56 Hour Week Is Coming

[orientedtoself]

Agree, there are alot of residencies where 56 hrs would work. Surgery is definitely not one of them, but neither is medicine. Yeah some of the subspecialities, ie Rheum, Endo, etc. But not the Medicine residency. As an intern except on my 3 consult mths, all wards were 70-75hrs/wk and the 2 ICU were 80-85.

Someone on here onetime posted about their program's EMR being able to print daily progress notes with vitals and labs already on them. Something like that could cut 5-10 hrs/wk off. Having more/better social workers = maybe 5 hrs a week. Do those things and now maybe we could do better on hours and I would be all for that. I don't see how midlevels would help medicine much though.

But just cutting hours without doing something else, I just don't see how it would work and I DON'T want to do more years for any reason!

i agree, if medicine went to 56 hours then the training would have to be longer. internal medicine is so broad that you really need the experience with different conditions. we take care of the whole patient and are expected to have some depth of knowledge in diseases involving all organ systems. i'm glad i'll be done in a year so i won't have to lengthen my training. can you imagine medicine being four or five years? then another two to three year fellowship on top of that? i'd rather bite the bullet and keep things as they are.

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[Winged Scapula]

There are a couple of studies out that show that post work hour restriction, there was no change in the number of cases performed, and one was actually done with orthopods. That said I think this is because most programs don't adhere to work hour restrictions.

Sorry but MAJOR flaw in that (and other like-minded studies).

In the old days, just as now, you could get in trouble for doing TOO MANY cases. Therefore, residents would shave off the number of cases they did to get under the max allowable. Several of my Chiefs and senior residents did it, as did I in the early years (before work hour restrictions).

So its a farce...the number of cases don't appear to change because residents are doing fewer cases but reporting more of them, so it evens out.

 

[deleted109597]

i agree, if medicine went to 56 hours then the training would have to be longer. internal medicine is so broad that you really need the experience with different conditions. we take care of the whole patient and are expected to have some depth of knowledge in diseases involving all organ systems. i'm glad i'll be done in a year so i won't have to lengthen my training. can you imagine medicine being four or five years? then another two to three year fellowship on top of that? i'd rather bite the bullet and keep things as they are.

How would medicine being 3 years and 56 hours per week make them any less educated about the adult male than Family Medicine already is. If anything is broad, FM is that, and they would (I argue that they already do) need more years.
Remember, Med/Peds is FM without women's health, and it is already a year longer.

 

[deleted109597]

QFT. There's a reason why every year some "good" residents fail their boards. One can reasonably put on a good show of being a good resident (hard working, good attitude, on time, technically adept) without reading ... then cram in a panic the last couple months ... then maybe pass, maybe fail. I read more now as a resident than I did as an MS3 or MS4.

Um, you made the same point I did. So why should I quit talking?
I think we should all read more. I support shorter, more frequent EM shifts because I feel that people read more after working 9-10 hours than they do 12-13. And since a lot of people don't read on their days off, having more of them doesn't necessarily mean more reading time.

 

[iridesingltrack]

Not too long ago we had a grand rounds where a UK physician spoke about these very issues. He expressed great frustration about the work hour restrictions steming from the EU saying that they quite simply "didn't think it would happen" and so they didn't really fight the reduced work hours. One of the results has been lengthening residency, which has been discussed, but one of the more interesting results was that they now have a heirarchy of attendings, whereby junior attendings require oversight by more senior attendings.

Personally, I think this would be a bad idea and unfortunately it is quite plausable that a well meaning gov't official might make this happen. EMTALA is a great example of a well meaning mandate that went seriously off track.

 

[orientedtoself]

How would medicine being 3 years and 56 hours per week make them any less educated about the adult male than Family Medicine already is. If anything is broad, FM is that, and they would (I argue that they already do) need more years.
Remember, Med/Peds is FM without women's health, and it is already a year longer.

true, family medicine is broader than internal medicine. however, i think people expect family medicine docs to have less depth due to the breadth of their practice.

i don't think you can just cut down the hours and keep medicine a three year residency. you would see 2/3 of the patients we do currently, and i just don't think that's enough. there are plenty of conditions that i haven't seen, and i'm at the end of my second year of residency. for example, my knowledge of rheumatology and endocrinology is horrendous. lupus? what's that? i'm plenty comfortable seeing chest pain/ chf exacerbation/ copd exacerbation/ pna/ cellulitis/ sepsis/ gi bleed/ dka. it's the uncommon things that i still need to see more of. that, and i think most people feel less confident in managing outpatient issues, since residency is so skewed toward inpatient care.

 

[Tired]

Obviously 56hrs/wk makes no sense in most specialties. Obviously it would be extremely difficult, if not impossible, to make a straight transition from what we have now to what they want. Even with a slow taper down in hours, it would be enormously difficult.

Yes, they do 56hrs/wk in Europe. But from what my most recent British med student tells me, you can't get a cardiac cath at night, no CTs except in true true emergencies, OR starts at 9am, hospitals are essentially depopulated on weekends, and on and on and on. The expectations of American health consumers cannot be met under the European system.

Possible solutions to this include forcing more attendings to stay overnight (watch the mass exodus to private practice), taking more residents into each program (massive dropoff in cases done as a resident), increase length of training (what a total CF that would be), or hire more PAs (bankrupting the hospital).

None of these are good solutions. All have massive downsides that few outside of the physician world recognize. But I think it is naive to think that these downsides will in any way prevent the passage of a shorter work week.

I train in a system where unfunded and poorly thought-out mandates are the norm. For example, I am required to have a will. I completed the interview to have the will drawn up three months ago. However, I can only sign this will at 10:00am on Tuesdays. Until I can take vacation (of which I only get 14 days this year) on a Tuesday, I cannot sign my will, which is mandatory and I was supposed to have completed by last December.

You don't understand how little non-medical government people care about us. We are all screwed.

Thanks again to the AMA and our senior physician leaders for standing up for us. [/sarcasm]

 

[swpm]

Um, you made the same point I did. So why should I quit talking?

QFT = quoted for truth

 

[c5a]

I train in a system where unfunded and poorly thought-out mandates are the norm. For example, I am required to have a will. I completed the interview to have the will drawn up three months ago. However, I can only sign this will at 10:00am on Tuesdays. Until I can take vacation (of which I only get 14 days this year) on a Tuesday, I cannot sign my will, which is mandatory and I was supposed to have completed by last December.

You don't understand how little non-medical government people care about us. We are all screwed.

Thanks again to the AMA and our senior physician leaders for standing up for us. [/sarcasm]

you might be able to do it on line at legalzoom.com (and for cheap).

 

[RTrain]

Obviously 56hrs/wk makes no sense in most specialties. Obviously it would be extremely difficult, if not impossible, to make a straight transition from what we have now to what they want. Even with a slow taper down in hours, it would be enormously difficult.

Yes, they do 56hrs/wk in Europe. But from what my most recent British med student tells me, you can't get a cardiac cath at night, no CTs except in true true emergencies, OR starts at 9am, hospitals are essentially depopulated on weekends, and on and on and on. The expectations of American health consumers cannot be met under the European system.

Possible solutions to this include forcing more attendings to stay overnight (watch the mass exodus to private practice), taking more residents into each program (massive dropoff in cases done as a resident), increase length of training (what a total CF that would be), or hire more PAs (bankrupting the hospital).

None of these are good solutions. All have massive downsides that few outside of the physician world recognize. But I think it is naive to think that these downsides will in any way prevent the passage of a shorter work week.

I train in a system where unfunded and poorly thought-out mandates are the norm. For example, I am required to have a will. I completed the interview to have the will drawn up three months ago. However, I can only sign this will at 10:00am on Tuesdays. Until I can take vacation (of which I only get 14 days this year) on a Tuesday, I cannot sign my will, which is mandatory and I was supposed to have completed by last December.

