56 Hour resident work hour restrictions

[keithslc]

Has anyone heard anymore about the new IOM recommendations and,if they are going to be implemented by the ACGME?

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[Droopy Snoopy]

Has anyone heard anymore about the new IOM recommendations and,if they are going to be implemented by the ACGME?

So what does that work out to, like 9 hour days, 6 days/week with no call yeah I can see that happening.

 

[mcl]

Has anyone heard anymore about the new IOM recommendations and,if they are going to be implemented by the ACGME?

In March I attended a conference where Dr. Nasca stated that the 80 hour total would likely remain, but that the 24+6 time frame would decrease--possibly to 16 but nothing was firmly decided yet.

Here is a link to an interview with him in April:
http://pn.psychiatryonline.org/cgi/content/full/44/8/13

 

[NotAProgDirector]

The IOM recommendations were published last December, and are on their website. There is no 56 hour week. As mentioned, there are tighter rules recommended about time off, protected sleep time (otherwise known as "nap time"), etc. The IOM is advisory only, so these are recommendations only. The ACGME is reviewing the issue. New duty hour rules will be implemented likely July 2011 per the ACGME at the last APDIM meeting. There is broad agreement at the ACGME that they do not support all of the IOM recommendations, and it's unclear what any new rules will be. The ACGME has promised an open discussion with all stakeholders -- we will see.

 

[nope80]

I definitely think that they need to do something about this 80 hour week. The thing that people sometimes forget is that this isn't just 80 hours of regular work, its stressful, physically draining, mentally exhausting, and far from just simply sitting behind a desk, for ex, and working your merry way. Sometimes I think we forget in medicine that moderate is key; having residents that are well rested, have time to read, time to spend with their family, time to regroup and just reflect at the end of the day/week is very valuable. I just don't understand this black and white, almost sadistic culture that exists where we think we have to work work work residents/interns to death because that is part of this right of passage. Its horrible. They should reduce the 80 hour work week and enforce it! Ironically we are in the field of healthcare, yet induce incredibly unhealthy lifestyles. The sad part is that I know if they wanted to make it "easier" (ie more moderate) they could but its this stickler old medicine culture that gets in the way.

 

[SOUNDMAN]

Oh now, 80 hours is not that bad. It should not be any less, I don't want to lengthen residency anymore than it already is, and that is what will have to happen in order to learn the volume of material we are needing to learn.

 

[ANCAdoc]

I don't want to lengthen residency anymore than it already is, and that is what will have to happen in order to learn the volume of material we are needing to learn.

Not sure where this idea came from. As far as I know, there is no data to suggest that 80hrs is the breakpoint at which less time spent = learning less.

On the contrary, when I have time off I tend to, yes, spend time with my family and friends but this is the time I generally keep up to date by reading NEJM, the Annals of IM, JAMA, etc. The more I work, the less time I get to read, sleep, and consolidate those important concepts.

We Americans have this tendency to think more of everything is better. In this case, I like to think of medicine as a lifelong pursuit.

I am OK with a 24hr call shift. I disagree with a 24+6 shift. Those extra 6 hours are brutal. In those 6 hours I do what I normally take an entire day to do (round, staff pts, write orders/notes, call consults, etc). So already fatigued after working 24hrs, I have to work super fast. I don't understand why we try to defeat human physiology.

In my opinion, attendings need to step up to the plate. In many cases they staff only so many weeks/months each year. Not sure why they think they are immune to writing daily notes to create more human working conditions for house staff. If I remain in academic medicine, I won't forget the injustice.

 

[med2UCC]

Oh now, 80 hours is not that bad. It should not be any less, I don't want to lengthen residency anymore than it already is, and that is what will have to happen in order to learn the volume of material we are needing to learn.[/QUOT

That's absolutely not true. I'm doing residency in Canada, never work more than a 60 hour week and I'm having no problems learning what I need to know. I love my program. The arguments against shortening the work week are all geared around the hospitals being able to extract the maximum amount of work from residents for the minimum amount of money, nicely dressed up as "for your own good".
Cheers,
M

 

[bunbury]

On the contrary, when I have time off I tend to, yes, spend time with my family and friends but this is the time I generally keep up to date by reading NEJM, the Annals of IM, JAMA, etc. The more I work, the less time I get to read, sleep, and consolidate those important concepts.

We Americans have this tendency to think more of everything is better. In this case, I like to think of medicine as a lifelong pursuit.

Residents have to train for a certain number of hours to obtain the clinical experience they need to work independently. Cutting down resident work hours will extend the length of training. In Europe, residency training is much more humane. It takes longer to become an attending, but it also allows more time for reading, research, and, of course, having a life outside work. Their system may not be perfect, but they certainly have a better grasp on the notion of balance in life.

 

[trp2006]

Residents have to train for a certain number of hours to obtain the clinical experience they need to work independently. Cutting down resident work hours will extend the length of training. In Europe, residency training is much more humane. It takes longer to become an attending, but it also allows more time for reading, research, and, of course, having a life outside work. Their system may not be perfect, but they certainly have a better grasp on the notion of balance in life.

In Europe though, people start with medical school right after high school. So in reality, it takes longer to become a physician in US then Europe...

 

[KidDr]

I am OK with a 24hr call shift. I disagree with a 24+6 shift. Those extra 6 hours are brutal. In those 6 hours I do what I normally take an entire day to do (round, staff pts, write orders/notes, call consults, etc). So already fatigued after working 24hrs, I have to work super fast. I don't understand why we try to defeat human physiology.

I completely agree. In residency I had 6-10 months of q4 call per year (3 year peds residency). Making it to 24 hours was definitely do-able, I felt like I learned a lot, and I (for the most part) enjoyed the work. BUT...the 6+ hours on the past call day were brutal. You can make the argument that you're the best person to be caring for your patients on the post-call day, because you know them really well, but you could also make the argument that you're the best person to be caring for your patients on the first post-call afternoon, evening, night, and so on, because, again, you know them really well...and all of a sudden you're back in the 70s and 80s in the days of 36+ hour call. You have to sign out sometime. 24 hour call seems about right to me (this is just my opinion--I realize it's not necessarily supported by any patient outcome or sleep research).

In regards to the topic of this thread, I'll be very curious to see where this goes, and how/if the ACGME alters their work hours restrictions.

