56 Hour Week Is Coming

[Winged Scapula]

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

Clearly.

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.

Surgeons, and others need to be more creative in they way they work the call schedule. Perhaps shifts are reasonable; perhaps blocking off office schedule for the day after overnight call, or cases scheduled after 24 hrs on goes to one of your partners. I watch my friends in more call heavy surgical practices, even larger ones, still face being up all day the night after call.

---

Members don't see this ad.

 

[Faebinder]

You guys cant ignore the sleep deprivation effect anymore. It is national at this point. Even the cnn has occasional things popping up about it. If you sleep deprive a resident, dangerous decisions will be made. I would much rather see the deprivation of sleep happening at the attending level.. at least they have the experience to back up their decisions vs the resident who is functioning without or with less decision making experience. My beef is not with the 56 hours rule.. it's with the shift length rule. There is no execuse to have anyone working more than 18 hours..certainly not more than 24 hours. At this day and age, we should be able to set up a night shift that holds the fort till day time. The problem is resistance... "I learned this way and so can you" mentality and the mentality of "If it aint broken then don't fix it".

Now I will admit.. the system is not broken now... 80 hours is FINE but there is room for improvement on the use of the 80 hours.

 

[sirus_virus]

You guys cant ignore the sleep deprivation effect anymore. It is national at this point. Even the cnn has occasional things popping up about it. If you sleep deprive a resident, dangerous decisions will be made. I would much rather see the deprivation of sleep happening at the attending level.. at least they have the experience to back up their decisions vs the resident who is functioning without or with less decision making experience. My beef is not with the 56 hours rule.. it's with the shift length rule. There is no execuse to have anyone working more than 18 hours..certainly not more than 24 hours. At this day and age, we should be able to set up a night shift that holds the fort till day time. The problem is resistance... "I learned this way and so can you" mentality and the mentality of "If it aint broken then don't fix it".

Now I will admit.. the system is not broken now... 80 hours is FINE but there is room for improvement on the use of the 80 hours.

Good post. The problem here is that at some point both sides of the argument have to concede something about their positions. Time needs to be spent in training but that does not translate to abuse of basic human function (sleep). Patients do not benefit from sleep deprived doctors, sleep deprived doctors do not benefit from sleep deprived training. The only people benefiting are the employers.

People are becoming more concerned about this issue because it is one of those things you would have thought was a no brainer. Some people can actually drive while drunk, but we don’t let them. Some pilots can fly without sleep, but we don't let them. Some truckers can drive 24 hours straight, but we don’t let them. But somehow the medical community wants to sneak one past society with this twisted argument that sleep deprivation actually has some advantages in this arena. Then we wonder why lawyers are having a hay day beating the crap out of the medical community, when the community itself does not even sound competent.

 

[DarthNeurology]

Clearly.



Surgeons, and others need to be more creative in they way they work the call schedule. Perhaps shifts are reasonable; perhaps blocking off office schedule for the day after overnight call, or cases scheduled after 24 hrs on goes to one of your partners. I watch my friends in more call heavy surgical practices, even larger ones, still face being up all day the night after call.

I would think that mostly it is trauma surgeons up at night? If there was a problem with a floor patient after say a colectomy done by a GI surgeon, the chief resident took care of it and the GI surgeon wasn't woken up, so maybe for those going in to surgery being in academics is better

 

[deleted109597]

I would think that mostly it is trauma surgeons up at night? If there was a problem with a floor patient after say a colectomy done by a GI surgeon, the chief resident took care of it and the GI surgeon wasn't woken up, so maybe for those going in to surgery being in academics is better

Actually, if I call the attending surgeon it had better be because the patient is asleep on the table ready for their re-exploration. Ours don't take lightly to being woken up for pretty much anything.

 

[Winged Scapula]

I would think that mostly it is trauma surgeons up at night? If there was a problem with a floor patient after say a colectomy done by a GI surgeon, the chief resident took care of it and the GI surgeon wasn't woken up, so maybe for those going in to surgery being in academics is better

It depends. Remember people with acute surgical needs other than trauma come into the ED at all hours. Or perhaps they came in at a decent hour, but the work-up by the ED wasn't completed until the wee hours.

Some attendings will come in all the time, regardless of who the Chief resident is, some will only come in with certain Chiefs, in some hospitals a mid-level or mid-year resident is seeing the patient and a Chief is at home or is otherwise busy, and some never come in. Some attendings want to be called about everything, and some about nothing.

Academics seem like it would be easier because you can presumably have residents do things for you, but OTOH there are many painful calls you have to listen to (which you could have easily solved yourself), there is teaching which is a burden to some, and possibly research expectations. And of course, there is the lower salary for the privilege of being at an academic medical center.

Its the great fallacy that residents make your job easier.

