an inpatient service) doesn't fit any more.
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That would be unfortunate, I think we tend to learn the most on night call. Its brutal, but its a right of passage (though I wouldnt mind it being reduced to q7 sometimes)
 
TheDuke2K said:
That would be unfortunate, I think we tend to learn the most on night call. Its brutal, but its a right of passage (though I wouldnt mind it being reduced to q7 sometimes)
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It's "rite" as in "ceremony," I agree with the comment that the data suggests that we learn best when we're awake, and I'd also like to point out that (in case you think all the cool stuff happens at night, which might have some truth) it doesn't seem likely that residents will stop working nights altogether; it's just that it might not be right after an entire day (e.g. night float). Patients will continue to get sick at night, attendings will continue to like to stay at home with their families, and residents will continue to fill in the gap. If they're little more well-rested when they do it, I say all the better.
 
jdh71 said:
The data suggests otherwise
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I wasnt aware that there was data that compared learning during the day shift vs. night call.

Just anecdotally, however, I do feel as if Ive learnt the most on night call when there are not as many people around and you are forced to make decisions.

I do think it does wear on you though, and sleeplessness can lead to medical errors. That said, I still maintain that night call is useful educationally... and definitely moreso if it could be done less frequently as to minimize fatigue but maintain that level of learning.
 
TheDuke2K said:
I wasnt aware that there was data that compared learning during the day shift vs. night call.

Just anecdotally, however, I do feel as if Ive learnt the most on night call when there are not as many people around and you are forced to make decisions.
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I'm glad you've stated your feelings. Maybe we can all hold hands and sing kuhm-bye-ya . . .

I do think it does wear on you though, and sleeplessness can lead to medical errors. That said, I still maintain that night call is useful educationally... and definitely moreso if it could be done less frequently as to minimize fatigue but maintain that level of learning.
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There is something magical about learning at night? Is that when the pixies and ferries sprinkle their dust and it just goes into your brain better?

Bottom line, almost everyone learns better by doing. Since patients also come into the hospital at night, one can also learn at night. The efficiency of learning at night after already being awake 12+ is LESS than merely working a night shift alone, furthermore you get the added bonus of more medical errors. 👍 Therefore, limiting shifts is not only the sane thing to do, it will also help your learning, irrespective of when you are working.
 
jdh71 said:
There is something magical about learning at night? Is that when the pixies and ferries sprinkle their dust and it just goes into your brain better?

Bottom line, almost everyone learns better by doing. Since patients also come into the hospital at night, one can also learn at night. The efficiency of learning at night after already being awake 12+ is LESS than merely working a night shift alone, furthermore you get the added bonus of more medical errors. 👍 Therefore, limiting shifts is not only the sane thing to do, it will also help your learning, irrespective of when you are working.
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Snippy.

Alternative bottom line: You get the most out of your learning experience when you admit AND manage. That is, you see the initial presentation, you fully manage the critical first 24 hours in the hospital, you continue to care for the patient throughout their illness, and you arrange disposition. Working for 12 hours a day five days a week then checking out is bad for learning and for patient care. Sign-outs are dangerous, and too many of them rob you of the chance to take ownership of your patients.

I am glad I've had overnight call, and not just because I have "feelings" but because it has made me a better and more confident physician. You are free to feel otherwise, but don't think it's because you're adhering to logic and I'm an idiot. 👍
 
RTrain said:
Snippy.

Alternative bottom line: You get the most out of your learning experience when you admit AND manage. That is, you see the initial presentation, you fully manage the critical first 24 hours in the hospital, you continue to care for the patient throughout their illness, and you arrange disposition. Working for 12 hours a day five days a week then checking out is bad for learning and for patient care. Sign-outs are dangerous, and too many of them rob you of the chance to take ownership of your patients.
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The data clearly shows you do not work as well and make more mistakes the longer you have been awake and on service. There is no debate. You may think staying awake for 30 hours has made you a hero, but it has not it has only made you more prone to mistakes not only in the hospital but out. There are certain natural limitations to the human animal, and REAL and not alternative bottom line is that the safety of patients is paramount to whatever perceived extra learning you may think you get.

Sign-outs have been shown to completely safe if handled in a standardized formal fashion.