 

[GreatSaphenous]

If the ACGME tries to cut hours any further, I hope the surgical programs find another source of accredidation. Seriously, where is our sense of commitment? I hate scutwork as much as the next resident, but this shiftwork mentality dishonors our profession. Even the current rules ignore our commitments. If I am scrubbed in a case that goes late I should either scrub out or not round on my patients the next day all to insure that I have 10 hours off in between "shifts". What kind of professional are we seeking to train?

If you want free time go into derm or PM&R, but don't complain that the sick people need you during your prime sleeping time. And until someone shows an improved board pass rate that correlates with reduced work hours, don't claim that residents will read more when they have time off. Finally don't expect attendings who put in 100+ hours in their residencies to work more now, so you can work even less.

Sorry if I am being unkind, but we signed up to be doctors.

 

[Winged Scapula]

Iand all of a sudden you're back in the 70s and 80s in the days of 36+ hour call.

Try before 2004. It wasn't THAT long ago that we were working 36 hrs+.

I agree with GS and note that while perhaps there might be enough time to train in other specialties with reduced work hours (and no lengthening of residency - I do not know, as I've never been an IM, etc. resident), I am not at all convinced that surgical specialties can be trained mentally and physically in that amount of time.

Going home and reading about things after you leave the hospital sounds great, but most of us know that residents don't use the extra free time to read but rather to sleep, socialize, etc. And learning about surgery requires DOING IT, not just reading. You go home early, you aren't doing surgery.

 

[ANCAdoc]

If the ACGME tries to cut hours any further, I hope the surgical programs find another source of accredidation. Seriously, where is our sense of commitment? I hate scutwork as much as the next resident, but this shiftwork mentality dishonors our profession. Even the current rules ignore our commitments. If I am scrubbed in a case that goes late I should either scrub out or not round on my patients the next day all to insure that I have 10 hours off in between "shifts". What kind of professional are we seeking to train?

If you want free time go into derm or PM&R, but don't complain that the sick people need you during your prime sleeping time. And until someone shows an improved board pass rate that correlates with reduced work hours, don't claim that residents will read more when they have time off. Finally don't expect attendings who put in 100+ hours in their residencies to work more now, so you can work even less.

Sorry if I am being unkind, but we signed up to be doctors.

Someone else is saving you from your own incompetence. I call it incompetence because in the end there is a plethora of research to show long hours correlate with increased patient harm. Research on residents has shown increased rates of depression, marital problems, and even accidents. You still work like a dog in the face of all the data. That's incompetence. Patients cannot believe I work so much. 90% of them tell me on their own accord that it is wrong. I think one can make an ethical argument, too, but I will spare this for now.

Plenty of professions have humane work hours. Not sure why one cannot fathom a profession having work hour limitations.

As for attendings, I can see why they would resist. After all, "they put in their time". We have an abuse system in academic medicine. The "I worked 100 hours a week and so should you" simply because I did is wrong. The main rebuke to this is that simply put, hospitals were not as busy then as they are today. They actually got taught during the day, not busy work all day long.

 

[nope80]

Someone else is saving you from your own incompetence. I call it incompetence because in the end there is a plethora of research to show long hours correlate with increased patient harm. Research on residents has shown increased rates of depression, marital problems, and even accidents. You still work like a dog in the face of all the data. That's incompetence. Patients cannot believe I work so much. 90% of them tell me on their own accord that it is wrong. I think one can make an ethical argument, too, but I will spare this for now.

Plenty of professions have humane work hours. Not sure why one cannot fathom a profession having work hour limitations.

As for attendings, I can see why they would resist. After all, "they put in their time". We have an abuse system in academic medicine. The "I worked 100 hours a week and so should you" simply because I did is wrong. The main rebuke to this is that simply put, hospitals were not as busy then as they are today. They actually got taught during the day, not busy work all day long.

I could not agree more!! I'm not a resident yet but I see this in the hospital everyday. I am shocked that the system hasn't already changed - people are miserable and I can totally see why. When you don't have time to eat properly, sleep properly, decompress mentally you cannot be expected to act in the best way for your patients. It's obvious! People that are happier and well rounded are more invested and energetic. Medicine needs tons of physical, mental and emotional stamina and hence even more of a reason to give us more breaks. I hate this hardliner culture in medicine that thinks opposite.

 

[GreatSaphenous]

Someone else is saving you from your own incompetence. I call it incompetence because in the end there is a plethora of research to show long hours correlate with increased patient harm. Research on residents has shown increased rates of depression, marital problems, and even accidents. You still work like a dog in the face of all the data. That's incompetence. Patients cannot believe I work so much. 90% of them tell me on their own accord that it is wrong. I think one can make an ethical argument, too, but I will spare this for now.

Call me incompetent if you will, but how many of your studies have compared resident fatigue to sign-out coverage in regards to patient safety? How much better is a well-rested, but ignorant resident? Keep in mind, patient safety did not show any improvement under the 80 hour restrictions. Now you can argue that it didn't go far enough and continue to restrict residents until we're all working banker's hours, but I didn't sign up to be a banker and neither did you.

Your sense of fairness seems to go only one way. Sure we should'nt work 120 hours a week just because our predecessors did, but neither can we legitimately whine that they're not doing their "fair share." You complain that they were less busy and had more time to learn during the day, well maybe that had something to do with the fact that a third of them didn't have to leave at 9:00 every morning.

Perhaps we're coming at this from different perspectives. I assume you're in a medicine-based field and I'm from a surgical one. Medical residents may very well be able to be trained in less hours. At my program our senior medicine residents average in the 60s per week. But surgical residents require increased time in the hospital and will resist any further restrictions on our training.

All for now, go back to your french toast.
I am the Great Saphenous!!!!!

 

[GreatSaphenous]

P.S. Questioning incomplete and weak data does not constitute incompetence. Save your name-calling for the playground.

 

[nope80]

Call me incompetent if you will, but how many of your studies have compared resident fatigue to sign-out coverage in regards to patient safety? How much better is a well-rested, but ignorant resident? Keep in mind, patient safety did not show any improvement under the 80 hour restrictions. Now you can argue that it didn't go far enough and continue to restrict residents until we're all working banker's hours, but I didn't sign up to be a banker and neither did you.

Your sense of fairness seems to go only one way. Sure we should'nt work 120 hours a week just because our predecessors did, but neither can we legitimately whine that they're not doing their "fair share." You complain that they were less busy and had more time to learn during the day, well maybe that had something to do with the fact that a third of them didn't have to leave at 9:00 every morning.