 

[yaah]

You guys cant ignore the sleep deprivation effect anymore. It is national at this point. Even the cnn has occasional things popping up about it. If you sleep deprive a resident, dangerous decisions will be made. I would much rather see the deprivation of sleep happening at the attending level.. at least they have the experience to back up their decisions vs the resident who is functioning without or with less decision making experience. My beef is not with the 56 hours rule.. it's with the shift length rule. There is no execuse to have anyone working more than 18 hours..certainly not more than 24 hours. At this day and age, we should be able to set up a night shift that holds the fort till day time. The problem is resistance... "I learned this way and so can you" mentality and the mentality of "If it aint broken then don't fix it".

Now I will admit.. the system is not broken now... 80 hours is FINE but there is room for improvement on the use of the 80 hours.

Yeah, but at what point does sleep deprivation cease being the hospital/residency program's "fault" and start being the resident's fault? If you are working over 100 hours a week, that begins to cut down on actual sleep time, because commuting + simple hygeine and eating + work takes up more than 16-18 hours per day. But at 80 hours a week, not so much. While life is not that fun, you do have sufficient time to meet daily needs and get sleep. At some point it has to become a resident's responsibility to efficiently meet these needs and go to sleep. You can't keep blaming work hours.

I agree though, much room for improvement on using the 80 hours. In pathology we are relatively isolated from such shenanigans, but even we have a lot of sub-educational paperwork and phone calls and meetings, etc. One of the main problems in medicine is sheer disorganization amongst departments, organizations that require paperwork, and the people who insist on MDs documenting everything 8 times.

 

[AwesomO]

You guys cant ignore the sleep deprivation effect anymore. It is national at this point. Even the cnn has occasional things popping up about it. If you sleep deprive a resident, dangerous decisions will be made. I would much rather see the deprivation of sleep happening at the attending level.. at least they have the experience to back up their decisions vs the resident who is functioning without or with less decision making experience. My beef is not with the 56 hours rule.. it's with the shift length rule. There is no execuse to have anyone working more than 18 hours..certainly not more than 24 hours. At this day and age, we should be able to set up a night shift that holds the fort till day time. The problem is resistance... "I learned this way and so can you" mentality and the mentality of "If it aint broken then don't fix it".
/quote]

I actually wouldn't mind 24 hour call, at the tail end I can probably muster up enough brain power to keep things from completely going to hell. What I hate is the extra 6 hours they can tack on there for "continuation of care." Which from what I understand the spirit of the rule is that the additional 6 hours is for a patient you are working on (ie you are allowed to finish up the admins or procedures you were doing at 6:55 AM). However most programs seem to think this means rounding and clinic since techinically you are participating in someone's "continuation of care."

 

[MR1]

I can't agree more with the 24 hour call. I have never had a problem going 24 hours, it is always that last 6 which gets me. Especially when you have to pre-round, round with an attending that feels like teaching that day, get patients discharged, deal with social work issues, and make a decent check out list so your patient's don't suffer.

 

[fakin' the funk]

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).

I didn't know what this was a reference to...so I googled it...is this a reference to the Chewbacca-lives-on-Endor South Park episode from 1998?

 

[DrDre311]

I didn't know what this was a reference to...so I googled it...is this a reference to the Chewbacca-lives-on-Endor South Park episode from 1998?

Yes. I think it's called "Chef Aid."

Johnnie Cochran first uses the Chewbacca Defense to get the jury to side with Alanis Morrissette's record company exec and then later uses it to get Chef out of the judgement.

 

[saanjana]

I'm just wondering why they are thinking of cutting down the work hours to 52 from 80....it seems like the 80 hour work weeks are working out fine at most places...so what is the reason for the change?

 

[AwesomO]

http://www.cleveland.com/medical/index.ssf/2008/05/residents_expecting_to_work_fe.html

So what should residents expect come December, when workload recommendations will be announced? Dr. Lisa Bellini, an associate dean at the University of Pennsylvania Health System, would consider (pdf) a cap in patients per resident; better management of residents' time (less phone time, better use of technology and fewer clerical tasks); and training in sleep hygiene, which would include mandatory naps.

SCORE

 

[Coastie]

Mandatory naps?



Please tell me that's pediatrics residents only.

http://www.cleveland.com/medical/index.ssf/2008/05/residents_expecting_to_work_fe.html



SCORE

 

[Faebinder]

Oh God... There is no way in hell I can do mandatory naps. You might as well shoot me now.

 

[racerx]

Mandatory naps?



Please tell me that's pediatrics residents only.

Right after milk and cookies, they'll pull out their mats and lay down.

 

[NotAProgDirector]

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?

