56 Hour Week Is Coming

[8744]

The other thing you all have to realize is that times have changed since your crusty old-school attendings were residents. Nowadays, we routinely get patients who are so sick and carry so many competing comorbidities that they could not have been imagined forty years ago in the so-called Golden Age of medical training when residents knew their place and nobody ever made a mistake.

At least twice a night I get a patient with congestive heart failure, end-stage renal disease on hemodialyis, emphysema, coronary artery disease with a distant triple vessel bypass and four stents, atrial fibrillation with a pacer-defibrillator, diabetes, really bad peripheral vascular disease, alzheimer's, distant stroke with dysphagia and dysarthria, MRSA, bed sores, cancer of one flavor or another who has had resections, amputations, colostomies, feeding tubes, every organ out that can be removed and some that shouldn't, and who is on thirty different medications but who is nonetheless stable and whose family expects them to survive their hospital stay to squeeze a few more months out of that crappy thing called Their Life. What do you do with a patient like that whose chief complaint may be "Weakness" or "Difficulty Breathing" and more importantly, how can mistakes be avoided with so much going wrong and so many antagonistic medications and conditions?

I'm lucky. I get to pass these patients off to the admitting service and then I can forget about them but it takes a toll on those poor internal medicine residents. I once gave one of these residents a patient like that and as he read the "Past Medical History" his shoulders slumped, he got a defeated look on his face, and he looked at me and said, "Jesus Christ, doesn't anybody die anymore?"

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[8744]

The other thing you all have to realize is that times have changed since your crusty old-school attendings were residents. Nowadays, we routinely get patients who are so sick and carry so many competing comorbidities that they could not have been imagined forty years ago in the so-called Golden Age of medical training when residents knew their place and nobody ever made a mistake.

At least twice a night I get a patient with congestive heart failure, end-stage renal disease on hemodialyis, coronary artery disease with a distant triple vessel bypass and four stents, atrial fibrillation with a pacer-defibrillator, diabetes, really bad peripheral vascular disease, alzheimer's, distant stroke with dysphagia and dysarthria, MRSA, bed sores, cancer of one flavor or another who has had resections, amputations, colostomies, feeding tubes, every organ out that can be removed and some that shouldn't, and who is on thirty different medications but who is nonetheless stable and whose family expects them to survive their hospital stay to squeeze a few more months out of that crappy thing called Their Life. What do you do with a patient like that whose chief complaint may be "Weakness" or "Difficulty Breathing" and more importantly, how can mistakes be avoided with so much going wrong and so many antagonistic medications and conditions?

I'm lucky. I get to pass these patients off to the admitting service and then I can forget about them but it takes a toll on those poor internal medicine residents. I once gave one of these residents a patient like that and as he read the "Past Medical History" his shoulders slumped, he got a defeated look on his face, and he looked at me and said, "Jesus Christ, doesn't anybody die anymore?"

And if I'm lying, I'm dying. I am quite sure that most of the other residents on SDN could chime and confirm what I am saying about the nature of modern patients.

 

[Tired]

And Panda strikes again! As far as I'm concerned, this is the coup de grâce point that ends the sleep deprivation argument.

True enough. If you're looking for a solid source on why physicians shouldn't work too hard, there's really no better place to start than an EM resident.

 

[DrDre311]

The other thing you all have to realize is that times have changed since your crusty old-school attendings were residents. Nowadays, we routinely get patients who are so sick and carry so many competing comorbidities that they could not have been imagined forty years ago in the so-called Golden Age of medical training when residents knew their place and nobody ever made a mistake.

At least twice a night I get a patient with congestive heart failure, end-stage renal disease on hemodialyis, emphysema, coronary artery disease with a distant triple vessel bypass and four stents, atrial fibrillation with a pacer-defibrillator, diabetes, really bad peripheral vascular disease, alzheimer's, distant stroke with dysphagia and dysarthria, bed sores, cancer of one flavor or another who has had resections, amputations, colostomies, feeding tubes, every organ out that can be removed and some that shouldn't, and who is on thirty different medications but who is nonetheless stable and whose family expects them to survive their hospital stay to squeeze a few more months out of that crappy thing called Their Life. What do you do with a patient like that whose chief complaint may be "Weakness" or "Difficulty Breathing" and more importantly, how can mistakes be avoided with so much going wrong and so many antagonistic medications and conditions?