Perhaps we're coming at this from different perspectives. I assume you're in a medicine-based field and I'm from a surgical one. Medical residents may very well be able to be trained in less hours. At my program our senior medicine residents average in the 60s per week. But surgical residents require increased time in the hospital and will resist any further restrictions on our training.

All for now, go back to your french toast.
I am the Great Saphenous!!!!!

Why is someone that is well rested have to necessarily be incompetent?

 

[GreatSaphenous]

Ignorant, not incompetent. Ignorant because they got sign-out on 30 patients they never met, examined, or operated on.

 

[sirus_virus]

Call me incompetent if you will, but how many of your studies have compared resident fatigue to sign-out coverage in regards to patient safety? How much better is a well-rested, but ignorant resident? Keep in mind, patient safety did not show any improvement under the 80 hour restrictions. Now you can argue that it didn't go far enough and continue to restrict residents until we're all working banker's hours, but I didn't sign up to be a banker and neither did you.

Your sense of fairness seems to go only one way. Sure we should'nt work 120 hours a week just because our predecessors did, but neither can we legitimately whine that they're not doing their "fair share." You complain that they were less busy and had more time to learn during the day, well maybe that had something to do with the fact that a third of them didn't have to leave at 9:00 every morning.

Perhaps we're coming at this from different perspectives. I assume you're in a medicine-based field and I'm from a surgical one. Medical residents may very well be able to be trained in less hours. At my program our senior medicine residents average in the 60s per week. But surgical residents require increased time in the hospital and will resist any further restrictions on our training.

All for now, go back to your french toast.
I am the Great Saphenous!!!!!

Great post, that is why I suggest we raise surgical specialty hours back to >120 and reduce the others to <60. That way you get the training you crave and the others get the rest/sanity they crave. I do not see any reason why we should reduce work hours for those that believe they need more hours.

As for handoffs or sign outs, remember that regardless of how long your shift is, you still need to handoff pts at some point. I have worked in Europe and seen their handoff protocols, and I tell you now that it is bulletproof in some instances. Probably ten times safer than whatever miserable advantage the 120hr shifts gave pt safety in the U.S. If there are safety issues with handoffs in our system, we need to fix it by fixing the actual protocol. Increasing work hours to fix handoff issues is like not taking a shower, then spraying cologne to cover up the smell; at some point you will still stink.

 

[ANCAdoc]

If there are safety issues with handoffs in our system, we need to fix it by fixing the actual protocol. Increasing work hours to fix handoff issues is like not taking a shower, then spraying cologne to cover up the smell; at some point you will still stink.

100% true. We need to fix the protocol. Increasing hours to fix this problem is not fixing the problem.

Perhaps it is different, as GS suggests, between medicine and surgical fields. But, medicine is still a lifelong pursuit. A marathon, not a sprint.

 

[KidDr]

Try before 2004. It wasn't THAT long ago that we were working 36 hrs+.

ha! good point. not sure what I was thinking when I wrote that...

 

[Winged Scapula]

ha! good point. not sure what I was thinking when I wrote that...

No worries. I've just noticed a common theme of:

1) people forgetting that the work hour rules weren't instituted (outside of NY) THAT long ago and that some people still in training or early attendingship remember what it was like (cue violins )

2) stating that when residents did work 120 hrs per week patients were much less sick, there was less work and more time to read, etc. It is true that patients in the hospital are sicker and that patients in our current ICUs would have been dead decades ago.

The misconception is that this sea change occured recently, when it actually happened in the 60s and early 70s. Most physicians who trained then are no longer working.

I don't know about you, but most of my attendings were in their 50s, with a few in their 30s, 40s and 60s. Rarely one approaching 70s. So most of your attendings who worked those ridiculous hours did so with very sick patients and a constant stream of work...just like you.

As S-V suggests (perhaps facetiously), it might not be a bad idea to tailor work hours to specialties. I cannot fathom reducing surgical residency work hours more and producing someone who learns what they need to.

 

[ANCAdoc]

I don't know about you, but most of my attendings were in their 50s, with a few in their 30s, 40s and 60s. Rarely one approaching 70s. So most of your attendings who worked those ridiculous hours did so with very sick patients and a constant stream of work...just like you.

As S-V suggests (perhaps facetiously), it might not be a bad idea to tailor work hours to specialties. I cannot fathom reducing surgical residency work hours more and producing someone who learns what they need to.

Good point. However, even in the last 5-10 years hospitals have gotten even busier. Heck, in the last two years our VA hospital has exploded, with teams capping frequently.

I think the trend has been getting less and less sleep, on average, while on call. I think this is dangerous to ourselves and to our patients.

Winged Scapula, I've always liked hearing your opinion. I generally agree with them. What do you think of the 24+6 hour call? Is that extra 6 hours really necessary? Seriously, I have to cram a full day of work into those 6 hours for sign out. The team rarely picks up the duties. Not sure why residents and attendings can't write a few notes, call some consults.

 

[SocialistMD]

Winged Scapula, I've always liked hearing your opinion. I generally agree with them. What do you think of the 24+6 hour call? Is that extra 6 hours really necessary? Seriously, I have to cram a full day of work into those 6 hours for sign out. The team rarely picks up the duties. Not sure why residents and attendings can't write a few notes, call some consults.

I know I'm not WS, but I will chime in on this.
First off, let's not kid ourselves; you know you aren't doing an entire day's work in 6 hours. You may stay and round and write a couple discharge summaries, but you aren't the primary person involved in patient care (i.e. the nurses aren't calling you for patient issues, they are calling the team on for that day). From a surgical perspective, it is more frustrating because you often want to stay and take that appy that you worked up overnight to the OR, but you "have" to leave in order to make your hours. You just have to bank on the fact that the same will happen to you when you are on days and your "numbers" will balance out, even though it isn't the same person with whom you established a rapport.

The only place I think it is "necessary" is the ICU. It is difficult to sign out everything on an ICU patient and make sure it is complete in the time constraints normally present for signout. Attending morning rounds in the ICU (which will typically run until around noon) is best for the patient because it ensures the person who was on the previous 24 hours is able to communicate issues and progress to the entire team. Again, you aren't making critical decisions about patient care during that time, you are simply there to ensure proper communication. It isn't necessary for that person to do any "work," only to present the patients. When I was a junior resident in our CTICU, we would round out of bed order- rounding on the patients of the post-call team first so they could leave as early as possible while still ensuring communication was adequate. Now, our ICUs have changed to shift work jobs and signout is a huge issue, as patient care depends on a 2-3 minute/patient signout. It kind of scares me, but we haven't seen any issues (that I've heard about, anyway) due to this signout, so maybe it is okay.