Although they'll be lots of posturing and threatening, I don't think so. For several reasons:

1. If IM did this and FP didn't, it would drive people from IM to FP which IM doesn't want.
2. Doing 4 years of IM to go into a specialty makes no sense at all. Allowing 3 years of IM -> specialty or 4 years into GIM will drive more people into specialties, which GIM doesn't want either.

So, I predict people will agonize over this but it will remain unchanged.

However, I think this workgroup isn't going to touch the 80 hour rule, but instead limit shifts to 16 hours, or something similar.

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.

I expect that the IOM report will be picked up by the JC. If so, any rules they make will apply to all physicians credentialed at hospitals, not just to residents.

Its the great fallacy that residents make your job easier.

Can I have this as my tag line?

Yeah, but at what point does sleep deprivation cease being the hospital/residency program's "fault" and start being the resident's fault?

Amen to this. This is a big challenge as a PD. Inefficient / slow residents bump up against duty hours and it's hard to tell if it's a system problem or a personel problem.

Mandatory naps?

This is one of Lisa Bellini's big pushes. She's done some research on this and published. Basically, she suggests that for some time during the night (let's say 2AM - 6AM) you get to sign out your pager and sleep without interruption. According to her findings, this helps mitigate the sleep fatigue issues. There hasn't been widespread acceptance, but it's probably a possible solution. My guess, though, is that this workgroup will simply limit work shifts to 16 hours.

 

[Long Dong]

I'm all for 16 hour max. Hell if safety is the concern then docs should have the same standard as truck drivers they are only allowed to drive 11 hours before they have to be off the road for 10 hours.

 

[Tired]

Academics seem like it would be easier because you can presumably have residents do things for you, but OTOH there are many painful calls you have to listen to (which you could have easily solved yourself), there is teaching which is a burden to some, and possibly research expectations. And of course, there is the lower salary for the privilege of being at an academic medical center.

Its the great fallacy that residents make your job easier.

Despite my level of training, I'll disagree with you here anyway. For the surgical services with strong Chiefs, the attending is essentially shielded from the painful calls. Plus, with the exception of morning report, attending teaching can be essentially nil (like my program) with most education flowing from the senior residents to the juniors.

If residents made life harder, everyone would go private. Lower salary with more work? Even docs aren't that stupid.

 

[xaelia]

I'm all for 16 hour max. Hell if safety is the concern then docs should have the same standard as truck drivers they are only allowed to drive 11 hours before they have to be off the road for 10 hours.

Are those >16 hour shifts killing you in Derm?

 

[AwesomO]

Are those >16 hour shifts killing you in Derm?

As a med student we had this patient with a funky rash. We didn't know what it was and it was 9 pm on a Saturday night. The resident asked me what I wanted to do. I said we should page derm to come see him. He couldn't stop laughing after I said that

 

[Strength&Speed]

As a med student we had this patient with a funky rash. We didn't know what it was and it was 9 pm on a Saturday night. The resident asked me what I wanted to do. I said we should page derm to come see him. He couldn't stop laughing after I said that

we had a patient who ? had stevens johnsons vs drug rash (or i suppose could have been both). Derm refused to come in to see patient. if they wont come in for that, i cant see them coming in for much else.

 

[Tired]

we had a patient who ? had stevens johnsons vs drug rash (or i suppose could have been both). Derm refused to come in to see patient. if they wont come in for that, i cant see them coming in for much else.

Once I got them to come in for a "r/o TEN".

The best part was that it was a total dump. The kid had a previous episode 2y prior, but was totally fine and just had an over-anxious mother.

"Surgical Recommendations:
1) No open skin requiring surgical management at this time, but cannot ignore possibility of TEN given patient's clinical history.
2) Recommend urgent Dermatology consult with possible admission for short-term observation
3) Surgery signing off, please re-consult should clear s/sx of TEN develop"

 

[NotAProgDirector]

Lower salary with more work? Even docs aren't that stupid.

Apparently, IM docs like myself are.

This is where medicine and surgery are very different. I get called by the ED for all admissions first. After hearing the story, if I accept the admission to the medicine service, then the resident gets called. All the bogus ED calls come to me, and I get to be "the wall" or "the sieve".

The residents do get all the cross cover calls, etc. Still, I would work less hours and make more money in private practice. One of my partners did that -- he left our academic center and opened an office in town. He wanted to make more money and have more time with his kids, and has done just that.

It may sound really cheesy, but I do it because I love the teaching and learning. I learn something every day.

 

[xaelia]

I get called by the ED for all admissions first. After hearing the story, if I accept the admission to the medicine service, then the resident gets called. All the bogus ED calls come to me, and I get to be "the wall" or "the sieve".