You don't understand how little non-medical government people care about us. We are all screwed.

Thanks again to the AMA and our senior physician leaders for standing up for us. [/sarcasm]

Agree on all counts (well, except the will, which I do not have to deal with). Regulations are imposed upon us by medical outsiders who have absolutely no grasp of the implications. I can only hope that a 56-hour week isn't imposed, but if it is, I'm sure the powers that be will think they've done us a huge favor.

 

[NotAProgDirector]

It's threads like this that keep me engaged in SDN. Lots of ideas posted above, I'm late to the game:

First, AHRQ is not in charge of this process. Actually, it's the IOM that is doing this. The head of AHRQ is part of the process and gave the opening address -- which is the first link in this thread. AHRQ doesn't have any teeth -- other than some primary care funding (through Title VII grants) it has little to do with GME funding or administration.

This is not good news, however. The IOM has a very interesting role here --> they have absolutely no constituency. There is no large membership in the IOM, they don't have to answer to anyone. If the ACGME tried to drop hours this far, PD's would revolt. If the ABIM tried to intervene, or the ACP, the same thing. If some student organization tried to intervene, students might revolt. You get the idea.

The IOM has no such problem. They can say anything they want, and piss anyone off, and nothing bad happens to them. They have no teeth though -- so on the surface it looks like it might not matter.

That is not true. The IOM will come out with this report, and someone will pick it up an implement it. I'll predict right now whom that will be. It's not going to be the ACGME, any of the ABMS boards, the AMA, or Medicare. Each of them is horribly conflicted, and would face immense pressure to do anything. Whom will it be?

It will be JCAHO. The Joint Commission is equally beholden to no one. And they wield great power. If JCAHO decides to implement any IOM directives, it immediately affects ALL HOSPITALS -- teaching, non teaching, residents, faculty, etc. Not complying with JC directives leads to loss of accreditation = loss of medicare billing = bankrupcy.

What's the report going to say? My guess:

• No overnight call
• Maximum shift length of 16 hours
• Some decrease of the 80 hour rule, but I doubt 56 will be the final target

"SCUT" -- A common idea is that we could save time by removing scut from residents' days. This is certainly true, to some extent. What's interesting is how the definition of scut has changed over time. Scut used to be drawing blood, transporting patients to CT, performing EKG's, starting IV's, etc. Most programs have replaced all of these resident functions with 24 hour RN/tech coverage. Now scut is documentation, discharge planning, EMR management, etc. Some of these are necessary skills -- you will end up using them in your job. I certainly agree that programs that force you to dictate rather than type your notes are foolish, and that we can clearly try to be more efficient, but I worry that while we try to transfer more "scut" to other "workers" in the hospital, we may find there isn't much for us to do anymore...

56 hour weeks are an interesting thought. In my program there is morning report daily (5 hr/week), noon conference (5/week), teaching rounds (usu 4-5/week). Add in rounding with consultants, reviewing films in radiology, etc for at least another 5/week. That only leaves 36 hours per week for actually taking care of patients.

As others above have pointed out, if a mandated decrease in resident hours comes to be, hospitals will need to find other ways to fill the gap. More residents is not going to happen -- Medicare is going bankrupt already and can't afford more residents, and the only way this can happen is a large increase in IMG residents (not necessarily a bad thing, but would need to be addressed) or closing some programs to allow others to expand. Instead, hospitals will have faculty do this, or NP/PA's, etc. As faculty are busier, or not available, teaching will suffer. In addition, as the costs mount, hospitals will fce reality and realize that it will be financially smarter to close their residency (or decrease it's size dramatically) and simply rely on non-residents to do the work.

Which leads to the next problem -- if the hospital shifts so that resident labor is not really needed, then residents become "extras" plastered onto the smooth running system. This essentially recreates the medical student role. What separates Med students from residents is responsibility. If that responsibility is removed, the core of being a resident is lost.

I think that decreasing hours to allow residents to moonlight is crazy. If we're limiting residents to 56 hours because that allows them to function in the hospital safely, having them work another 20 hours moonlighting completely nullifies that. Either it's safe to work 80 hours, or it's not. Similar example: if we feel that it's only safe to drive a truck for 10 hours a day, you can't buy two trucks and drive each of them for 10 hours a day.

Another unintended consequence of duty hour restrictions is inefficient residents. In the "old" days, before duty hours, being inefficient was a self correcting problem. If you were inefficient and needed to stay until 11 PM every day to get your work done, you were free to do so -- but most people figured out this was unsustainable and would find a way to be more efficient. Now, I have the problem where a resident doesn't get all their work done and hits their duty hour limit -- what does that mean? Did I assign them too much work? Are they too slow, and fail the rotation? Should I design the rotations such that the slowest resident can get all the work done in the allotted time, and the fastest resident goes home at 11AM? Lowering the hours further is likely to worsen this issue.

I think it is almost certain that the IOM is going to state, unequivicably, that shift limits of 16 or 18 hours will be the max. And honestly, I agree with them. Working 24-30 hours straight, unless there is a reasonable amount of sleep expected, is really non-sustainable. And I don't think that it "teaches" you ow to do this -- that's like saying that if you drink large amounts of alcohol regularly, you get used to it and can drive with a higher alcohol level. That's "Chewbacca-on-endor crazy". (Ed note: I like that phrase, I'm going to try to work it into every lecture/workshop I give from now on).

And the JC is going to take it and run. It will apply to all docs -- faculty, privates, etc. A 24 hour shift with rare phone calls will be fine, but if you're a surgeon and you're called to the OR at 2AM, you're not going to be operating at all the next day.

How residency programs are going to adjust to this is unclear. Some have already removed overnight call. We have mixed services -- some with call, some with night float. Removing the rest of the call will be very difficult -- either I'm going to pull out of many services to focus on just a few (which will also mean more NF for my residents), or I'll tell services thatr residents no longer take overnight call and they have to find some way to cover it themselves. At least if the JC makes it happen, it will apply to all programs, all fields, all specialties, all hospitals simultaneously, and I can go to my colleagues and state that there is "nothing I can do". Still, I think it is the right thing to do in the long run, as long as the amount of night resident coverage remains reasonable.

Sorry for the ramble.

Prepare to be assimilated. Resistance is futile.

 

[RTrain]

Prepare to be assimilated. Resistance is futile.

That sounds ominous. Especially given the revelations that preceded it.

Do you know the ETA on all this?

 

[Faebinder]

Good post APD. Agree that much of the scut work people believe is scut is infact our job.

I still insist that the major trouble of hours come from the surgery specialties mostly... they keep exceeding the limits more than the non-surgical specialties. Surgeons are hard people to change.. they will keep using the same ABX even if you produce articles and articles to them showing that another ABX works better. Likewise they will be the last to cave in to the hours issue.

Also feel that the 80 hour limit would not be viewed as too large if the residents were paid more. The problem is how will that money come in.

 

[DarthNeurology]

What's the report going to say? My guess:

• No overnight call
• Maximum shift length of 16 hours
• Some decrease of the 80 hour rule, but I doubt 56 will be the final target

56 hour weeks are an interesting thought. In my program there is morning report daily (5 hr/week), noon conference (5/week), teaching rounds (usu 4-5/week). Add in rounding with consultants, reviewing films in radiology, etc for at least another 5/week. That only leaves 36 hours per week for actually taking care of patients.


Which leads to the next problem -- if the hospital shifts so that resident labor is not really needed, then residents become "extras" plastered onto the smooth running system. This essentially recreates the medical student role. What separates Med students from residents is responsibility. If that responsibility is removed, the core of being a resident is lost.
Now, I have the problem where a resident doesn't get all their work done and hits their duty hour limit -- what does that mean? Did I assign them too much work?

I think it is almost certain that the IOM is going to state, unequivicably, that shift limits of 16 or 18 hours will be the max. And honestly, I agree with them.