 

[Goran]

Now you can argue that it didn't go far enough and continue to restrict residents until we're all working banker's hours, but I didn't sign up to be a banker and neither did you.

You keep emphasizing how you signed up for medicine and not some other profession on the basis of hours worked. Funny, I thought the reasons for choosing medicine vs banking were more qualitative than that. You know, taking care of patients and all. Not working x number of hours per week.

As a surgical resident, I suppose you would argue that hours worked is directly proportional to improvements in patient care. But how much are you really learning after 30 or 36 hours on call?

 

[SocialistMD]

You keep emphasizing how you signed up for medicine and not some other profession on the basis of hours worked. Funny, I thought the reasons for choosing medicine vs banking were more qualitative than that. You know, taking care of patients and all. Not working x number of hours per week.

As a surgical resident, I suppose you would argue that hours worked is directly proportional to improvements in patient care. But how much are you really learning after 30 or 36 hours on call?

Something you need to understand is that for a surgeon's (and obstetrician's) entire career, s/he will have to come in in the middle of the night for an emergency and still work the entire next day in the OR, a place where mistakes can be catastrophic. Making sure our training "trains" us to be capable of that is very important for us. The same really can't be said for medical specialties, as the number of times you'll be called in for a 2-3 hour procedure in the middle of the night is minimal (the only exception of which I can think is interventional cardiology, as GI will occasionally be called in for the emergent scope of a GI bleed, but any lines that need to be placed, codes that need to be run, etc... are handled by the intensivist in house or the NPs/PAs that have been hired to field night calls; I moonlighted in two community hospitals and that is the general practice I saw- the only people to come in during the middle of the night are the cardiologists and the surgeons). It isn't the same as rounding on your patients, making changes in medications and following up with results; most of that can be done from home. When your job requires you be in the hospital for your work, you need to know you can do it, and it is far better to practice that when you are under the wing of an attending than when you are on your own.

 

[Winged Scapula]

Good point. However, even in the last 5-10 years hospitals have gotten even busier. Heck, in the last two years our VA hospital has exploded, with teams capping frequently.

That may be the case for medical specialties; I don't know and take your word for it. I come from a surgery background where caps do not exist so I cannot say it has been any busier.

I think the trend has been getting less and less sleep, on average, while on call. I think this is dangerous to ourselves and to our patients.

Again, it was a rare night when I got any sleep on call, at least until I was a Chief resident, when most of the pages went to the interns. And my colleagues say that hasn't changed.

Winged Scapula, I've always liked hearing your opinion. I generally agree with them. What do you think of the 24+6 hour call? Is that extra 6 hours really necessary? Seriously, I have to cram a full day of work into those 6 hours for sign out. The team rarely picks up the duties. Not sure why residents and attendings can't write a few notes, call some consults.

I agree that working without sleep isn't ideal and potentially dangerous. What I find aborrent is the insistence that:

a) interns have to do all the work (if your residents are doing that to you, its program specific. I have always advocated, as did my program, a team approach. Your residents and attendings SHOULD be doing some of these things.)

b) that 24+6 means you HAVE to stay that extra 6 hours even if there isn't anything to do. We had to have a talk with some of our attendings that 24+6 /=/ going home at noon when the residents were coming in at 4:30 or 5:00 am. A little basic math was in order.

Now while I doubt you do a "whole day's work" in those 6 hours (unless you have a ridiculously slow day usually), there is no reason why you should be staying 6 hrs to follow-up on things that the day team could/should be doing.

c) BUT...staying those 6 hrs is important in certain situations - mostly like Socialist notes, the ICU, where there are a number of complex patients and having the person who received the calls and took care of them around is vital.

d) If we reduce hours to 16 per shift, doesn't that imply that you will be on call every 2nd or 3rd day or cross covering more and more patients? How is that restful? Perhaps for an IM program with 20 residents per year can handle it, but surgical programs with an average of 4 or 5 residents? Frankly, I'd rather do 24 hrs and be on call twice a week at most than do 16 hrs and be on 3 or more times especially if its the night shift.

The mindset is simply different in surgery than it is in the medical specialties. That doesn't mean its better or worse, its just different. Most successful surgical residents and attendings able to function on less sleep, an important factor when, as Socialist notes, you are called in and asked to operate in the middle of the night, or all weekend. You HAVE to be able to wake up and be alert regardless of the hour because the patient depends on it.

You keep emphasizing how you signed up for medicine and not some other profession on the basis of hours worked. Funny, I thought the reasons for choosing medicine vs banking were more qualitative than that. You know, taking care of patients and all. Not working x number of hours per week.

As a surgical resident, I suppose you would argue that hours worked is directly proportional to improvements in patient care. But how much are you really learning after 30 or 36 hours on call?

I don't want this to be an argument about who should and shouldn't work long hours. Taking care of patients does take time. Its not about working X hours per week, but GS recognizes that taking care of patients is BEING THERE. Now you could argue that, like a long distance relationship or being away from home, its the quality and not the quantity of hours spent. But there is something said for BEING THERE. This is the argument people use for not going into surgery - they want more hours home with their family because BEING THERE means taking care of their family. Its the same thing with patients. You have made a commitment to medicine and your patients, not to the clock.

I've been around long enough to know that the person who has seen the patient's wound, who has looked at their face, received the calls, etc. is the one who knows the patient the best. No sign out is going to give you that because it has to be experienced. Do we need to go back to 120+ hrs per week? No. But I honestly don't think surgical residents can learn what they need to with work hours reduced any further. There is value in being around when things happen because there might not be another operative GI Bleed (I was one of the few residents in my program to ever do a truncal vagotomy and antrectomy and yes, it was late at night...I was there. It could have easily been Dre, Ep, or my other Chief resident colleagues.)

This is why I would advocate a work hour restriction differential based on specialty. I have no business telling an internist that his residents could learn the specialty in X number of hours per week anymore than a non-surgeon telling us that we should be able to learn what we need to know in any arbitrary number of hours.

 

[Tigerz_Fan]

Totally agree with making the work hour restrictions specialty-specific.