Interesting; where I'm at, there's essentially no mechanism for the ward teams to "refuse" admissions. They can choose to discharge patients directly from the Emergency Department without admitting them, but they're responsible for them from the time the EM resident calls up the admitting team on the phone. It's also partly a mechanism of the ED having no ability to schedule follow-up; if there's a patient who isn't really sick enough to come in, but doesn't have a way to be seen in the near future, they have to be given to the inpatient teams to "hook them in" with whatever tests need to be done.

Outpatient CTs and MRIs take weeks/months to schedule, as well, so patients get admitted for those, too.

 

[Long Dong]

Are those >16 hour shifts killing you in Derm?

Haven't started derm yet got 5 more 30 hour/overnight calls left before internship is over and never do a chest pain r/o ACS again.

Interesting; where I'm at, there's essentially no mechanism for the ward teams to "refuse" admissions. They can choose to discharge patients directly from the Emergency Department without admitting them, but they're responsible for them from the time the EM resident calls up the admitting team on the phone. It's also partly a mechanism of the ED having no ability to schedule follow-up; if there's a patient who isn't really sick enough to come in, but doesn't have a way to be seen in the near future, they have to be given to the inpatient teams to "hook them in" with whatever tests need to be done.

Outpatient CTs and MRIs take weeks/months to schedule, as well, so patients get admitted for those, too.

Yeap same here at my county hospital TY year too, we get major dumped on/plug into the system admits without an IM attending to block admits for us.

 

[MR1]

I get called by the ED for all admissions first. After hearing the story, if I accept the admission to the medicine service, then the resident gets called. All the bogus ED calls come to me, and I get to be "the wall" or "the sieve"

Oh I wish you were at every program. At mine, our attendings can block stupid admits but the trick is they have to come evaluate the patient and the have a face-to-face with the ED staff. This actually works maybe half the time during normal hours but after 2ish you can forget about it.

An attending should not have to evaluate a pt getting admitted "because they have no where else to go" or that came in because it was cold and when told nothing was wrong and he could go he says "oh I have chest pain now" - you can guess what the EKG and enzymes showed, but he still got admitted. These are two recent fun admits I remember.

 

[Faebinder]

Apparently, IM docs like myself are.

This is where medicine and surgery are very different. I get called by the ED for all admissions first. After hearing the story, if I accept the admission to the medicine service, then the resident gets called. All the bogus ED calls come to me, and I get to be "the wall" or "the sieve".

The residents do get all the cross cover calls, etc. Still, I would work less hours and make more money in private practice. One of my partners did that -- he left our academic center and opened an office in town. He wanted to make more money and have more time with his kids, and has done just that.

It may sound really cheesy, but I do it because I love the teaching and learning. I learn something every day.

Ya, after this year of fellowship, I gotta give you lotsa credit for that. Academic medicine is painful. So my thanks for caring about medicine... just dont let it get into your head too much.

Oh I wish you were at every program. At mine, our attendings can block stupid admits but the trick is they have to come evaluate the patient and the have a face-to-face with the ED staff. This actually works maybe half the time during normal hours but after 2ish you can forget about it.

An attending should not have to evaluate a pt getting admitted "because they have no where else to go" or that came in because it was cold and when told nothing was wrong and he could go he says "oh I have chest pain now" - you can guess what the EKG and enzymes showed, but he still got admitted. These are two recent fun admits I remember.

EMTALA vileness in action.

 

[Long Dong]

An attending should not have to evaluate a pt getting admitted "because they have no where else to go" or that came in because it was cold and when told nothing was wrong and he could go he says "oh I have chest pain now" - you can guess what the EKG and enzymes showed, but he still got admitted. These are two recent fun admits I remember.

Dude let me tell you when it rains or is cold outside at my hospital the homeless all come in with chest pain knowing they are going to get at least 8 hours of shelter. We have no attending after midnight so the medicine R2 can't block these admits from the the EM attending.

 

[BerlinNeuro]

Regardless if you love the idea of shorter hours or hate it, what do you REALLY think the odds are that this will happen?

 

[saanjana]

I highly doubt it will happen....implementing the 80 hour work week was hard enough, and enforcing it is still an issue at many hospitals...and that was a much more logistical approach...

Implementing a 50 hour work week, in my opinion, is going to be close to impossible and would take atleast 4-5 years....the entire residency system would have to be re-vamped....including the number of training years, perhaps the number of residents, and even faculty....It would be especially difficult to implement at the very busy county hospitals with a large number of residents...

So thats just my opinion...I'm curious to see what some of the more experienced people say about it :-D

 

[DrDawg]

Apparently, IM docs like myself are.

This is where medicine and surgery are very different. I get called by the ED for all admissions first. After hearing the story, if I accept the admission to the medicine service, then the resident gets called. All the bogus ED calls come to me, and I get to be "the wall" or "the sieve".

The residents do get all the cross cover calls, etc. Still, I would work less hours and make more money in private practice. One of my partners did that -- he left our academic center and opened an office in town. He wanted to make more money and have more time with his kids, and has done just that.