I think if a resident hits their hour limits they should leave the hospital and handover their work to the attending or fellow residents, (which makes them look bad and want to work harder/faster). Rules are rules for a reason, and if you break the rules then you are at fault period, you can't say it is a slow resident who needs to "learn". I think the core of being a resident is:

1. Increased depth of learning in desired specialty such as medicine, for example just by being in the hospital seeing Internal Medicine patients residents learn a lot.

2. Increased management skills. When a student write a SOAP note the assessment and plan are sort of guess at, and many times are off. What students are supposed to do is compare their ideal management and diagnostic plan with attendings and learn from their mistakes. This continues more actively in residency as residents write the order for discharge. Of course residents should do a discharge summary and write discharge orders, this helps with learning how to setup management outside the hospital which I think is important. However, this whole process I have observed is painfully drawn out by residents who work in an inefficient system. Consider that most supermarkets and online dvd rentals are more advanced than hospitals. The only way medicine can catch up with the modern world is to have automated electronic charting and discharge. For example, if I want to discharge a patient home who is recovering from say a CHF exacerbation, I would be able to re-fill pre-entered home meds with a click, and also write new prescriptions with a click of the mouse, and it is printed out or just sent electronically to the patient's pharmacy. For most professions the electronic age has increased productivity, but medicine has been buried in paperwork to a certain degree, although it is less than I thought would be the case. Attending physicians basically offer their guidance in terms of management and dictate their orders orally to residents and are allergic to doing paperwork.

For example an attending surgeon has the residents do the whole pre-op evaluation, op note, and they maybe do just a one page note for the surgery. Likewise, medicine attendings write less than residents, much less the more senior, like perhaps a paragraph documenting only what is important to document, and letting the resident do the rest. I think attendings will be required to do more and more paperwork as being the "doctor of record" while come to mean they are the doctors who do the records . . . because legally if an attending doesn't document something it looks bad.

There are great programs out there that let you do a progress note in much less time than simply writing it, i.e. click for normal lung sounds if listened too, plus if vitals are included and routed into the program it will take no time to do it. Typing at a fast rate should be a more important requirement than step 2 cs, really, as hand-written notes slow everyone down, physicians and residents.

What also is important is that work expands into the time alotted to do it, so if you give only 16 hours for rounds and a days work then residents will worked more efficiently to get it done and hopitals will develope these automated systems. I do not believe that attendings and residents are anywhere near being as efficient as they could be. With a totally automated system, an attending and a team of residents could exam a patient each day in 5-10 minutes, review labs/teach in 5-10 minutes, write/click notes in 10 minutes and basically on an inpatient medicine service see 8 patients in the a.m. for fours and basically be DONE with the day except for following up studies in the pm via working from one computer station and go home at 2-3pm everyday, many places do this already WITH an hour for lunch. Add on 2 hours for educational activities and you have bankers hours of 8-5 or 45 hours a week, and that gives you 11 extra hours for a long call or something.

Basically it is a huge waste of time physically writing GEN HEENT CARDIAC each day AND spending 20 minutes total each day looking for charts, with an electronic chart that can be accessed by multiple people you will have hordes of happy residents and attendings with tablet-like PCs who can access their patients information wherever. Medicine has never been forced to be efficient until now as costs are out of control, with this new efficiency more patients can be seen by attendings and residents and less mistakes could be made. Look at an airport, the airlines must be efficient to operate, this is why there are computer tracking everything and air-traffic controlers tracking everything in the sky . . . Hospitals are still in the middle ages. Give me a computer that shows vitals, medications, labs, x-rays results and lets me enter electroinc progress notes on a pda and view a chart electronically and I only need to get up to examine the patient and I could see many more patients than without these tools. If you can see two times as many patients than not, . . . then you can cut your work week in half, however, of course you need resident in-house to deal with issues when they come up with patients, however, with these work rules changes attendings will once again become their patient's doctors, perhaps have to see fewer patients as they will have more call/responsibilities.

I think that these days everybody works on the team, but the residents are the patient's main doctor, i.e. have a large share of the responsibility, but maybe it is too much and attendings should shoulder some of the burdens of being available for patients to do little things. These days if a patients hemoglobin drops 3 points, the resident evaluate if a blood transfusion is needed at 5 pm . . . but maybe with the work rules attendings will have to shoulder some of this "responsibility" now. I feel sorry for attendings, but with electronic records and such attendings hopefully would have less "paperwork" but have to take more call.

As a aProgDirector should know resistance to such automation will be futile and like seven of nine attendings and residents will have to learn to be more "efficient". (While I loved TNG when it came out and was actually a fan of the original star trek before TNG premiered, I think Voyager was the best series, at least for me! I hope the new Star Trek movie inspires a new television series, please, please, please, as well as more Section 31, voyager and DS9 books . . . )

 

[NotAProgDirector]

That sounds ominous. Especially given the revelations that preceded it.

Do you know the ETA on all this?

I do not.

However, I hope you see that sign off line as a reference to my avatar. It's Borg, from ST:TNG (which is Star Trek: The Next Generation). I'm a total geek. I can't remember what my score on the geek test was, but it was high.

To be fair (and to respond to Darth's note above), I work in a wonderful place with an EMR, e-faxing prescriptions to pharmacies with a click of the mouse, completely digital radiology (i.e. all studies can be pulled up on any computer within 5 minutes of the scan completion), etc. I forget sometimes that not everyone has these tools. Despite all of this, my residents are still working 70+ hours on their ward months. Somehow, work expands to fill the time.

As above, I worry that when we define the hours of the job, it creates a situation where working slower is rewarded. If you get paid for working 40 hours regardless of how much you get done, you tend to work as little as possible. I have had a few residents who seem to work slowly "on purpose" -- it's easier, and you can just sign everything undone out to the next guy. This is bad, and it's a morale killer in a program. It's just hard for me to do anything about it. "It's that workhour rule boss, there's nothing I can do.... Time to go home...."

 

[DarthNeurology]

I do not.



To be fair (and to respond to Darth's note above), I work in a wonderful place with an EMR, e-faxing prescriptions to pharmacies with a click of the mouse, completely digital radiology (i.e. all studies can be pulled up on any computer within 5 minutes of the scan completion), etc. I forget sometimes that not everyone has these tools. Despite all of this, my residents are still working 70+ hours on their ward months. Somehow, work expands to fill the time.

As above, I worry that when we define the hours of the job, it creates a situation where working slower is rewarded. If you get paid for working 40 hours regardless of how much you get done, you tend to work as little as possible. I have had a few residents who seem to work slowly "on purpose" -- it's easier, and you can just sign everything undone out to the next guy. This is bad, and it's a morale killer in a program. It's just hard for me to do anything about it. "It's that workhour rule boss, there's nothing I can do.... Time to go home...."

I have spent *hours* sitting around with residents in the cafeteria lounge will they call spouses on cell phones, talk sports for hours a day and this is when things are "hectic" --- I think that residents with electronic charting eventually get to where they have a good chunk of free time, however, they have to be in the hospital because the work fluctuates on a sine curve. I use my own work of ethic which I call "flexing the curve" (yeah I know I need help) I learned it from family members who are physicians who constantly complain how slow their residents 30 years younger than them walk and how slow their colleagues are and finish their work at 2 pm everyday. This is what I do:

Darth's Flexing the Curve:

1. If you aren't being productive you are wasting time. I LEAVE my residents who are chatting in the lounge to get work done. Why? Not because I enjoy work more, but, because you have to smooth out what you are doing during the day so that you are not overwhelmed. I could always find something productive to do. For example, if the residents are waiting for a patient's hemoglobin to comeback and everything is "quiet" I just check my patient's labs and see what is brewing with the other patients. Invariably, I run into a consult team from neurology or something else happens and it get me ahead of the curve. If I am pre-rounding and a patient is in the bathroom, I don't wait, I go to the next patient or review labs on patients, rather than waiting and shooting the breeze.