I am glad I've had overnight call, and not just because I have "feelings" but because it has made me a better and more confident physician. You are free to feel otherwise, but don't think it's because you're adhering to logic and I'm an idiot. 👍
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If you think you are a better physician to you patients for having been up all night after being on service all day, then I am not the idiot, you are. The data is clear you are more dangerous and mistake prone. The logical person looks at the data and sees what the best course of action is based on what is empiric. The idiot, thumps his chest, grabs his d1ck, and tells everyone else he's "ok," this is the BEST way for things to be . . . :laugh:

I don't "feel" otherwise. I'm making my case from the established data. Are you? Your argument isn't with me, but with what has been shown to be safe. And before running your mouth, maybe you should do some investigating? Might help. Evidence based medicine is all the rage these days . . .
 
jdh71... do you even read your posts before you send them? you have a chip on your shoulder?
 
Search for "Harvard Work Hours, Health and Safety Group" for a pile of references.

Here's a list of that group's published research:

https://workhours.bwh.harvard.edu/2007-12-01_HWHHSG_Manuscripts.html

Conclusions from http://content.nejm.org/cgi/content/full/351/18/1829:
"Eliminating interns' extended work shifts in an intensive care unit significantly increased sleep and decreased attentional failures during night work hours."

From http://content.nejm.org/cgi/content/full/351/18/1838:
"Interns made substantially more serious medical errors when they worked frequent shifts of 24 hours or more than when they worked shorter shifts. Eliminating extended work shifts and reducing the number of hours interns work per week can reduce serious medical errors in the intensive care unit."

From: http://jama.ama-assn.org/cgi/content/abstract/296/9/1055
"Extended work duration and night work were associated with an increased risk of percutaneous injuries in this study population of physicians during their first year of clinical training."

From: http://content.nejm.org/cgi/content/full/352/2/125
"In months in which interns worked five or more extended shifts, the risk that they would fall asleep while driving or while stopped in traffic was significantly increased."

These studies can (and have been) criticized for various reasons. Besides methodology and bias concerns, another warning is that by hiring more interns to cover the same amount of ICU time the overall learning opportunities by interns are reduced:
http://content.nejm.org/cgi/content/full/352/7/726
This is a long-winded way of saying "when I was the only intern in the hospital over night I learned a lot more than if there had been three interns."
 
Another interesting bit of work hour trivia is how the limit was devised. Dr. Bertrand Bell (of the "Bell Commission") writes:
http://jama.ama-assn.org/cgi/content/full/298/24/2865-b
The specific "80-hour week" was actually determined by a colleague on my porch and was based on the following informal reasoning: (1) there are 168 hours in a week; (2) it is reasonable for residents to work a 10-hour day for 5 days a week; (3) it is humane for people to work every fourth night; (4) subtracting the 50-hour week (10 hours per day x 5 days) from 168 hours leaves 118 hours; (5) divide 118 by 4 (every fourth night) and add to the 50 hours and, eureka, that equals an 80-hour week.
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jdh71 said:
The data clearly shows you do not work as well and make more mistakes the longer you have been awake and on service. There is no debate. You may think staying awake for 30 hours has made you a hero, but it has not it has only made you more prone to mistakes not only in the hospital but out. There are certain natural limitations to the human animal, and REAL and not alternative bottom line is that the safety of patients is paramount to whatever perceived extra learning you may think you get.
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The data are conflicting. The study in the July 2007 Annals (Ann Intern Med. 2007 Jul 17;147(2):97-103) showed that outcomes such as pharmacist intervention to prevent errors have been reduced, but the big outcomes like length-of-stay and in-hospital death were not affected. Most will agree that the present data are inconclusive with respect to an improvement in patient safety.
Sign-outs have been shown to completely safe if handled in a standardized formal fashion.
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I can't find studies demonstrating safety. I find a lot of studies demonstrating unsafe hand-offs and suggesting fixes. If there are data that show "complete safety" of standardized sign-outs, please share.
If you think you are a better physician to you patients for having been up all night after being on service all day, then I am not the idiot, you are. The data is clear you are more dangerous and mistake prone. The logical person looks at the data and sees what the best course of action is based on what is empiric. The idiot, thumps his chest, grabs his d1ck, and tells everyone else he's "ok," this is the BEST way for things to be . . . :laugh:
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1. I didn't say you were an idiot, I said you think I'm an idiot, which you restate above.
2. I don't think I'm a better physician when I'm sleep deprived. I think I know my patients better when I care for them in a continuity fashion - speaking only for myself, I can say with certainty that I have the most complete understanding of my patients' conditions when I am post-call, because nothing happened overnight in which I was not directly involved. Does this mean I think I should be on call every night, live in the hospital? Of course not. But I think just reducing hours is not the sole key to improving education or outcomes - there is obviously more to it than that.
3. I don't have a d*ck.
I don't "feel" otherwise. I'm making my case from the established data. Are you? Your argument isn't with me, but with what has been shown to be safe. And before running your mouth, maybe you should do some investigating? Might help. Evidence based medicine is all the rage these days . . .
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I fail to see how you are adhering more to the evidence with your argument than I with mine. You are all over "the data" but quote none of it. I have a PubMed search window open.
 