It may sound really cheesy, but I do it because I love the teaching and learning. I learn something every day.

Our trauma attendings don't stay in house, I have to believe we are making their lifes easier.

 

[captaincrunch]

I find it interesting that so many people actually want to switch to the 56 hour week. As a medical resident, I don't think it would be possible to take care of patients, teach and attend conferences in such a short period of time. At our institution, a typical resident (even with an intern) cares for fewer patients than a hospitalist. We're also protected by admission caps and team caps. I agree that sleep deprived doctors make bad decisions, but if we actually work less than attendings it becomes hard to learn. I personally feel a certain amount of pride going through residency, and I think much of the respect medicine commands would be lost if these changes are put in place. Medicine is no different than many other desirable professions, such as law or business. If you want to succeed, you have to put in the hours. If pre-rounding is eliminated or labs are not not carefully documented in notes (as some posters have suggested), then residents don't really help in patient care. We would be nothing more than glamorized medical students; simply along for the ride. I think it is essential for residents to the primary ones responsible for patient care, which includes pre-rounding, checking labs, discharging patients, etc. Unfortunately, this simply takes time and can't be pawned off to NPs/PAs.

I also wonder why work-hour limits don't apply to attendings as well. It seems that a sleep deprived attending is just as likely to commit an error as a resident. Perhaps work-hour limits should apply to all practicing physicians. I think the 80/30 hour system in place is a good compromise. It ensures a certain amount of academic rigor, but prevents some the blatant resident abuse that occur ed in the past. If the system is not broken, don't fix it!

 

[StealthNerd]

To those that say the current system is fine: even if it was actually followed, 80/30 is still stupid. There is no good reason in the world to force a person to stay awake for 30 hours just to do a job. Period. You're going to suck at that job because your brain is shutting down. You can never, repeat never, "train" yourself to not need sleep. That's like saying it's okay to starve residents because then they'll learn how to be a great doctor without needing to stop and eat. It's absurd.

The reason there are currently no limits on attendings is because most people, of their own free will, are absolutely not going to work for 30 hours straight because it sucks way too much. Sure, some folks work 24 hours at a time but they take a lot of time off before the next 24 hour shift.

I am completely in favor of the 56 hour limit. Honestly, I think we should ditch the entire system. There should be no need to force a limit on hours. Just get rid of the Match and let the free market reign supreme. If residents could leave their programs and move around at will with their $100K of federal funding then you can bet your ass there'd be a lot of humane residency programs out there. Work hour restrictions wouldn't be necessary. They'd come down naturally as hospitals were forced to become more effecient. We'll get to where doctors do nothing but treat patients and give treatment plans... with all other scut work, paper work, etc, taken care of by cheaper people (ER techs with a few high school grads thrown in to work computers).

Bottom line: if you get a hard-on for cutting people at 3AM, then more power to you. I don't. So if there's any way for me to get more time with my wife and kids then I'm in favor of it.

 

[8744]

Interesting; where I'm at, there's essentially no mechanism for the ward teams to "refuse" admissions. They can choose to discharge patients directly from the Emergency Department without admitting them, but they're responsible for them from the time the EM resident calls up the admitting team on the phone. It's also partly a mechanism of the ED having no ability to schedule follow-up; if there's a patient who isn't really sick enough to come in, but doesn't have a way to be seen in the near future, they have to be given to the inpatient teams to "hook them in" with whatever tests need to be done.

Outpatient CTs and MRIs take weeks/months to schedule, as well, so patients get admitted for those, too.

Oh man. This is such a pet peeve of mine...namely patients who use the ED as a means to "jump the line" for CTs and other studies. Sometimes we fall for it and sometimes our attendings send them home with instructions to "Keep your follow-up appointment for your CT." the point is that the patients have become pretty savvy and many of them know enough to exaggerate their symptoms enough to "fool" us. Like the 10/10 abdominal pain patient who asks for something to eat.

Not everything is a friggin' emergency. Even if you have colon cancer you can still wait a week or two for your colonoscopy. It's not like you got it overnight and it's not exactly an emergency condition.

 

[8744]

I find it interesting that so many people actually want to switch to the 56 hour week. As a medical resident, I don't think it would be possible to take care of patients, teach and attend conferences in such a short period of time. At our institution, a typical resident (even with an intern) cares for fewer patients than a hospitalist. We're also protected by admission caps and team caps. I agree that sleep deprived doctors make bad decisions, but if we actually work less than attendings it becomes hard to learn. I personally feel a certain amount of pride going through residency, and I think much of the respect medicine commands would be lost if these changes are put in place. Medicine is no different than many other desirable professions, such as law or business. If you want to succeed, you have to put in the hours. If pre-rounding is eliminated or labs are not not carefully documented in notes (as some posters have suggested), then residents don't really help in patient care. We would be nothing more than glamorized medical students; simply along for the ride. I think it is essential for residents to the primary ones responsible for patient care, which includes pre-rounding, checking labs, discharging patients, etc. Unfortunately, this simply takes time and can't be pawned off to NPs/PAs.