A moving target can't be hit. There is an adage on surgery that you eat when you can, sleep when you can, and something about the pancreas. Same thing with medicine. If it is slow then do something you need to do anyway like go eat lunch at 11 am or dinner at 3 pm to get it out of the way. OR work on a discharge summary. I did consults with residents and I had plenty of time as I got their a little early to see the first consults, go to morning report, and proactively jot down the discharge summary before it is even time.

2. Don't work linearly. Rounds usually go linearly, i.e. first we will see the patients in order then do other stuff . . . I think if you keep an eye on where everything is with all the patients you can take advantage of say the right time to do that paracentesis or other procedure. After rounds especially, it helps to review what need to be done with ALL the patients and do what can be done easily now if nothing is urgent. Key is doing something that can be done quickly now rather later.

3. Discharge planning starts with admission from the ER. When you admit a patient you should have a good idea of what you want to do for the patient, and this will help you plan for the discharge at the end. I think it helps to get everything done in the ER as much as possible, rather than trying to sort things out on the floors. This is when you spend more time, but it is more efficient because you don't have to go back over the history a million times.

4. Read, read, and read. I use all my down-time to read. 5 minutes before morning report, 5 minutes before grand rounds, 5 minutes while on rounds and the attending is answer a call, it adds up big time. Then go home and read comfortably. What does this have to do with efficiency? Plenty, if you know what the plan will be and what to order then you work much more efficiently and understand all the consults in the chart.

5. Cut it short. No, we don't need to have a conversation about how a pain in the booty SNFs are, let's just fill out the paperwork and FIND something to do as we will be swamped in two hours if we don't. If you have four hours to drive to Ft. Lauderdale on Memorial break and you have a clear stretch of road do you slow down? No! You go the speed limit because you know you will hit bad traffic.

I have seen residents sign out stuff that they should have done, usually they are flaky and seem very centered on themselves. Residents joke around when they try to shift blame on themselves, laugh, i.e. "I had three admission, I couldn' t do the fourth so I had to give it to . . ."

I have seen attending keep on them until they aren't so giggly and realize they are holding up the team. I have had to work with a group of students, and yes students do work too, and when one student doesn't pull their weight then it is bad for morale, but if this happens morale was bad to begin with, if a person feels part of the team then they will want to help out everybody. I think morale boosting activities such as unofficial but "required" social outings such as pizza after work and discussion about how to work as a team is helpful. (It won't be lost on the residents that this time they must spend socializing with the PD could have been spent with their families if they had been more helpful.) I have tried peer pressure, otracizing lazy students, but this seems ineffective, at least amoung students, as they became lazier in retaliation. The best teams in medicine are like the Maquina Naranja or the "Orange Machine" a famous successful soccer team, i.e. you have to fit together like a machine and work towards a common goal. I think residents could have an orientation to residency where they talk about working like a team and how if they help out another resident on a busy day, then they get help on one of their busy days. Some residencies REALLY stress this, others don't. I have seen some PDs who really want their residents to gel together perfectly so these problems don't arise. This is why in business the office does paint ball together or something, to be more efficient.

It also may work to have a higher-up talk to the residents I would guess, though I don't know for sure. Such as a famous cardiology attending or CEO of the hospital center talk about how he/she heards they need team work. It is like Star Wars when the Death Star commander complains to Darth Vader that he needs more manpower to finish the work on the Death Star which is behind schedule. Darth Vader simply tells him that he can "Explain it to the emperor when he arrives." and quickly the commander of the death star remarks that his team "Will re-double their efforts." I think this is why big-shot attendings come in to talk to residents about getting the right diagnosis or research, it is really to "find new ways to motivate them" in the words of Darth Vader. It is easier to inspire people to do the right thing, than to chastize them and hope it changes.

 

[elwademd]

For me, I'd be satisfied with having no particular cap, but mandating 10 hours per day rest, averaged over a 7 day period, with a maximum on duty time of say 18 hours. This would still leave at a minimum, 6 hours of rest, would allow over 90 hours if a particular educational situation demanded it, yet, would insure that residents got at least marginally adequate daily rest. Make it an 80 hour week, and the numbers change to 12 hours rest per day averaged over a 7 day period. Wait, isn't that what EM does now? And they didn't extend their residency!

i really think other residencies need to take a look at em, and see if they can incorporate the way in which they've worked it out into their respective fields.

#1, I don't believe it will happen. The drop to 80 hrs has not been shown to improve pt outcomes, so why go lower?

a problem that i've noted with this concept is that it assumes that it is only the resident, and nothing else within the system (techs, nurses, cna's, pharmacy, transporters, etc.), that contributes to patient outcome. also, there are some patients who are going to have bad outcomes despite what we do, while there are others who are going to have bad outcomes because of what we do.

as others have already pointed out in this thread, the 80 hour work week also has benefits to the resident beyond what the studies have been focusing on, which is their own health.

Agree, there are alot of residencies where 56 hrs would work. Surgery is definitely not one of them, but neither is medicine. Yeah some of the subspecialities, ie Rheum, Endo, etc. But not the Medicine residency. As an intern except on my 3 consult mths, all wards were 70-75hrs/wk and the 2 ICU were 80-85.

Someone on here onetime posted about their program's EMR being able to print daily progress notes with vitals and labs already on them. Something like that could cut 5-10 hrs/wk off. Having more/better social workers = maybe 5 hrs a week. Do those things and now maybe we could do better on hours and I would be all for that. I don't see how midlevels would help medicine much though.

But just cutting hours without doing something else, I just don't see how it would work and I DON'T want to do more years for any reason!

It's threads like this that keep me engaged in SDN. Lots of ideas posted above, I'm late to the game:

First, AHRQ is not in charge of this process. Actually, it's the IOM that is doing this. The head of AHRQ is part of the process and gave the opening address -- which is the first link in this thread. AHRQ doesn't have any teeth -- other than some primary care funding (through Title VII grants) it has little to do with GME funding or administration.

This is not good news, however. The IOM has a very interesting role here --> they have absolutely no constituency. There is no large membership in the IOM, they don't have to answer to anyone. If the ACGME tried to drop hours this far, PD's would revolt. If the ABIM tried to intervene, or the ACP, the same thing. If some student organization tried to intervene, students might revolt. You get the idea.

The IOM has no such problem. They can say anything they want, and piss anyone off, and nothing bad happens to them. They have no teeth though -- so on the surface it looks like it might not matter.

That is not true. The IOM will come out with this report, and someone will pick it up an implement it. I'll predict right now whom that will be. It's not going to be the ACGME, any of the ABMS boards, the AMA, or Medicare. Each of them is horribly conflicted, and would face immense pressure to do anything. Whom will it be?

It will be JCAHO. The Joint Commission is equally beholden to no one. And they wield great power. If JCAHO decides to implement any IOM directives, it immediately affects ALL HOSPITALS -- teaching, non teaching, residents, faculty, etc. Not complying with JC directives leads to loss of accreditation = loss of medicare billing = bankrupcy.

What's the report going to say? My guess:

• No overnight call
• Maximum shift length of 16 hours
• Some decrease of the 80 hour rule, but I doubt 56 will be the final target

"SCUT" -- A common idea is that we could save time by removing scut from residents' days. This is certainly true, to some extent. What's interesting is how the definition of scut has changed over time. Scut used to be drawing blood, transporting patients to CT, performing EKG's, starting IV's, etc. Most programs have replaced all of these resident functions with 24 hour RN/tech coverage. Now scut is documentation, discharge planning, EMR management, etc. Some of these are necessary skills -- you will end up using them in your job. I certainly agree that programs that force you to dictate rather than type your notes are foolish, and that we can clearly try to be more efficient, but I worry that while we try to transfer more "scut" to other "workers" in the hospital, we may find there isn't much for us to do anymore...