jdh71 said:
I'm glad you've stated your feelings. Maybe we can all hold hands and sing kuhm-bye-ya . . .



There is something magical about learning at night? Is that when the pixies and ferries sprinkle their dust and it just goes into your brain better?

Bottom line, almost everyone learns better by doing. Since patients also come into the hospital at night, one can also learn at night. The efficiency of learning at night after already being awake 12+ is LESS than merely working a night shift alone, furthermore you get the added bonus of more medical errors. 👍 Therefore, limiting shifts is not only the sane thing to do, it will also help your learning, irrespective of when you are working.
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Classy. 🙄

So where's the data to back your claim that you learn less at night? Oh wait, you dont have any either... at least I admit straight up Im speaking from personal experience.

And no, there is nothing magical about the night, if you had actually read my post you would see that the only reason I feel we learn more at night is because you get to do more-- no one else is around.

If there was some way to take the autonomy we get at night and combine it with more humane hours during the day, Id be all for it... who wouldnt?
 
Thanks pjm, I appreciate the links. What I was a little more interested in though was the previous posters claim that there are data to suggest that resident education is better without overnight call. Does anyone know of the papers he's referring to?

In my search I found a few things--one study about medical students on their surgery rotation and some neuropsych data about cognition during sleep deprivation--but the difficulty in establishing hard end points to define "quality of education" I think make it hard to make blanket statements like, "overnight call is not a good educational experience." I'm wondering if there are additional studies out there I'm not aware that strengthen that argument.
 
RTrain said:
The data are conflicting. The study in the July 2007 Annals (Ann Intern Med. 2007 Jul 17;147(2):97-103) showed that outcomes such as pharmacist intervention to prevent errors have been reduced, but the big outcomes like length-of-stay and in-hospital death were not affected. Most will agree that the present data are inconclusive with respect to an improvement in patient safety.
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I see. So you are arguing that mistakes are not a problem since patients don't stay longer and don't die more? This now makes mistakes "ok".

I can't find studies demonstrating safety. I find a lot of studies demonstrating unsafe hand-offs and suggesting fixes. If there are data that show "complete safety" of standardized sign-outs, please share.
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I will also refer you to the link above Christopher Landrigan at ground rounds NIH. He discusses this point.

1. I didn't say you were an idiot, I said you think I'm an idiot, which you restate above.
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Yes

2. I don't think I'm a better physician when I'm sleep deprived. I think I know my patients better when I care for them in a continuity fashion - speaking only for myself, I can say with certainty that I have the most complete understanding of my patients' conditions when I am post-call, because nothing happened overnight in which I was not directly involved. Does this mean I think I should be on call every night, live in the hospital? Of course not. But I think just reducing hours is not the sole key to improving education or outcomes - there is obviously more to it than that.
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The problem is, your version of "control" is at odds with what is being reported. You are unable, as is anyone, to objective about yourself. Anything important that happened overnight can easily be told to you through a structured handoff.

3. I don't have a d*ck.
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The allusion need not be literal to have power. You're quibbling.

I fail to see how you are adhering more to the evidence with your argument than I with mine. You are all over "the data" but quote none of it. I have a PubMed search window open.
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I will refer you again to the link above. I'm not going to do all of the heavy lifting.
 
TheDuke2K said:
Classy. 🙄

So where's the data to back your claim that you learn less at night? Oh wait, you dont have any either... at least I admit straight up Im speaking from personal experience.

And no, there is nothing magical about the night, if you had actually read my post you would see that the only reason I feel we learn more at night is because you get to do more-- no one else is around.

If there was some way to take the autonomy we get at night and combine it with more humane hours during the day, Id be all for it... who wouldnt?
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No ones taking away the night smart guy. You'll still have the night and your autonomy. You just won't have the night after working all day long first. Do I have to connect all the dots?
 