I also wonder why work-hour limits don't apply to attendings as well. It seems that a sleep deprived attending is just as likely to commit an error as a resident. Perhaps work-hour limits should apply to all practicing physicians. I think the 80/30 hour system in place is a good compromise. It ensures a certain amount of academic rigor, but prevents some the blatant resident abuse that occur ed in the past. If the system is not broken, don't fix it!

Yeah, but why should I waste my time copying lab values onto a note? In our ED, I can press a button on my tablet and the labs are copied automatically whereupon I review them and press another button to document that I reviewed them.

See my point? Hospitals with residents are hugely inefficient places that are 30 years behind my local Jiffy Lube when it comes to information technology. They are like this for many reasons but one has to be that there has always been a steady supply of minimum wage residents to do all the backwards-ass paperwork.

 

[8744]

To those that say the current system is fine: even if it was actually followed, 80/30 is still stupid. There is no good reason in the world to force a person to stay awake for 30 hours just to do a job. Period. You're going to suck at that job because your brain is shutting down. You can never, repeat never, "train" yourself to not need sleep. That's like saying it's okay to starve residents because then they'll learn how to be a great doctor without needing to stop and eat. It's absurd.

The reason there are currently no limits on attendings is because most people, of their own free will, are absolutely not going to work for 30 hours straight because it sucks way too much. Sure, some folks work 24 hours at a time but they take a lot of time off before the next 24 hour shift.

I am completely in favor of the 56 hour limit. Honestly, I think we should ditch the entire system. There should be no need to force a limit on hours. Just get rid of the Match and let the free market reign supreme. If residents could leave their programs and move around at will with their $100K of federal funding then you can bet your ass there'd be a lot of humane residency programs out there. Work hour restrictions wouldn't be necessary. They'd come down naturally as hospitals were forced to become more effecient. We'll get to where doctors do nothing but treat patients and give treatment plans... with all other scut work, paper work, etc, taken care of by cheaper people (ER techs with a few high school grads thrown in to work computers).

Bottom line: if you get a hard-on for cutting people at 3AM, then more power to you. I don't. So if there's any way for me to get more time with my wife and kids then I'm in favor of it.

****ing A, bubba.

 

[Long Dong]

Yeah, but why should I waste my time copying lab values onto a note? In our ED, I can press a button on my tablet and the labs are copied automatically whereupon I review them and press another button to document that I reviewed them.

See my point? Hospitals with residents are hugely inefficient places that are 30 years behind my local Jiffy Lube when it comes to information technology. They are like this for many reasons but one has to be that there has always been a steady supply of minimum wage residents to do all the backwards-ass paperwork.

No Shiit brother. I spend an F**king hour every moring while on medicine writing down vitals/meds/labs on my skeleton note before seeing my patients. This is such a waste of time get me one of those computers please, oh but 2 more weeks of this BS and internal medicine kiss my a$$.

 

[8744]

No Shiit brother. I spend an F**king hour every moring while on medicine writing down vitals/meds/labs on my skeleton note before seeing my patients. This is such a waste of time get me one of those computers please, oh but 2 more weeks of this BS and internal medicine kiss my a$$.

I just want to reinforce what you said: Copying lab values from a computer screen onto a paper note is so backwards, so counterintuitive, so frankly inefficient that if you proposed doing something like this in any other business they would laugh at you. And I repeat, with the exception of medicine, every single other enterprise in this country handles its routine paperwork by computer. When I was an engineer for example, I had an almost paperless office and I strove mightily to streamline, integrate, and coordinate every aspect of my business to minimize wasted time and maximize productive (billable) activities.

Why? Because hand-writing a parts list or similar took time that I could devote to some other paying activity. Like medicine, I was paid by the job, not by the hour, so I had an incentive to minimize my time spent per job. My emergency department realizes that time is money and we are not paid by the hour so they have a very nice EMR that streamlines things considerably. It's beautiful. Is most of the note generated by the thing useless boilerplate? Sure it is. Do I care? No. Billing requires that I check certain boxes so I may as well have the computer arrange it rather than spend time laboriously documenting my exam. I type enough "freestyle" to document unusual aspects of the history, physical exam,decision making, and diagnosis so I maximize my useful "cognitive" time and minimize my useless "clerical" time.