56 hour weeks are an interesting thought. In my program there is morning report daily (5 hr/week), noon conference (5/week), teaching rounds (usu 4-5/week). Add in rounding with consultants, reviewing films in radiology, etc for at least another 5/week. That only leaves 36 hours per week for actually taking care of patients.

As others above have pointed out, if a mandated decrease in resident hours comes to be, hospitals will need to find other ways to fill the gap. More residents is not going to happen -- Medicare is going bankrupt already and can't afford more residents, and the only way this can happen is a large increase in IMG residents (not necessarily a bad thing, but would need to be addressed) or closing some programs to allow others to expand. Instead, hospitals will have faculty do this, or NP/PA's, etc. As faculty are busier, or not available, teaching will suffer. In addition, as the costs mount, hospitals will fce reality and realize that it will be financially smarter to close their residency (or decrease it's size dramatically) and simply rely on non-residents to do the work.

Which leads to the next problem -- if the hospital shifts so that resident labor is not really needed, then residents become "extras" plastered onto the smooth running system. This essentially recreates the medical student role. What separates Med students from residents is responsibility. If that responsibility is removed, the core of being a resident is lost.

I think that decreasing hours to allow residents to moonlight is crazy. If we're limiting residents to 56 hours because that allows them to function in the hospital safely, having them work another 20 hours moonlighting completely nullifies that. Either it's safe to work 80 hours, or it's not. Similar example: if we feel that it's only safe to drive a truck for 10 hours a day, you can't buy two trucks and drive each of them for 10 hours a day.

Another unintended consequence of duty hour restrictions is inefficient residents. In the "old" days, before duty hours, being inefficient was a self correcting problem. If you were inefficient and needed to stay until 11 PM every day to get your work done, you were free to do so -- but most people figured out this was unsustainable and would find a way to be more efficient. Now, I have the problem where a resident doesn't get all their work done and hits their duty hour limit -- what does that mean? Did I assign them too much work? Are they too slow, and fail the rotation? Should I design the rotations such that the slowest resident can get all the work done in the allotted time, and the fastest resident goes home at 11AM? Lowering the hours further is likely to worsen this issue.

I think it is almost certain that the IOM is going to state, unequivicably, that shift limits of 16 or 18 hours will be the max. And honestly, I agree with them. Working 24-30 hours straight, unless there is a reasonable amount of sleep expected, is really non-sustainable. And I don't think that it "teaches" you ow to do this -- that's like saying that if you drink large amounts of alcohol regularly, you get used to it and can drive with a higher alcohol level. That's "Chewbacca-on-endor crazy". (Ed note: I like that phrase, I'm going to try to work it into every lecture/workshop I give from now on).

And the JC is going to take it and run. It will apply to all docs -- faculty, privates, etc. A 24 hour shift with rare phone calls will be fine, but if you're a surgeon and you're called to the OR at 2AM, you're not going to be operating at all the next day.

How residency programs are going to adjust to this is unclear. Some have already removed overnight call. We have mixed services -- some with call, some with night float. Removing the rest of the call will be very difficult -- either I'm going to pull out of many services to focus on just a few (which will also mean more NF for my residents), or I'll tell services thatr residents no longer take overnight call and they have to find some way to cover it themselves. At least if the JC makes it happen, it will apply to all programs, all fields, all specialties, all hospitals simultaneously, and I can go to my colleagues and state that there is "nothing I can do". Still, I think it is the right thing to do in the long run, as long as the amount of night resident coverage remains reasonable.

Sorry for the ramble.

if we turned traditional im, or any other residency, on its head, do you think we could make it work? i'm about to finish residency in 5 weeks, so the issue won't affect me (i'm not going into academic medicine and have no plans too, though i suppose i can't rule it out in the future, but i digress). for example, if there were a mix of 8, 10, 12 hour shifts... if the day didn't always start at 7/8/9 am... some residents come at 7 am, others at 1 pm, others at 6 pm (or some variation thereof), like emergency medicine.

there seems to be a lot of holding onto the way that we do things because that's the way they've been done, instead of searching for solutions that can be reasonable for all parties involved.

it seems that er attendings are fine with the current work hour limits because they seem to be ok with a staggered work schedule. im, and perhaps other specialties, seems to still hold onto a 9-5 mentality, even though we all know and admit that taking care of patients is a 24/7 enterprise. you see this reflected in the way hospitals operate, where the bulk of staff is present 9-5. you see this in clinic, which is open from 9-5. but the worst of the worst seems to be "after hours."

i don't know. perhaps i'm reaching. but i think it would be interesting if im attendings would go for something similar to they way that er does it.

i think what's interesting for im residency is the weekend. saturday and sunday seem to be efficient as hell. you get in, you see your patients. you do what needs to be done. you leave. why can't it be like that during the week with the lectures thrown in?!!?

if the residency work hour rule really is/was decreased, i think a lot of program directors really would look at what is efficient, and what isn't. spending 5-10 minutes talking about all the different potential causes of dka in a diabetic who tells you he didn't take his insulin for 2 weeks isn't efficient nor prudent. 5-10 minutes/patient on just 10 patients is 50-100 minutes per day. do that over 5 days, you have 250-500 minutes (4-8 hours). throw in more patients, and you can start to see that little conversations here and there really add up.

maybe we should really ask ourselves how efficient we're being, and if we can change that, perhaps we have a starting point.

Prepare to be assimilated. Resistance is futile.

desire is irrelevant

 

[Strength&Speed]

true, family medicine is broader than internal medicine. however, i think people expect family medicine docs to have less depth due to the breadth of their practice.

i don't think you can just cut down the hours and keep medicine a three year residency. you would see 2/3 of the patients we do currently, and i just don't think that's enough. there are plenty of conditions that i haven't seen, and i'm at the end of my second year of residency. for example, my knowledge of rheumatology and endocrinology is horrendous. lupus? what's that? i'm plenty comfortable seeing chest pain/ chf exacerbation/ copd exacerbation/ pna/ cellulitis/ sepsis/ gi bleed/ dka. it's the uncommon things that i still need to see more of. that, and i think most people feel less confident in managing outpatient issues, since residency is so skewed toward inpatient care.

Get back to us in a year. I bet you wouldnt say 56 is too long in medicine. You'll be scratching and clawing to be on your own after 2.5 yrs.

 

[Strength&Speed]

true, family medicine is broader than internal medicine. however, i think people expect family medicine docs to have less depth due to the breadth of their practice.

i don't think you can just cut down the hours and keep medicine a three year residency. you would see 2/3 of the patients we do currently, and i just don't think that's enough. there are plenty of conditions that i haven't seen, and i'm at the end of my second year of residency. for example, my knowledge of rheumatology and endocrinology is horrendous. lupus? what's that? i'm plenty comfortable seeing chest pain/ chf exacerbation/ copd exacerbation/ pna/ cellulitis/ sepsis/ gi bleed/ dka. it's the uncommon things that i still need to see more of. that, and i think most people feel less confident in managing outpatient issues, since residency is so skewed toward inpatient care.

Get back to us in a year. I bet you wouldnt say 56 is too long in medicine. You'll be scratching and clawing to be on your own after 2.5 yrs. And as far as you not feeling comfortable about rheumatology and endocrinology....it doesn't matter. If you can take care of general IM emergencies and admits...you can consult for such things...or look them up in UptoDate and be fine. I find my knowledge of Rheum doesn't matter. I have to end up consulting most times anyway--there's no way you can keep up with all the subspecialty nuances each year anyway.

 

[cleansocks]

Personally I like the idea of requiring reasonable hours for residents.

It solves the proven problems associated with sleep deprivation. It also makes medicine a more attractive field to people who want to be a good spouse/dad/mom.