It may be a good idea to cut the hours in some specialties (IM, FM, Rads) but others (surgery) may not be able to achieve this. Also, residencies will be much longer and residents need to graduate to work to pay debts. I don't know if fellowships(GI, Endo, PCCM, Cards, Rheum) have a problem with hours but and I also dont know if the 80 hour rule applies to fellowships. Do fellowships go over 80 rs a week regularly? In the surgery forum they posted something regarding the ACS meeting saying that in maybe 5 years there could be an implantation of a european-like model in the US (40 hours/week). There may be a need to cut down on hours but come on 40 hrs is just too much. I think a happy medium (around 60-70) is possible, and things wont be disrupted so much because FREIDA lists many IM programs with average hours around the 60s weekly.
 
aProgDirector said:
However, this study post implementation of the 80 hour rule failed to demonstrate any change in mortality.
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The real question if the 80 hour rule was successful shouldn't measure 80 hours vs. mortality, it should measure 80 hours vs. physician errors because not all physician errors because such errors can increase morbidity without increasing mortality. So I'd have to say that such a study starts from a flawed premise.
 
RTrain said:
Alternative bottom line: You get the most out of your learning experience when you admit AND manage. That is, you see the initial presentation, you fully manage the critical first 24 hours in the hospital, you continue to care for the patient throughout their illness, and you arrange disposition. Working for 12 hours a day five days a week then checking out is bad for learning and for patient care. Sign-outs are dangerous, and too many of them rob you of the chance to take ownership of your patients.

I am glad I've had overnight call, and not just because I have "feelings" but because it has made me a better and more confident physician. You are free to feel otherwise, but don't think it's because you're adhering to logic and I'm an idiot. 👍
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I'm a fan of overnight call for exactly these reasons, but the typical 30-hour shift - in Medicine, anyway - doesn't often fit the ideal. In my hospital, few/no patients are admitted at 8a and followed for 30 hours. Many, many patients are admitted 10p-4a, with the plan just in place by morning and most of that "following" done by the day-covering team. I bonded with many patients overnight and learned some important "gut" lessons (maybe not so much detailed Medicine), but can't help but wonder if a shift like 4p-6a, during which I would be reasonably awake the entire time, might have been an even better experience. Some places do that. In fact, every program seems to have a different shift arrangement. If there is a new discussion about work hours, it should be lively.

Pet peeve: Signouts should not be dangerous. They become dangerous because the functional (as opposed to formal) documentation of patients is often poor, and because in many places signout is done to a different person every night. These problems are easily remedied with an efficient electronic signout that residents are trained to use effectively, and letting the night person/team get to know the patients by having a regular night float team or night component of the primary team.
 
aProgDirector said:
At the last APDIM meeting, the medicine RRC chair was asked about this. They responded that there was no such ongoing discussion to their knowledge, and no interest in decreasing workhours further.

Much of the push for this was over concerns for patient safety. Some focused studies had suggested that medical errors were decreased when duty hours were lowered. However, this study post implementation of the 80 hour rule failed to demonstrate any change in mortality.

I doubt we will see any further lowering of the 80 hour limit.
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Old_Mil said:
The real question if the 80 hour rule was successful shouldn't measure 80 hours vs. mortality, it should measure 80 hours vs. physician errors because not all physician errors because such errors can increase morbidity without increasing mortality. So I'd have to say that such a study starts from a flawed premise.
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this also seems to pre-suppose that the physician(s) are the only ones that contribute to mortality... that nothing else in the system contributes to mortality.

in another way, if one wants to truly believe that there's no difference in mortality whether we work 80 hours a week vs 120 hours a week vs some other number higher than 80, one could argue that we've become more efficient! in a way, that the same thing (patients dying/mortality) is unchanged whether we working an inordinate amount of hours (pre-80 hour rule) or not (post-80 hour rule).

RTrain said:
Snippy.

Alternative bottom line: You get the most out of your learning experience when you admit AND manage. That is, you see the initial presentation, you fully manage the critical first 24 hours in the hospital, you continue to care for the patient throughout their illness, and you arrange disposition. Working for 12 hours a day five days a week then checking out is bad for learning and for patient care. Sign-outs are dangerous, and too many of them rob you of the chance to take ownership of your patients.