From the IM standpoint, I hated the 24+6 as a resident. Mainly because medicine rounds can be neverending, and more than once we rounding right up until the 6 hour limit postcall. Our PD had to speak to more than one attending regarding this. During the weekdays, the senior can pick up the work for the interns, but on the weekends, the seniors stayed overnight as well. And our attendings didn't help our with the postcall work. So when I was a senior on the floors, if I worked any weekend, I was basically there until at least 4p. Things are improving, and now everyone is getting out about 10a.

If they reduce the total number of hours, in addition to the 24+6 and dedicated "nap time," then I have no idea (even with 24 residents/class) how we will staff the floors. Where I did residency, we had 5 medicine teams, and all were basically capped daily with 24 patients each. Our residents are at two hospitals, and really there are no additional residents to shift to a shiftwork model. Add to that ACGME decreased the total cap. Basically, we need more residents to pull this off. And we all know that noone will supply the funding for that. Many places are hiring hospitalists, but unfortunately my former institution seems to be behind modern times with that one. Decreasing the 24+6 to just 24 without the other recommendations may be possible.

But also, the more we restrict hours, the more we lose continuity for our patients. Yes, the fatigue may be dangerous for our patients, but loss of continuity is also dangerous.

 

[GreatSaphenous]

This is turning out to be quite a good discussion. I was afraid that it was going to devolve into fecal hurling.

I have no problem with IM, Peds, Psych or whatever specialty limiting their hours further. However I do have a problem with the IOM touting reducing shifts to 16 hours with required nap time in the name of "patient safety." If the public, or worse our legislators, adopt the idea that it is dangerous for a resident to be in the hospital on hour 17, we won't be able to be specialty specific with our training guidlines.

All for now, go back to your sun-dried tomato aioli.
I am the Great Saphenous!!!!!

P.S. Winged Scapula, I have gotten 2 V&A in my training; Although I had to go to Ethiopia to do the first one.

 

[PatientLurker]

Sorry if I am being unkind, but we signed up to be doctors.

I am an outsider, from a field of industry where rest rules are strictly regulated for our own and for public safety, if that makes any difference.

I just wanted to draw attention to this particular quote, not because of it's relation specifically to medicine, but because it reflects a general attitude that rather disappoints me...

...it says, "This is the way it is, and I don't care if someone has a better way to do things. This way was good enough for me, and gosh-dang-it, it's good enough for you, too."

Now, specifically regarding medicine, I'm sure GreatSaphenous and other staunch defenders can point out many reasons why the doctor career field is "different," or "special," but I can assure you, that's a gross exaggeration. What is particularly "special" in this case, is that medicine has a long, and for some bizarre reason, respected, tradition of abusing its own. It vainly clings to that same "machismo" which dominated early aviation... machismo that died as a result of natural selection, almost literally.

I would like to suggest that what you are dealing with, is merely a system of training that has certain advantages, and certain disadvantages. I've seen first-hand the psychological effects of the current system on so many medical trainees, and forgive my French, but it's asinine.

(True, you are not "bankers." Although some bankers work far longer and more stressful hours than residents, see their families even less, and make 100x more $ for their trouble, by the way.)

Medicine is certainly special for what you do and for the contribution it makes to society. But using that as an excuse to justify a poorly-implemented training system is a tragic lack of creativity. I'm heartened that so many residents are standing up for common sense these days. The old guard is moving on.

Medicine is not the first, nor the last, great profession to experience this turnover of cultural attitudes. But I humbly suggest getting used to it...

Working 27 hours straight, making yourself miserable, being a danger to your patients, violating laws, are all just d-u-m-b. Can't spell it out any simpler than that!

(As I'm sure you are all frequently reminded, your patients do read this board. And I'm not letting any sleep deprived doc operate on me, thank you. After all, you don't want me working for you after I've been up 27 hours. The difference is, we both might die)

 

[SocialistMD]

Working 27 hours straight, making yourself miserable, being a danger to your patients, violating laws, are all just d-u-m-b. Can't spell it out any simpler than that!

(As I'm sure you are all frequently reminded, your patients do read this board. And I'm not letting any sleep deprived doc operate on me, thank you. After all, you don't want me working for you after I've been up 27 hours. The difference is, we both might die)

Assuming you are in the airline industry, take into account there are several differences between your profession and ours. First, you are only responsible for your passengers from the time they board the plane to the time they exit. Therefore, you are not expected to be there for them 24 hours a day. We are. Second, when you are responsible for your passengers, they are all on the same time schedule (read: they are all on the plane at the same time), which allows you to have your rest. Our patients are not, but rather staggered throughout the day. Therefore, if one patient needs us at 2:00 am, we still have to be there for the next one at 7:30 am. Finally, as the pilot, you aren't the one who has to go to your passengers and tell them the flight is delayed/cancelled. Furthermore, your livelihood won't be affected if the flight is delayed/cancelled, as the airline for which you work is the one that has that burden, not you. If we cancel or delay a procedure, we have to tell our patients and they may opt to go to another surgeon, hurting our income.

I'm not saying it is ideal to have a surgeon operate after being awake for 24 hours and there are some hospitals that make sure their surgeons do not operate when they are post-call. Some hospitals are adapting an acute care surgical service or "surgical hospitalist" that deals with the overnight emergencies that come through the emergency room (to take that burden off of daily operating surgeons). The fact still remains, though, that I am personally responsible for my patients and if I think it is safer/better for my patient for me to operate on them than for me to sleep, that is what I will do.

 

[Winged Scapula]

Patients are welcome on SDN.

However, they are reminded that this is a site for physicians and that they may not understand all the complexities of which they speak. There are legitimate reasons for working long hours and it doesn't begin with "because I did it". "Danger" is a relative term and shouldn't be thrown around loosely.

Please be advised that harassment of physicians and our other core communities is a violation of the Terms of Service agreement you signed when you registered.

 

[PatientLurker]

SocialistMD,

Thank you for your thoughtful reply! First let me say that I am not in the airline industry. As an aside, I feel as a matter of principle, I don't want to argue from authority. I could claim to be an attending, a resident, a med student, a pilot, or a nuclear material handler, but it's irrelevant, because if my words are stupid, it doesn't matter who I am

I think some of your contrasts are reasonable, and some are inaccurate, but I don't think that they necessarily argue in favor of a system of chronic sleep deprivation. I would tend to agree that pilots are only responsible for their passengers from boarding until exiting. But that could be a very long time on a flight from, say, New York to Beijing, could it not? Modern aviation has adopted standards suitable for this type of situation, but if any comparison could be drawn, I would posit that medicine is still has a long way to evolve.