Beyond that, it provides an unusually strong incentive for hospitals to improve efficiency: make better use of your residents' time or... your hospital will not function. Since exorbitant costs prohibit the hospitals from spending more to fill the new gap, they will have to improve the way the hospital runs.

As many posters above have mentioned and provided examples for, residents are paid very little for a ton of work that could be done in much less time IF ONLY hospitals would implement relatively inexpensive changes (ie vitals/labs recording systems, abolishing pre-rounding, discharge templates, inventory systems, etc).

These one-shot additions, even the implementation of a better EMR, would likely appear far more cost-efficient in a hospital analyst's proforma income statement than hiring additional personnel to fill gaps. Thus hospitals would likely prioritize cost-saving efficiency improvement over expensive alternatives. Additionally I think these changes would end up reducing administrative costs in unforeseen ways.

I do not think hospitals would abandon their residency training program; few realize that the "match" is a brilliant way of completely eliminating resident negotiating power. Residents cannot band together to form union-like associations. Thus hospitals can pay residents as little as possible without causing an outcry - and they do. Residents are invaluable, overworked, undercompensated assets at 80 hrs or 56.

As for reducing training time: excuse my bluntness but all of you aside from the surgeons are freakin' crazy! Final year residents barely need to pay attention on rounds - they're usually bored out of their minds! Who doesn't want more free time and less time seeing the 500th COPD exacerbation, or more to the point in this case, dictating the 9th half-hour long discharge summary? I see two "solutions" for those who support the ridiculous notion that training for ~10 hrs per day for several years "isn't enough."
1. Different hour requirements for surgeons. Unfortunately this discrepancy will make gen surg even more unappealing but maybe not that significantly for the type of people that end up going into gen surg anyway (ie masochistic/workaholic types - no offense =).
2. Allow moonlighting. Thus if some residents want those extra hours, they can have them. I don't think this would diminish the benefits of the reduced hours requirement on a whole because most people will not spend the extra free time working.

 

[MedGoatTX]

The necessary element of repetition might be more pronounced in surgery, but the above implication that it doesn't exist in other fields is just ignorant. No you probably don't really need more time to see that 500th CHF exacerbation, just like the surgeons don't need more time to do their 500th appy. But what about the 50th? Also it's the rare cases or rare presentations that you might get five of in a residency that you need to see as much of as possible. Because when you're out on your own without an attending who trained in the days when men were men backing you up, you have to be able to deal with it yourself. And I have yet to work with a final-year resident, in any specialty, who is "bored out of their mind." If you're already in that place at the end of residency, where are you going to be after 10, 20, or 30 years of practice?

And people seem to beat on efficiency as an ultimate goal far too often here and in this debate. Are there things that could be more efficient? Sure. But we shouldn't push efficiency at the cost of everything else. Patient care should be the ultimate goal with education close behind, and those don't always go hand-in-hand with super-efficiency. You can't push being efficient to the point where it negatively impacts why we're actually there.

 

[Strength&Speed]

The necessary element of repetition might be more pronounced in surgery, but the above implication that it doesn't exist in other fields is just ignorant. No you probably don't really need more time to see that 500th CHF exacerbation, just like the surgeons don't need more time to do their 500th appy. But what about the 50th? Also it's the rare cases or rare presentations that you might get five of in a residency that you need to see as much of as possible. Because when you're out on your own without an attending who trained in the days when men were men backing you up, you have to be able to deal with it yourself. And I have yet to work with a final-year resident, in any specialty, who is "bored out of their mind." If you're already in that place at the end of residency, where are you going to be after 10, 20, or 30 years of practice?

And people seem to beat on efficiency as an ultimate goal far too often here and in this debate. Are there things that could be more efficient? Sure. But we shouldn't push efficiency at the cost of everything else. Patient care should be the ultimate goal with education close behind, and those don't always go hand-in-hand with super-efficiency. You can't push being efficient to the point where it negatively impacts why we're actually there.

really? you've never seen a final year resident who's bored?

 

[MedGoatTX]

I imagine every student, resident, and attending is bored at some time or another. But my point was that I've never run across a senior who felt compelled to share with me how they were so "bored out of their mind" that they didn't need to be there anymore.

 

[RTrain]

However, I hope you see that sign off line as a reference to my avatar. It's Borg, from ST:TNG (which is Star Trek: The Next Generation). I'm a total geek. I can't remember what my score on the geek test was, but it was high.

Oh, yes, I got the Borg reference. My geek quotient was pretty high too - high enough that I didn't post it.

 

[c5a]

aProgDirector,

In your opinion, if our work hours were reduced significantly (56 hrs), do you expect to see a lengthened amount of training for IM, i.e., 4 years?

 

[cleansocks]

The necessary element of repetition might be more pronounced in surgery, but the above implication that it doesn't exist in other fields is just ignorant. No you probably don't really need more time to see that 500th CHF exacerbation, just like the surgeons don't need more time to do their 500th appy. But what about the 50th? Also it's the rare cases or rare presentations that you might get five of in a residency that you need to see as much of as possible. Because when you're out on your own without an attending who trained in the days when men were men backing you up, you have to be able to deal with it yourself. And I have yet to work with a final-year resident, in any specialty, who is "bored out of their mind." If you're already in that place at the end of residency, where are you going to be after 10, 20, or 30 years of practice?

And people seem to beat on efficiency as an ultimate goal far too often here and in this debate. Are there things that could be more efficient? Sure. But we shouldn't push efficiency at the cost of everything else. Patient care should be the ultimate goal with education close behind, and those don't always go hand-in-hand with super-efficiency. You can't push being efficient to the point where it negatively impacts why we're actually there.

That is why, for the rare few who actually want to work more in medicine and who are as vociferous as you so as to make it seem like a lot of people want that too, extra training time should be available in the form of moonlighting.

For rare cases, consult. Seeing 2 or 3 more rare cases by working 30 extra hours a week is not worth the cost or patient morbidity associated with medical errors. In fact an attending who is more "scared" of a rare diagnosis and orders a consult as a result will likely serve a patient better than one who arrogantly assumes they know how to manage it because they've seen a whole case (while SLEEPY! reduced stage 3/4 sleep -> less memory!) during residency.

Healthcare efficiency should not be underestimated. It is basically another word for cost (time is money, etc). Cost is what raises insurance premiums and promotes the level of uninsured individuals that exist in this country. It is what delays or prevents necessary patient care. It is what is rising steadily towards and past 20% of GDP, a ridiculous figure and trend that will be unsustainable. In fact one statistic suggests that 31% of healthcare cost is associated with excessive administration, and that successfully reducing such a cost would be enough to cover the majority of the uninsured population. http://content.nejm.org/cgi/content/short/349/8/768. (I do not support the conclusion that we should switch to a canadian healthcare system but the point is made nonetheless).

The quality of healthcare suffers as a result of inefficiency to a MUCH greater extent than it does due to "lack of training." In this example, it is because of inefficiency that residents have to work such long hours and as a result make mistakes. It is because of inefficiency that people that can't find the flow sheet say "screw it." It is one of the reasons ER's are so overwhelmed and critical patient care is delayed. It contributes to sloppy hand-writing and incorrect medication dosages. The list continues endlessly. Doctors work very hard; it is the system in which they work that results in poorer quality, not the doctors themselves. It is not training that is the problem, but the system we are trained into. Measures such as this that FORCE change from the bottom up (rather than encourage change from the top down) are necessary.

 

[3dtp]

Also it's the rare cases or rare presentations that you might get five of in a residency that you need to see as much of as possible. Because when you're out on your own without an attending who trained in the days when men were men backing you up, you have to be able to deal with it yourself.

This is true, but will always be true. Whether residency is 1 year or 10 years. If, as it sometimes seems, the purpose of residency is to train you to memorize grocery lists of every rare presentation and its management, then you're correct. On the other hand, if the purpose of residency is to train you how to approach, analyze and respond to a rare presentation, then this becomes substantially less true.