I'm lucky. I get to pass these patients off to the admitting service and then I can forget about them but it takes a toll on those poor internal medicine residents. I once gave one of these residents a patient like that and as he read the "Past Medical History" his shoulders slumped, he got a defeated look on his face, and he looked at me and said, "Jesus Christ, doesn't anybody die anymore?"

Yes...I think we forget that none of these diseases existed back then. Nobody smoked or drank, nobody was fat, everybody exercised and everything was easier on those jackass old school guys--they're just picking on us.

 

[tr]

Yes...I think we forget that none of these diseases existed back then. Nobody smoked or drank, nobody was fat, everybody exercised and everything was easier on those jackass old school guys--they're just picking on us.

Yeah, but the patients had one thing wrong, or two, or maybe three. Not sixteen, any one of which would have killed them fifty years ago.

I was speaking with my sister about this (she is around here somewhere but doesn't cruise the Residency fora yet) because she did a couple of med school rotations in a small European country where the medicine isn't so advanced as it is here. She said the pace was a lot slower and the residents far less knowledgeable, but it didn't seem to matter so much because the patients weren't nearly as complicated. If they got something really bad, they died. Otherwise, they got over their CAP or whatever and went home happy.

 

[8744]

Yes...I think we forget that none of these diseases existed back then. Nobody smoked or drank, nobody was fat, everybody exercised and everything was easier on those jackass old school guys--they're just picking on us.

You totally missed my point. Forty years ago there was, for example, no real treatment for a heart attack and you either died or became so debillitated that you didn't live long afterwards. Today we are so adept at managing many once-fatal diseases that people routinely build up an impressive catalogue of comorbidities that would have been unheard of in the past.

 

[DrDre311]

You totally missed my point. Forty years ago there was, for example, no real treatment for a heart attack and you either died or became so debillitated that you didn't live long afterwards. Today we are so adept at managing many once-fatal diseases that people routinely build up an impressive catalogue of comorbidities that would have been unheard of in the past.

No, I didn't. I haven't been an attending medicine doctor for 40 years, so I won't comment on how an MI would have been managed at that time. Increasing lists of medical comorbidities may be a consequence of improvements in survival, but what about the proliferation of imaging and testing modalities, subspecialties, CYA medicine, and patients seeing a zillion different docs? Sick people existed long before we had "a pill for every ill" and not all of them died.

But the point is this: maybe those old guys from the bad old days still have something to teach us. Maybe there's a grain of truth to the notion of the lost art of the physical exam, and maybe there's something to the complaint against the current medical culture in which everything is the fault of the "system" as opposed to personal accountability. Maybe we're all a little too concerned with how we're being mistreated, and not concerned enough with the care and well-being of those who need us.

Maybe all the energy you spend bitching about the slave drivers who trained in the dark ages would be better spent improving your grasp of your chosen profession. The fact that you're a resident in a lifestyle specialty and you haven't taken call since your 'tern year doesn't lend credibility to any rant about how many hours you work and how hard your job is. If you're seeing a bunch of old gomers with a past medical history that reads like the index of Harrison's, then get tough and learn how to manage those conditions instead of focusing on how easy it used to be when everybody who was sick just went ahead and died.

 

[deleted109597]

Side comment, if residency years were to increase and more time off is given, people can always moonlight to compensate. It's up to the person to do it. They will know how much they can and cannot do.

You left out the all important "if they let you". Some places have such arbitrary moonlighting policies and so many residents that there are 100 people out there fighting to do physicals on high school football players.

 

[8744]

No, I didn't. I haven't been an attending medicine doctor for 40 years, so I won't comment on how an MI would have been managed at that time. Increasing lists of medical comorbidities may be a consequence of improvements in survival, but what about the proliferation of imaging and testing modalities, subspecialties, CYA medicine, and patients seeing a zillion different docs? Sick people existed long before we had "a pill for every ill" and not all of them died.

But the point is this: maybe those old guys from the bad old days still have something to teach us. Maybe there's a grain of truth to the notion of the lost art of the physical exam, and maybe there's something to the complaint against the current medical culture in which everything is the fault of the "system" as opposed to personal accountability. Maybe we're all a little too concerned with how we're being mistreated, and not concerned enough with the care and well-being of those who need us.