Do not get me started here. I once was on a rotation where the attending insisted that admission H and Ps be both written out by hand and dictated. In one of my few rebellious moments, I refused to write notes by hand if I could dictate them and they would appear on the chart in the morning. I wrote a brief Assessment and Plan in case somebody just absolutely needed to read something at 3AM with the notation "Full H and P dicatated" and that was that. Nobody ever complained and, as I talk faster than I write, I could dictate a note in three minutes that would take fifteen to write by hand.

In the ideal world the Emergency Medicine Physician would have a tablet on which he could seamlessly view and annotate both lab values and imaging studies as well as a docking station all his own where he could type his brief notes. Vitals, medication lists, and triage notes would be on line and could be reviewed and inserted into the note. The tablet would have a GPS to annotate when the doctor entered the room and would alert the doctor to write his follow-up note. Computerized order entry is a must.

 

[AwesomO]

Yeah, but why should I waste my time copying lab values onto a note? In our ED, I can press a button on my tablet and the labs are copied automatically whereupon I review them and press another button to document that I reviewed them.

See my point? Hospitals with residents are hugely inefficient places that are 30 years behind my local Jiffy Lube when it comes to information technology. They are like this for many reasons but one has to be that there has always been a steady supply of minimum wage residents to do all the backwards-ass paperwork.

How much do you want to bet that old attendings will say searching for lab values and writing them down is a learning exercise? Or one of their oh so sacred traditions that must be carried on forever?

I interviewed at a place that was completely paperless. Every morning they could just click a few buttons and lab values would be added to the daily progress notes and they could copy/paste/edit yesterdays note instead of writing it all out by hand. They got done with rounding in about half the time my home school did with paper charts.

I'm usually against big brother butting in to anything but I hope that Medicare decides that unless you are completely paperless you don't get payments. Thats pretty much the only way we'll get Hospitals caught up with the local Jiffy Lube.

 

[PeepshowJohnny]

I just want to reinforce what you said: Copying lab values from a computer screen onto a paper note is so backwards, so counterintuitive, so frankly inefficient that if you proposed doing something like this in any other business they would laugh at you. And I repeat, with the exception of medicine, every single other enterprise in this country handles its routine paperwork by computer.

I have to say, I don't think I've agreed with anyone on this website on anything as much as this.

Medicine is the most horribly inefficient enterprise I've ever been involved with. And the most frustrating part is an almost "anti-intellectual" esque response that comes when you suggest that changing "the way it's always been done" may help.

I had the fortunate/unfortunate experience of following an attending (who is actually a pretty level headed guy) on a rotation at another hospital that was going to consider going to a new computer system (vs. their "Wargames" 1980's version). He was going to a meeting about the system and asked that I come along so I could learn about it. I thought it was a pretty bogus reason, but whatever.

So, the disdain among the docs there was palpable the whole time, but the eruption that came about physician order entry option was freaking amazing. Instead of writing "BMP in AM" on an orders page, handing it to a clerk who puts it in the system, the physician (after documenting) could just add what labs he wanted drawn the next morning (of routine ones).

To anyone who's used any operating system, it was pretty much just as easy as writing the order and would save time by cutting out the middleman, but the backlash was ridiculous. It was like asking the attendings to draw it themself or something the fuss they made. Now, there WOULD still be unit clerks to handle orders requiring more coordination (scheduling imaging studies or ordering stuff for bedside procedures). The saddest thing was nobody could articulate what was really "wrong" about the physician entering he wanted a CBC, CMP, and PT/INR in the morning other than the fact it was "different".

 

[Bart Clarridge]

...

Medicine is the most horribly inefficient enterprise I've ever been involved with. And the most frustrating part is an almost "anti-intellectual" esque response that comes when you suggest that changing "the way it's always been done" may help.

...

I remember many times thinking I would have been much more useful as a systems engineer.

The medical "system" is pathetic. The most annoying part is the arrogance the attendings often display when their backward ways are pointed out to them. They can't argue the points, i.e., they can't logically defend the "good old days."

"What, you don't want to work 120 hours a week? Back in my day..."

And they complain about oversite

 

[Faebinder]

The saddest thing was nobody could articulate what was really "wrong" about the physician entering he wanted a CBC, CMP, and PT/INR in the morning other than the fact it was "different".

Simple...

Old schoolers who can barely type refuse to "waste" time to learn how to input an order on the computer... the computer fear runs deep into the old school attendings. Remember many had their bachelors back in the days before the internet realy flourished and was on something like "History" which in those days you hardly ever needed a computer... I bet many will sit and tell you about the days when USMLE step 1 was a three day paper exam. The system will eat them sooner or later and they will be forced to learn to be friends with the computer.

Indeed, resistance is futile.. they will be assimulated to residency hours as well to the fact that "The computer" is their "friend".

 

[sirus_virus]

I don't think it would be possible to take care of patients, teach and attend conferences in such a short period of time.!