No matter how long you've been in residency, you will come up with a case that you've never seen before and a possibility that no one else has ever seen before. In 1980, practically no one saw an HIV kaposi. In 1990, most saw at least one, likely several in some areas of the country, and today, we rarely see them anymore. The next what is this???? disease will certainly pop up and if residency hasn't trained us to figure it out, call for help when needed, then we're doing the wrong things. Sometimes the diseases have not read the same text books and journals that we have.

And people seem to beat on efficiency as an ultimate goal far too often here and in this debate. Are there things that could be more efficient? Sure. But we shouldn't push efficiency at the cost of everything else. Patient care should be the ultimate goal with education close behind, and those don't always go hand-in-hand with super-efficiency. You can't push being efficient to the point where it negatively impacts why we're actually there.

We do not need automotive style efficiency where engineers spend a lifetime trying to figure out how to save 3 cents in the manufacter of a $50 part. This is true.

But, medical care costs are rising faster than society is willing to tolerate. No small part of that rate of increase is due to better and more effective care.

But a substantial portion is also related to the costs of overhead. And that we absolutely must address. We must and should bring modern systems to bear. It will improve the efficiency and effectiveness of health care. The ability to sit in an exam room with a patient, pull up medical images laboratory values and progress notes and discuss with them their disease the [urgent/emergent/elective] nature of their treatment and other similar efficiencies will have a profound impact on medical efficiency, access to information pertinent to the discussion at hand and enable rapid and more accurate decision making and execution of those decisions.

This will enable physicians to be more productive, reduce medical error, and help contain medical costs and give our patients a better outcome.

Efficiency is not the ultimate goal. It is the highest and best use of resources to achieve that goal.

 

[AwesomO]

See link: http://www.ahrq.gov/news/sp120307.htm

The AHRQ final report is due to come out in about 9 months. People I know who are involved in the process tell me that the recommendation will be to decrease the maximum hours from 80 to 56 per week. The unresolved issue apparently is whether the number of years of residency training will be lengthened and by how much (for example will IM be changed to a 4 yr. residency, etc.)

Lovely so I'll get to put in the 80 hours a week as an intern then not be able to moonlight during my 2nd or 3rd year (my program doesn't allow moonlighting if it violates your 80 hours or in the future 56).
Sorry to sound immature but screw that. If I put in 80 hours as an intern I should be able to do that during 2nd and 3rd year if I want to.

 

[Winged Scapula]

Lovely so I'll get to put in the 80 hours a week as an intern then not be able to moonlight during my 2nd or 3rd year (my program doesn't allow moonlighting if it violates your 80 hours or in the future 56).
Sorry to sound immature but screw that. If I put in 80 hours as an intern I should be able to do that during 2nd and 3rd year if I want to.

Uhmmm....it will take years to implement if the regulation is made. You will be long finished with residency if and when the reduction happens.

They may be out of touch, but these bodies realize that programs cannot make such a significant reductions in work hours without sweeping changes to staffing, schedules, etc.

 

[DrDre311]

Uhmmm....it will take years to implement if the regulation is made. You will be long finished with residency if and when the reduction happens.

They may be out of touch, but these bodies realize that programs cannot make such a significant reductions in work hours without sweeping changes to staffing, schedules, etc.

WS, how long was the 80 hour restriction discussed before it was enacted? I know NY had it very early, but I'm just wondering how long an idea like this has to gather momentum and fester before it gets forced on everyone. It hasn't even been that long that the 80 hour restriction has been in effect. I don't think enough time has passed to be able to evaluate whether the 80 hour limit has impacted quality of education/attending competence...certainly too early to go tweaking things yet.

 

[Winged Scapula]

WS, how long was the 80 hour restriction discussed before it was enacted? I know NY had it very early, but I'm just wondering how long an idea like this has to gather momentum and fester before it gets forced on everyone. It hasn't even been that long that the 80 hour restriction has been in effect. I don't think enough time has passed to be able to evaluate whether the 80 hour limit has impacted quality of education/attending competence...certainly too early to go tweaking things yet.

I think we can trace widespread talks about resident work hours back to 1999. This was followed by calls from a Public Advocacy group and the AMA for OSHA to enact work hour restrictions. OSHA deferred to ACGME. ACGME announced in June 2002 that programs had to reduce work hours (etc.) starting on July 1, 2003. I believe osteopathic programs started a year earlier.

 

[Doowai]

On the other hand, if the purpose of residency is to train you how to approach, analyze and respond to a rare presentation, then this becomes substantially less true.

No matter how long you've been in residency, you will come up with a case that you've never seen before and a possibility that no one else has ever seen before. ....... Sometimes the diseases have not read the same text books and journals that we have.

This will enable physicians to be more productive, reduce medical error, and help contain medical costs and give our patients a better outcome.

Efficiency is not the ultimate goal. It is the highest and best use of resources to achieve that goal.

Very quotable

 

[8744]

I would do an extra year of residency in exchange for decent hours if I was in a specialty like Surgery or OB/Gyn. Then I would have time to moonlight at Home Depot to make some extra money.

 

[Tired]

I would do an extra year of residency in exchange for decent hours if I was in a specialty like Surgery or OB/Gyn. Then I would have time to moonlight at Home Depot to make some extra money.

Of course you would, with your three year residency.

What if it was six, and you suddenly were faced with an extra 2?

 

[DrDre311]

Of course you would, with your three year residency.

What if it was six, and you suddenly were faced with an extra 2?

This is what I'm afraid of.

 

[Tired]

This is what I'm afraid of.

It's part of what I'm afraid of.

Other things that scare me:

1) Limiting call, reducing access to emergent cases coming out of the ED.

2) Reducing clinical hours, rather than administrative hours, meaning that no matter how many years you add, it's just more paperwork with fewer cases.

3) An influx of soft residents, attracted by the cushy hours, without the historic toughness of real surgical residents.

4) More women in the field. And not the "hot-but-mean" type we currently fill our programs with, but the "I need time off to have my third baby" kind.

 

[Kubed]

It's part of what I'm afraid of.

Other things that scare me:

1) Limiting call, reducing access to emergent cases coming out of the ED.

2) Reducing clinical hours, rather than administrative hours, meaning that no matter how many years you add, it's just more paperwork with fewer cases.

3) An influx of soft residents, attracted by the cushy hours, without the historic toughness of real surgical residents.

4) More women in the field. And not the "hot-but-mean" type we currently fill our programs with, but the "I need time off to have my third baby" kind.

:: Shudders :: Sorry, a dark chill just ran down my spine

 

[Winged Scapula]

It's part of what I'm afraid of.

Other things that scare me:

1) Limiting call, reducing access to emergent cases coming out of the ED.

2) Reducing clinical hours, rather than administrative hours, meaning that no matter how many years you add, it's just more paperwork with fewer cases.

3) An influx of soft residents, attracted by the cushy hours, without the historic toughness of real surgical residents.

Very realistic fears, IMHO. I think there was evidence of #3 even with 80 hrs.

4) More women in the field. And not the "hot-but-mean" type we currently fill our programs with, but the "I need time off to have my third baby" kind.

Glad to see you have captured our persona realistically.

But you might want to ask Castro about his experience with a female resident taking time off for babies during their residency clinical years. They *are* out there already.

 

[sirus_virus]

You can always argue in favor of anything. Hell, even the south tried to justify slavery. I remember when some super gurus in the medical community argued that sleep deprived residents were actually safer for patients than well rested ones. Now that the empirical evidence suggests otherwise, the next line of action is to threaten trainees with longer years of training. So after 5 years of FP training, you can come out and stand right next to a Nurse practitioner doing the same exact thing, and lord knows maybe for the same or less pay.