I also disagree with the contrast that physicians, but not pilots, have to be there 24 hours a day for their patient. On one hand, many jobs require "on alert" pilots 24/7. The system has evolved to ensure that a pilot is available when needed, but that adequate rest is available too. Why not medicine? Obviously, not even the most super-human physician can function 24x7 hours without rest. So it's a matter of where you draw the line and let the doc sleep.

As for the staggered-throughout-the-day patient arrival, vs. a pilot-and-passengers-on-the-same-schedule contrast, that is also a phenomenon of the current system. Taking your line of reasoning to an extreme, you could say that since a doctor in a hospital continually gets new patients, he is never allowed to rest! But of course, he has to rest at some point, even if a patient is in need--hence we have other doctors, right? It has become a matter of tradition that we let him rest after, say 12, 18, or 24 hours or so forth. Aircrew members often work several flights consecutively, and not necessarily with the same crew, either. It would be simple enough (and possibly cheaper, by some measures) to design a schedule that kept aircrew working for longer stretches, with varying passengers and co-workers, making it less unlike some aspects of medical work.

Again, I think it boils down to systems and professional culture.

As for pilots, flight cancellations, and the effect on livelihoods... In some organizations it is indeed the pilot who tells the passengers that the flight is canceled, and on some level, as a company owner or employee, his livelihood is indeed affected by the cancellation. But cancellations are an inevitable cost of doing business. Aviation has evolved a system that involves many standardized, codified rules for cancellations. Medicine has not yet adopted some of these very effective ideas.

If we cancel or delay a procedure, we have to tell our patients and they may opt to go to another surgeon, hurting our income.

This statement is one I'd particularly take issue with, despite it's obvious truth. Because if a pilot were to disregard his fitness to fly because he needed to maintain his income, that would be considered unethical. In medicine, however, a doctor who practices in a fatigued state is admired for toughness. I am not accusing anyone of being unethical here, and there are often other reasons to disregard your fatigue state due to the situation at hand. But I think it's interesting how these comparable situations are held to opposite standards, and to debate how that situation developed.

I am personally responsible for my patients and if I think it is safer/better for my patient for me to operate on them than for me to sleep, that is what I will do.

Could this be a false dichotomy? What about having another person operate on them? Hypothetically, is it possible that one has too many patients, if one is routinely sacrificing sleep for them? (that opens a whole other can of worms, doesn't it...) I'm sure no one would exercise anything but their best judgement in a critical case such as this. But our judgement is shaped by tradition, culture, peer pressure, fatigue, and a host of other factors that can muddy the waters. Many professions other than medicine have made great strides in setting clear-cut guidelines. One of the things about medicine that practitioners often value the most is the independent judgement they are allowed to exercise. But this also carries great risk.

WingedScapula: Thank you- I certainly have no intention of harassing doctors or any other medical colleagues! I recognize that there are distinct reasons why the current system has evolved, but what I seek to better understand, is the spectrum of attitudes toward the system and toward change. I'm not an MD, but I am part of the core SDN community ("outsider" was too strong a term- happy to provide more details via PM). I have strong opinions, but I will always try to back them up with reason, and listen to others' reasoning. And I don't want to personally offend anyone- that makes for a lousy debate anyway.

Best wishes, PL

 

[GreatSaphenous]

I just wanted to draw attention to this particular quote, not because of it's relation specifically to medicine, but because it reflects a general attitude that rather disappoints me...

...it says, "This is the way it is, and I don't care if someone has a better way to do things. This way was good enough for me, and gosh-dang-it, it's good enough for you, too."

Since you find my attitude so dissapointing, it would help to fully understand what it is. I have no devotion to doing things the way they have always been done. However we always need to ask ourselves whether or not there was a legitimate reason for the original practice.

Furthermore when I tell a collegue to cowboy up because he/she signed up to be a doctor, I'm trying to remind them of the nature of patient care and the pledge they made to it, not blindly advocating sadistic training practices.

As Socialist very clearly explained, the differences between aviation and surgery are immense despite paid advocates assertions to the contrary. Surgery doesn't benefit from the standardization that aviation has. In a DC-10 the altimeter in always in the same place; The same cannot be said for the right hepatic artery.

When I recently had a patient rebleed after emergent repair of his ruptured AAA, I could have sent my rested 4th year resident in my place, but I knew this patient better. I saw where his lumbar arteries were. I knew what type of graft we placed. I could zero in on the area where we cross-clamped the aorta. So I went in to the OR and fought for this guy. I didn't do it because Debakey was a compassionless jerk who abused hs residents. I didn't do it because Duke's program used to boast about their divorce rate. I did it because this man was a sick patient and I was one of his doctors. If you find that dissapointing or d-u-m-b I won't offer any apologies.

I will however faithfully remain the Great Saphenous!!!!
Now go back to your honey roasted peanuts.

 

[Winged Scapula]

When I recently had a patient rebleed after emergent repair of his ruptured AAA, I could have sent my rested 4th year resident in my place, but I knew this patient better. I saw where his lumbar arteries were. I knew what type of graft we placed. I could zero in on the area where we cross-clamped the aorta. So I went in to the OR and fought for this guy. I didn't do it because Debakey was a compassionless jerk who abused hs residents. I didn't do it because Duke's program used to boast about their divorce rate. I did it because this man was a sick patient and I was one of his doctors. If you find that dissapointing or d-u-m-b I won't offer any apologies.

THIS is what others don't get. You cannot sign this stuff out. YOU had the experience, the visual memory to be able to the best one to help this man. Your 4th year would have done an adequate job, but it would have taken longer and the patient suffered for it.

Surgeons aren't sacrificing sleep because we have too many patients. We simply get called in the middle of the night because that's when most surgical emergencies happen. Patients present to the ED late and it sometimes takes several hours before the surgeon is called. Believe me, most of us would love it if that appy appeared in the ED at 0800 and we got called at noon. But it just doesn't happen that way.

And unfortunately, we cannot push back am rounds or cancel our cases or clinics the next day just because we were up all night. The patients come first.

 

[ANCAdoc]

THIS is what others don't get. You cannot sign this stuff out. YOU had the experience, the visual memory to be able to the best one to help this man. Your 4th year would have done an adequate job, but it would have taken longer and the patient suffered for it.