Maybe all the energy you spend bitching about the slave drivers who trained in the dark ages would be better spent improving your grasp of your chosen profession. The fact that you're a resident in a lifestyle specialty and you haven't taken call since your 'tern year doesn't lend credibility to any rant about how many hours you work and how hard your job is. If you're seeing a bunch of old gomers with a past medical history that reads like the index of Harrison's, then get tough and learn how to manage those conditions instead of focusing on how easy it used to be when everybody who was sick just went ahead and died.

Now, to be fair I did do two intern years, not one, and I was doing Q4 call for most of the time so I think I have the "street 'cred" to complain about call.

Forty years ago they did nothing for heart attacks but admit the patient to the hospital for a month or two of convalescence. No kidding. And I guarantee you that not only were the patients not nearly as sick but even in the busy hospitals there was not the constant, 24-hour-flood of admissions. The point is that things were different back in the Golden Age of Residency Training. Times have changed. The game has changed. Residency training needs to change.

 

[8744]

No, I didn't. I haven't been an attending medicine doctor for 40 years, so I won't comment on how an MI would have been managed at that time. Increasing lists of medical comorbidities may be a consequence of improvements in survival, but what about the proliferation of imaging and testing modalities, subspecialties, CYA medicine, and patients seeing a zillion different docs? Sick people existed long before we had "a pill for every ill" and not all of them died.

Sick people have always existed but, and I repeat, they have never been so sick, so old, and so numerous as they are now, at least from the perspective of how much care they demand and get from the medical system. Forty years ago most hospitals were sleepy places where nature took its course. Today, even in small cities the hospital in town is a 24-hour hive of activity and often the anchor of the local economy. The current residency training system was designed for a time when hospitals operated at a leisurely pace and people actually slept on call, something I rarely got to do.

 

[StealthNerd]

True enough. If you're looking for a solid source on why physicians shouldn't work too hard, there's really no better place to start than an EM resident.

So... was that sarcasm? 'Cause honestly, I completely agree. Sure, EM docs work less hours than most physicians but more often than not they're busting their ass. It's a lifestyle specialty only because there are, on average, fewer hours and a more flexible schedule... not because it's an easy job that any old '**** could do.

It really doesn't matter what specialty we're talking about. We have crew rest requirements for pilots and truckers, why not doctors? If I'm more likely to get sick, stab myself with a needle, or fall asleep at the wheel of a Goddamn car, all because I'm been awake for 30 some hours... then to hell with that. I'm goin' to bed.



By the way, totally off topic, the Supreme Court just came down with a ruling in the D.C. handgun ban... we get to keep the 2nd Amendment! Hurray!

 

[DrDre311]

And I guarantee you that not only were the patients not nearly as sick but even in the busy hospitals there was not the constant, 24-hour-flood of admissions. The point is that things were different back in the Golden Age of Residency Training. Times have changed. The game has changed. Residency training needs to change.

I bet I could find some old-schoolers (from the dark ages of, say, ten years ago) with stories about nonstop admits/sick-as-snot patients/all night cases followed by another full day of work and then call again the next day. And if patients are sicker now because we have improved treatment modalities to keep them alive, then by definition we should be able to manage those comorbidities.

By the way, residency training has changed. It changed 5 years ago and I personally don't think it needs to change again, at least not so soon. As far as your street cred goes, how many 100 hour weeks are you working now? In fact, how many times a month do you go over 80 hours? I've got no sympathy for q4 call when many residents have q3 call (and sometimes even q2 call), TICU/SICU/MICU/neuro ICU/burn ICU rotations, etc. Plus, as you yourself admit, you get to punt these sick patients off to various services at the end of your shift. Not everybody gets to do that.

I don't notice a great deal of surgery residents--the people that get their asses worked on trauma and ICU months for a big chunk of their training--advocating further reductions in work hours.

 

[8744]

I bet I could find some old-schoolers (from the dark ages of, say, ten years ago) with stories about nonstop admits/sick-as-snot patients/all night cases followed by another full day of work and then call again the next day. And if patients are sicker now because we have improved treatment modalities to keep them alive, then by definition we should be able to manage those comorbidities.