BTW, who actually funded research to show that sleep deprived doctors are bad for patients. Is that not supposed to be common sense? That is like research to find out if fat people weigh more than skinny people. What the hell?

 

[Strength&Speed]

You can always argue in favor of anything. Hell, even the south tried to justify slavery. I remember when some super gurus in the medical community argued that sleep deprived residents were actually safer for patients than well rested ones. Now that the empirical evidence suggests otherwise, the next line of action is to threaten trainees with longer years of training. So after 5 years of FP training, you can come out and stand right next to a Nurse practitioner doing the same exact thing, and lord knows maybe for the same or less pay.



BTW, who actually funded research to show that sleep deprived doctors are bad for patients. Is that not supposed to be common sense? That is like research to find out if fat people weigh more than skinny people. What the hell?

God, aint that the truth. "You can argue in favor of anything". I am going to remember that because it's absolutely true. My other pet peeve with residency is everyone expects you to power through all 5 yrs. They should make it a little more allowable to take time off when you need it. People are not machines.

 

[DrDre311]

It's part of what I'm afraid of.

Other things that scare me:

1) Limiting call, reducing access to emergent cases coming out of the ED.

2) Reducing clinical hours, rather than administrative hours, meaning that no matter how many years you add, it's just more paperwork with fewer cases.

3) An influx of soft residents, attracted by the cushy hours, without the historic toughness of real surgical residents.

4) More women in the field. And not the "hot-but-mean" type we currently fill our programs with, but the "I need time off to have my third baby" kind.

All good points but:

2) This point will be the bottom line of any further hours reductions.

 

[Winged Scapula]

RE: tired residents taking "better" care of patients.

I think in the abstract that is ridiculous. But that was not the point that was being made in the articles which argued this.

Instead, it was a recognition that there are no work hour restrictions, no night floats, no going home after 24-30 hrs when you are an attending. So you may very well be asked to make decisions and treat patients when you are exhausted once you are out in the working world.

There was also a recognition that state dependent learning works in residency as well. If you are used to making decisions when you are tired, when you are tired in the future, your brain may be able to function better than someone who was naive to the experience. In addition, the body adjusts to a new status quo, whether that be getting less sleep, more exercise, or dealing with temperature changes.

Obviously a well rested, well trained physician takes the best care of patients. But I'm not sure I'd want someone who had *never* been up all night, never worked extended hours, etc. working on me in the middle of the night because of the very real observation that those who have, have developed mind and behavior maps for just such situations.

 

[Faebinder]

RE: tired residents taking "better" care of patients.

I think in the abstract that is ridiculous. But that was not the point that was being made in the articles which argued this.

Instead, it was a recognition that there are no work hour restrictions, no night floats, no going home after 24-30 hrs when you are an attending. So you may very well be asked to make decisions and treat patients when you are exhausted once you are out in the working world.

There was also a recognition that state dependent learning works in residency as well. If you are used to making decisions when you are tired, when you are tired in the future, your brain may be able to function better than someone who was naive to the experience. In addition, the body adjusts to a new status quo, whether that be getting less sleep, more exercise, or dealing with temperature changes.

Obviously a well rested, well trained physician takes the best care of patients. But I'm not sure I'd want someone who had *never* been up all night, never worked extended hours, etc. working on me in the middle of the night because of the very real observation that those who have, have developed mind and behavior maps for just such situations.

Hmm.. clearly I rather take that risk (the risk of making decisions when i am overworked and tired) when I am an attending as opposed to when I am a resident. You have more experience as an attending than as a resident.

 

[Winged Scapula]

Hmm.. clearly I rather take that risk (the risk of making decisions when i am overworked and tired) when I am an attending as opposed to when I am a resident. You have more experience as an attending than as a resident.

Yes, but less back-up support, fewer people to pass the buck to on the final decision.

I keep looking around for "the boss" only to realize its me.

 

[DarthNeurology]

There was also a recognition that state dependent learning works in residency as well. If you are used to making decisions when you are tired, when you are tired in the future, your brain may be able to function better than someone who was naive to the experience.

Obviously a well rested, well trained physician takes the best care of patients. But I'm not sure I'd want someone who had *never* been up all night, never worked extended hours, etc. working on me in the middle of the night because of the very real observation that those who have, have developed mind and behavior maps for just such situations.

Maybe they will limit attending physician hours as well? I think that when you work 36 hours in a row you brain may learn better. I.e. when I was doing ob/gyn for 36+ hours, up all night with deliveries, your brain ONLY thinks about ob/gyn (or mostly anyhow), and I felt I learned more than if my brain was allowed to cool down for 12 hours and drift to personal life, SND (ahem), etc . . . Same thing as when you want to learn a foreign language you actually go and live in that country, i.e. you have to speak the language 24-7 and start dreaming in it as well. I am now thinking that decreased residency time spread out over more years may be problematic due to this. Obviously there has to be a balance between functioning adequately to keep patients alive and being there to learn. I would think resident learn more at night as that is when the attendings aren't there.

 

[Winged Scapula]

Maybe they will limit attending physician hours as well?

There have been grumblings about it and we've discussed the logistics here (ie, its one thing to do when you are an academic physician who works at one hospital, quite another when you have two offices, multiple hospitals, etc.). I wouldn't be suprised if it becomes a real issue some time in the future.

I think that when you work 36 hours in a row you brain may learn better. I.e. when I was doing ob/gyn for 36+ hours, up all night with deliveries, your brain ONLY thinks about ob/gyn (or mostly anyhow), and I felt I learned more than if my brain was allowed to cool down for 12 hours and drift to personal life, SND (ahem), etc . . .Obviously there has to be a balance between functioning adequately to keep patients alive and being there to learn. I would think resident learn more at night as that is when the attendings aren't there.

Absolutely. Hah...and to think I thought we didn't agree on anything.

 

[elwademd]

Instead, it was a recognition that there are no work hour restrictions, no night floats, no going home after 24-30 hrs when you are an attending. So you may very well be asked to make decisions and treat patients when you are exhausted once you are out in the working world.

as i've stated in other threads, this is yet another reason to join a medium to large sized group practice... where the group actually values everyone working a reasonable load. i.e. not a group in name, but in day to day practice.
but, if we want to continue to do solo practices, or small group (less than 5 physician practices/groups), then it will continue to be the same way. i could go on, but i think it's beyond the scope of this thread (seeing as how it's about us lowly residents. )

 

[Winged Scapula]

A large group is not necessarily the salvation.

You still have to take call and it still may entail middle of the night visits to the ED and then a full clinic the next day, or finishing up operating on patients.

Call may not be q3 in a large group, but there is still the chance of being up all night and working a full day the following day unless your group works shifts (ie, you get off at 0700 and whomever is on the day shift operates on anyone you've booked the night before).

 

[elwademd]

A large group is not necessarily the salvation.

you're correct, a large group is not the salvation... but it can drastically reduce the amount of call days/nights in a month.

You still have to take call and it still may entail middle of the night visits to the ED and then a full clinic the next day, or finishing up operating on patients.

Call may not be q3 in a large group, but there is still the chance of being up all night and working a full day the following day unless your group works shifts (ie, you get off at 0700 and whomever is on the day shift operates on anyone you've booked the night before).

i should add that my comments were from the perspective of internal medicine. surgery definitely is a different world from internal medicine in respect to call and expectations of call, though i would be interested to see more of every specialty really try to strike a balance between professional and personal life. but again, i digress.

 

[Danbo1957]

A medium sized group is a perfect model - my Internal Medicine practice has twelve doctors (7 male, 5 female); our offices are connected to the hospital. Office hours are 9-5, work hours average 45-50 hours per 7-day week. All physicians get one weekday afternoon off, four days on call per month, eight weeks vacation per year. All doctors are on staff at two hospitals where four of our team (rotate) are always represented on Medical Staff commitees.