I disagree. Any other capable surgeon would be able to repair that AAA. I have no reason to believe the complication rate would be any higher.

GS makes it sound like he is a hero they way he writes about "fighting" for the patient. Assuming GS is a resident, I've been in enough surgeries to know that residents are assisting the attending surgeon under their supervision. The attending is calling the shots. Another more rested resident on the case would not have made a bit of difference.

 

[Winged Scapula]

I disagree. Any other capable surgeon would be able to repair that AAA. I have no reason to believe the complication rate would be any higher.

I didn't say that the AAA couldn't be repaired by any one else. But we aren't talking about doing a primary repair. We are talking about re-operative surgery when it is clear that the primary surgeon knows the patient the best. You have no reason to believe that the complication rate would be higher because you don't understand re-operative surgery and its complications. The complication rate IS higher with re-operative surgery of all types.

The difference is that the person who has done the previous surgery knows what the tissues look, feel and handle like, where the pitfalls are, the anatomical variations, exactly what was done. The other resident does not.

GS makes it sound like he is a hero they way he writes about "fighting" for the patient. Assuming GS is a resident, I've been in enough surgeries to know that residents are assisting the attending surgeon under their supervision. The attending is calling the shots. Another more rested resident on the case would not have made a bit of difference.

With all due respect, you are not a surgeon and cannot fully understand what we are talking about. As a medicine intern, you have only a passing experience with surgery and presumably with no more than 2 programs. Chief residents in many programs are DOING the operating and are more independent than you claim to have experienced. Your program may have been different but even with the attending "calling the shots", the fact is that GS KNOWS what the inside of THAT patient looks like. It is common for an attending to insist, when doing a re-operative case or a complicated case, to request the same resident to assist/do the case because we recognize that experience of having been in that body cavity is valuable and irreplaceable.

We are not discussing whether the case can technically be done by someone else. It can be. This is about knowing exactly where the lumbars are (which is probably the source of bleeding), where the cross clamp was placed, THIS patient's anatomy. Knowing all of this means that the repair will proceed more quickly, more smoothly and the patient will be off the table sooner.

But let's get back to the discussion of work hours. It is seemingly foolhardy to argue with surgeons about how to operate just as it would be for me to tell you how your IM program should run. Neither of us has enough experience of the other's world to do anything but speak ignorantly about the subject.

 

[ANCAdoc]

The complication rate IS higher with re-operative surgery of all types.

Let me re-phrase as my point was not interpreted correctly. I have no reason to believe the complication rate is would be higher for Resident B to scrub into the procedure with Attending A rather than Resident A, who was in on the original procedure with Attending A.

I know there is a higher complication rate with re-ops.

We are not discussing whether the case can technically be done by someone else. It can be. This is about knowing exactly where the lumbars are (which is probably the source of bleeding), where the cross clamp was placed, THIS patient's anatomy. Knowing all of this means that the repair will proceed more quickly, more smoothly and the patient will be off the table sooner.

In my opinion, this does not justify having a surgical resident past their 24th hour (or 24+6th) scrubbed into that operation. I do not believe the procedure would proceed more quickly with Resident A than rested Resident B. His diminished level of cognition may well harm the patient. I'd love to cite the physiological effects of sleep deprivation.

Let's say Resident A stays and performs that re-repair of the AAA at hour 28 and keeps him there until hour 35. Numbers are arbitrary. He leaves, speeding home at 70mph on the interstate. He is involved in an accident and the other motorists are killed. A mother and her two children. You know what caused this? SLEEP DEPRIVATION. Studies have shown that staying up for X number of hours results in driving performance equal to that of a drunk driver. I will try to find that study for you. It was on the national news not too long ago. The fact that you can take or alter innocent lives supersedes your notion of surgeons staying for long periods out of some archaic sense of duty to the patient.

"The Times They Are A-Changin"

 

[Winged Scapula]

I don't see anywhere where GS said he'd been up 24 or more hours when taking his AAA back. You are making assumptions which may or may not exist.

I have yet to see any sleep dep studies done on people like surgeons who are used to being up and working long hours while intensely focusing. And no one has answered the question of "does it make a difference in the OR?"

I am not supporting doing things out of machismo or for fear of change but no one has said a word about WHERE are you going to get surgery residents and surgeons from in the middle of the night? There aren't enough now to cover (esp things like Nsgy) what is going to happen when you mandate work hr restrictions but don't have enough people to cover the shifts?

There is nothing wrong with dedicating yourself to pts. Call it archaic if you want but we'll just have to disagree because I think its the right thing to do.

But IMHO its pretty arrogant for people who aren't surgeons to assume they know what's best and how and when we should work.

 

[GreatSaphenous]

For that matter why then should Attending A stay for the case? She could have signed out to one of her partners, then you'd have two parties who were well-rested but not as informed. Residents can't be spared from the reality of patient care at the attending level without hurting their training.

Forgive me but I found your last paragraph particularly confusing. So you conjured up a fictional account where I am involved in a MVC and that is supposed to negate my commitment to my patients? That must have gone over my head; I'm naught but a simple surgeon.

I realize that there is evidence comparing DUI with sleep-deprived driving, but there are differences between surgery and operating a motor vehicle. Driving is mostly a monotonous activity punctuated but periods where a quick reaction is necessary. An operation is an intense period of evaluation and intervention.

I guess I spoke too soon about this discussion devolving. Please keep in mind that a third year clerkship does not equip you to decide what factors make a successful operation.

All for now, go back to your veal Kabobs,
I am the great Saphenous!!!!

P.S. WS, if you're curious much of the bleeding came from the superior clamp site.

 

[ANCAdoc]

I just don't understand how GS and WS think they are providing good patient care working for so long in spite of the mounting evidence against. I do not believe they adequately consider the harms to their patients, to innocent bystanders, to their families, to society by working so many hours.

And no, sleep deprivation studies do not need to be performed in a subset of surgeons to convince the surgeons their work hours puts other people in danger. Surgeons are not supra-physiologic. They do not adapt any better than the average person.

It all comes down to work hour restrictions to save us from ourselves.

 

[Substance]

I see no other reason to resist lengthening of residency training under humane hours than income generation lost.

 

[GreatSaphenous]

I just don't understand how GS and WS think they are providing good patient care working for so long in spite of the mounting evidence against. I do not believe they adequately consider the harms to their patients, to innocent bystanders, to their families, to society by working so many hours.