I am glad I've had overnight call, and not just because I have "feelings" but because it has made me a better and more confident physician. You are free to feel otherwise, but don't think it's because you're adhering to logic and I'm an idiot. 👍
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at some point you have to sign out your patient(s)... unless you're advocating for staying in the hospital the entire stay of your patient(s) and/or advocating to being called/paged 24/7/365 (366 in a leap year)! the question is, in my mind at least, when should a physician be heading home since he/she can not stay for ever. it seems that, thus far, the 80 hour rule has shown that patients do no worse than they did before.

at the end of the day, some patients make it through because of what we do. other patients make it through despite what we do (some would call it the grace of God). some patients don't make despite what we do.
 
elwademd said:
it seems that, thus far, the 80 hour rule has shown that patients do no worse than they did before.
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Landrigan placed this data into context . . . informal survey's have shown that most resident's DO actually work over the 80 limit while on the wards. There is ZERO personal incentive to "ratting" on your program regarding this issue. Much like a dysfunctional family, you just don't talk about lest you bring down the wrath of the other members of the family. Therefore you wouldn't actually expect any less errors when you have a system that cannot adequately police itself.

I'm sure work hours average out nicely for the clinic/consult/elective/research months . . .

The europeans seem have have better clinical outcomes than we do. I wonder how they do it only working 56hrs per week . . .
 
jdh71 said:
Landrigan placed this data into context . . . informal survey's have shown that most resident's DO actually work over the 80 limit while on the wards. There is ZERO personal incentive to "ratting" on your program regarding this issue. Much like a dysfunctional family, you just don't talk about lest you bring down the wrath of the other members of the family. Therefore you wouldn't actually expect any less errors when you have a system that cannot adequately police itself.

I'm sure work hours average out nicely for the clinic/consult/elective/research months . . .

The europeans seem have have better clinical outcomes than we do. I wonder how they do it only working 56hrs per week . . .
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Don't get carried away now. While I'm sure there are people who work more than 80 hours in a given week I think it's also fair to argue that those might be the people who would otherwise be working crazy 100+ hour weeks. In other words, even if the rules are sometimes bent the 80 hour work week does reduce the number of hours residents work and the fact that this intervention has failed to show any effect on hard endpoints is an issue that proponents of further work hour restrictions need to seriously address--much more seriously than "well, I bet they were fudging their hours."

With regard to the Europeans, I don't think I have to tell you the reasons (you probably already know) that that's not a valid argument...different patient populations, different physicians, different healthcare systems even within europe, etc etc. Far too many uncontrolled factors to chalk it up to them working shorter weeks...
 
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velo said:
Don't get carried away now. While I'm sure there are people who work more than 80 hours in a given week I think it's also fair to argue that those might be the people who would otherwise be working crazy 100+ hour weeks. In other words, even if the rules are sometimes bent the 80 hour work week does reduce the number of hours residents work and the fact that this intervention has failed to show any effect on hard endpoints is an issue that proponents of further work hour restrictions need to seriously address--much more seriously than "well, I bet they were fudging their hours."
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Look . . . I'm only telling you what's been said about the topic. These are not my new and original ideas. Landrigan has stated that informal and completely anonymous surveys of residents have shown them working well over 80hrs per work while on a ward service, especially ICU. However, our formal survey method shows everything to be fine and in order . . . so what gives? Therefore, this throws a possible confound (and a lot of context) into the study published last fall about health outcomes and the new hours. If there has been no real change in work hours practically, then you wouldn't expect health outcomes to be any different. We cannot know with any clarity how well the new hours are helping UNLESS there is a system that allows for accurate reporting of hours. Like I said there is a lot of peer and program pressure to NOT say anything. Would you want your program to risk the loss of accreditdation because someone kept ratting about work hours? Imagine it's March of your third year . . . you'd just want people to shut the hell up. So the argument is a wee bit more sophistcated than, "I bet they were fudging their hours".

With regard to the Europeans, I don't think I have to tell you the reasons (you probably already know) that that's not a valid argument...different patient populations, different physicians, different healthcare systems even within europe, etc etc. Far too many uncontrolled factors to chalk it up to them working shorter weeks...
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Well, if I made it sound like the only reason the Europeans are doing so well on helath outcomes is because residents work shorter hours then you would be correct, but that wasn't my point. Which is quite simply . . . they do have better health outcomes and shorter work hours for residents is part of that equation. It wasn't meant to be an end all, be all argument.
 
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