56 hours is enough time to take care of patients, teach, attend conferences, and maintain a healthy, on the job romance with one of the nurses.

I think much of the respect medicine commands would be lost if these changes are put in place..

I think the word you were looking for is 'pity'.

We would be nothing more than glamorized medical students; simply along for the ride. .!

Taking a ride is a heck of a lot better than being ridden, and the system is ridding the crap out of residents presently.

Unfortunately, this simply takes time and can't be pawned off to NPs/PAs..

Yet the hospitals have pawned off your much desired respect and money to them.

I also wonder why work-hour limits don't apply to attendings as well..!

Because they are free agents, free to leave at will. Not so much the case for evaluation dependent, career on the line residents.

If the system is not broken, don't fix it!

Your own words and a lot of research has shown that sleep deprevation is bad for patients. So the system needs fixing.

 

[DrDre311]

Your own words and a lot of research has shown that sleep deprevation is bad for patients. So the system needs fixing.

Prove this to me. Show me definitive proof that patients suffer an increased rate of medical errors on the part of sleep-deprived residents under the 80-hour work week versus some other model involving fewer work hours.

 

[DrDawg]

I interviewed at a place that was completely paperless. Every morning they could just click a few buttons and lab values would be added to the daily progress notes and they could copy/paste/edit yesterdays note instead of writing it all out by hand. They got done with rounding in about half the time my home school did with paper charts.

Most of the notes I have seen from paperless systems suck. ICU patients with notes will have problems listed that have completely ressolved over a week ago, plans per consultants who have signed off, physical exams that don't match the patient, and are otherwise grossly incorrect. These systems are not that good, and teach lazy residents to be lazier. Just because the work gets done faster doesn't mean its done better.

 

[AwesomO]

Simple...

Old schoolers who can barely type refuse to "waste" time to learn how to input an order on the computer... the computer fear runs deep into the old school attendings. Remember many had their bachelors back in the days before the internet realy flourished and was on something like "History" which in those days you hardly ever needed a computer... I bet many will sit and tell you about the days when USMLE step 1 was a three day paper exam. The system will eat them sooner or later and they will be forced to learn to be friends with the computer.

Indeed, resistance is futile.. they will be assimulated to residency hours as well to the fact that "The computer" is their "friend".

If a 16 year old kid can work a program that tells the other 16 year old kid in the kitchen not to put pickles on my whopper I think the "we're the greatest medical generation evah cause we didn't have a work hour limit" physicians can learn how to click on "Daily BMPs" on the computer.

 

[DrDawg]

I guess all those exams I aced as an undergrad, and med student after allnighters were just a fluke.

 

[AwesomO]

Most of the notes I have seen from paperless systems suck. ICU patients with notes will have problems listed that have completely ressolved over a week ago, plans per consultants who have signed off, physical exams that don't match the patient, and are otherwise grossly incorrect.

Um those are problems you see in handwritten notes as well.
Looks to me that people simply don't know how to use the EMRs or the hospital invested in an overly complicated one.
All you need is a simple interface without all the bells and whistles. Blank text entry for the majority of the note with the program filling in lab values automatically.
For the next days note you should be able to edit the previous days note.

These systems are not that good, and teach lazy residents to be lazier. Just because the work gets done faster doesn't mean its done better.

With your fear being that people will be lazy I'm guessing your a surgical resident? Not trying to bust your balls, I've just noticed the same thing with my friends in surgery.

 

[8744]

Most of the notes I have seen from paperless systems suck. ICU patients with notes will have problems listed that have completely ressolved over a week ago, plans per consultants who have signed off, physical exams that don't match the patient, and are otherwise grossly incorrect. These systems are not that good, and teach lazy residents to be lazier. Just because the work gets done faster doesn't mean its done better.

I know what you're saying, but how about for something like a procedure (as an example). If I do a routine Lumbar Puncture with no complications, I can spend more time documenting it than it took to do it. Why do I have to write out, "Consent obtained...etc" or "Puncture site prepped with...." when I can just pull a couple of menu items and les voila?

It's not being lazy, it's being smart. The multiply redundant paperwork is not our profession, medicine is. In an ideal world most patients need about an index card's worth of notes. Nobody really reads most of what we write anyways except for the "Assessment and Plan." Most of the note is strictly for billing purposes.

Take our Emergency Department's EMR. Sure, it generates a lot of boilerplate but we generate a lot of boilerplate by hand too. That's why we have so many abbreviations like, "Lungs CTAB, BS =/=" or "RRR, no m/g/r." Automating some of this crap let's doctors concentrate more on decision-making and planning rather than clerical work.

Finally, if it is lazy to not want to come in at six when the hospital could buy some ten-year-old IBM PS2s and streamline things enough to let us come in at seven instead, well, I guess I am lazy.