And no, sleep deprivation studies do not need to be performed in a subset of surgeons to convince the surgeons their work hours puts other people in danger. Surgeons are not supra-physiologic. They do not adapt any better than the average person.

It all comes down to work hour restrictions to save us from ourselves.

Thank you for admiting that surgeons are not average. The idea that we must retreat to outside restrictions to govern our actions is regrettable. Part of being a professional is that we are supposed to govern ourselves. You may think its acceptable in this case because you agree with its goals, but you're advocating for a system that ultimately will deprive physicians of the autonomy that has long characterized our field.

You may agree with outside agencies limiting our work hours, but it won't stop there. We're getting off topic, but non-specific evidence is not a good basis for system-wide policies.

Now go back to your latkes.
I am the Great Saphenous!!!!

 

[Winged Scapula]

I refuse to be drawn into arguments with people who have no experience doing what I do. It is ridiculous and serves no purpose other than degrade the forums and make the experience unpleasant for everyone.

I may not be super-physiologic but I average about 4.5 hours of sleep a night and am well rested. I do not need 8 hrs to function; I don't know any surgeons that do. Therefore, perhaps those with different sleep needs are attracted to the field. We all know people who live in a fog without 10 hrs a night and those who can go on 6 or less. Why do you assume that everyone "needs" 8 + hrs of sleep a night to function at their maximum skill? And yes, we DO need studies because driving a car and operating at not the same thing. Nor is flying a plane. We self-govern and do a pretty good job of it. Surgeons recognize when they are too tired to operate. If we or anyone else thought we were dangerous and harming patients, we wouldn't do it.

I stand by my belief, and those of thousands before and after me, that a well trained but tired surgeon is a better choice than a well rested but undertrained and possibly ignorant surgeon. I agree that the reduction of work hours was a good thing...but to 56 hrs a week? I cannot (nor can any of my colleages) fathom training surgeons under those restrictions without SIGNIFICANTLY lengthening training - there would be very few who would be willing to spend 10+ years in general surgery and then add on fellowship.

When I see DeBakey in the afterlife, I'll let him know that the new generation of internists think he and every surgeon from his generation was dangerous. Be prepared to meet his wrath; he was not a pleasant man.

 

[drfunktacular]

When I see DeBakey in the afterlife, I'll let him know that the new generation of internists think he and every surgeon from his generation was dangerous. Be prepared to meet his wrath; he was not a pleasant man.

"Black Mike", they called him. One of his medical students from the 1950's was telling me stories about rounding on 150 patients with him at 11pm. And the fact that each of his 5 children were allotted one hour each per week to spend with him.

 

[ANCAdoc]

I refuse to be drawn into arguments with people who have no experience doing what I do. It is ridiculous and serves no purpose other than degrade the forums and make the experience unpleasant for everyone.

Not sure where this came from. The fact that you cannot debate the shortening of work hours to those outside of the surgical profession, and I argue you are no different than any other medical professional, is bothersome.

Not sure how what has been said degrades the forums. I think you are taking the issue much to personally and it is clouding your better judgement.

The notion that "I am a surgeon and you cannot possibly understand" is not a position a moderator on this forum should be taking.

I agree that the reduction of work hours was a good thing...but to 56 hrs a week?

Indeed, 56hrs is not a good thing. Way back I had proposed cutting out the +6 hours at the end of 24+6 call shifts. Everyone agrees with you about 56 hours.

When I see DeBakey in the afterlife, I'll let him know that the new generation of internists think he and every surgeon from his generation was dangerous. Be prepared to meet his wrath; he was not a pleasant man.

I don't agree with the way you wrote that. But, please do tell him I think he and every surgeon from his generation was dangerous when they were operating or treating patients past 24 hours without rest. I'd be pleased to share with him the journal articles supporting my stance, and the stance of the IOM.

 

[smq123]

IUSM - moderator or not, WS is certainly entitled to her opinion, and should be free to express that opinion within the confines of the TOS. Being a moderator does not strip you of the right to have an opinion.

Unlike WS, I am not a surgeon/surgery resident, but I DO see her point. With patients that I did not admit, I feel like it's a struggle to remember their story. I definitely do not know them as well as the ones that I admitted - those, I can rattle off their CBC from memory. When picking up a patient from someone else, I have to think for a few seconds to remember their PMH.

Now, for a regular floor pt., that's fine. A critical pt. on the OR table? Eh....that extra familiarity could be crucial.

 

[Winged Scapula]

Not sure where this came from. The fact that you cannot debate the shortening of work hours to those outside of the surgical profession, and I argue you are no different than any other medical professional, is bothersome.

Not sure how what has been said degrades the forums. I think you are taking the issue much to personally and it is clouding your better judgement.

The notion that "I am a surgeon and you cannot possibly understand" is not a position a moderator on this forum should be taking.

Why? Its simply a fact. It would be just as bothersome if I, having never done a day of Internal Medicine, told you and/or your attendings, what you needed to do to learn your craft, when you were tired and when you were dangerous.

I haven't violated the TOS and am allowed to state what is fact and what is my opinion. The truth is that the statement that you are not a surgeon and cannot understand, in full detail what that involves, is fact and my opinion. Moderators are allowed to state such. I did not mean for you to find it insulting nor am I taking this personally except as an attack on the profession that I hold dearly by someone who cannot understand it the way I do.

I have spent plenty of time here on SDN debating shortening of work hours, but your contribution to the discussion became about surgeons being dangerous and not knowing their limits. This is where I took exception because it is not up to you or IOM to decide when I and my colleagues are dangerous. You quoted Sleep Dep studies, which are well known to all of us, but are not directly relevant to the surgical condition.

You asked what I thought about the limits and I told you. I think further reductions in work hours will not work in surgical fields without significantly lengthening the training or deciding that surgeons are technicians only and do not need to manage anything outside of the operating room. YOU should be against that because that means that all surgical patients will then be admitted to medicine with surgeons as consultants, doing only the operating, with you doing all the peri-operative management.

That is all I have to say. I'm not trying to be argumentative and have stated that we see things differently. Even as a Moderator I am entitled to have a different opinion, an opinion which is shared by other surgeons.

 

[ANCAdoc]

but your contribution to the discussion became about surgeons being dangerous and not knowing their limits. This is where I took exception because it is not up to you or IOM to decide when I and my colleagues are dangerous.

Clarification: not just surgeons but every practicing medical professional (in the context of working 30hrs)