By the way, residency training has changed. It changed 5 years ago and I personally don't think it needs to change again, at least not so soon. As far as your street cred goes, how many 100 hour weeks are you working now? In fact, how many times a month do you go over 80 hours? I've got no sympathy for q4 call when many residents have q3 call (and sometimes even q2 call), TICU/SICU/MICU/neuro ICU/burn ICU rotations, etc. Plus, as you yourself admit, you get to punt these sick patients off to various services at the end of your shift. Not everybody gets to do that.

I don't notice a great deal of surgery residents--the people that get their asses worked on trauma and ICU months for a big chunk of their training--advocating further reductions in work hours.

You make your bed and you lie in it. Nobody held a gun to your head and made you pick surgery. I probably work less than fifty hours a week now that I am done with off-service rotations. Which is precisely my point. Long hours and sleep deprivation blow and I made sure to pick a specialty that minimizes this sort of barbaric thing both in residency and private practice.

And I have done a total of seven months of ICU/CCU/PICU in three years so I probably have as much experience in these areas as most of your fellow residents.

 

[8744]

True enough. If you're looking for a solid source on why physicians shouldn't work too hard, there's really no better place to start than an EM resident.

Oh, we work pretty hard on our shifts. I hate to repeat the mantra which is nonetheless true but in Emergency Medicine, when you walk out the door you are done with nothing to do or worry about until your next shift.

But it can get really busy.

 

[sirus_virus]

I don't notice a great deal of surgery residents--the people that get their asses worked on trauma and ICU months for a big chunk of their training--advocating further reductions in work hours.

Ofcourse, since one of the alternatives will be to increase the number of years of training. That however cannot be construed as their acceptance of 30 hour shifts.

If 80 hour work weeks are so gravy, why stop at residents? Let everyone log 80 hours weekly so patients can get more continuity of care. Nurses need to stop that whole 3 days a week nonsense too.

 

[What the pho]

Ofcourse, since one of the alternatives will be to increase the number of years of training. That however cannot be construed as their acceptance of 30 hour shifts.

If 80 hour work weeks are so gravy, why stop at residents? Let everyone log 80 hours weekly so patients can get more continuity of care. Nurses need to stop that whole 3 days a week nonsense too.

No **** an attendings too. It's all bunch of BS people getting on thier high horse about continuity of care, how many times as an intern did I hear an attending say "it's nothing personal, it's about the the patient" and then hand off the patient to another attending when they wanted to go home and take their kids to school or watch the laker game.

I see it's become a battle of the surgeons vs the lifestyle fields. I don't give a **** what all you stuck on your high horse sugery residents say it's not my fault you guys have no life and can't get laid. You should of picked a different field, you guys are just defending the long hours as a defense mechanism to justify the crap you go threw. While you guys are up all weekend cutting another diabetic foot, or another fat arse's gallbladder, I'll be at the strip club telling the hot stripper how good she would look with some lip injections.

 

[DrDre311]

You make your bed and you lie in it. Nobody held a gun to your head and made you pick surgery. I probably work less than fifty hours a week now that I am done with off-service rotations. Which is precisely my point. Long hours and sleep deprivation blow and I made sure to pick a specialty that minimizes this sort of barbaric thing both in residency and private practice.

And I have done a total of seven months of ICU/CCU/PICU in three years so I probably have as much experience in these areas as most of your fellow residents.

I did make my bed, and unlike most people posting on this thread, I like my job. I don't mind the hours. I like operating, and the wee hours are when I get to do the most operating. My point in mentioning surgery as a field was that surgery and its subspecialties are the most hour and labor intensive residencies (irrespective of perceived attending lifestyle after residency) and yet, the people complaining the most about hours are those in much less hour-intensive fields. That's ironic.

It's just not as bad as you guys make it out to be--and since you're not the neurosurg resident working a zillion hours a week your complaints ring a little hollow. Time/energy would be better spent trying to learn from those who have come before you instead of complaining about their barbaric views about archaic myths like patient advocacy and continuity of care.

Although I'm not a general surgery resident, between the TICU/SICU/transplant/burns months, I'd say the GS residents here (over 5 years) get a lot more than 7 ICU months. And you're not doing almost a full year of trauma plus several years of trauma call, like many GS residents do--that's the real miserable bitch service there. Your 2 'tern years do not give you the same street cred as a GS resident.

And as far as selling a hot stripper on lip injections, she'll tell you that she already got her breast aug from Dr. Dre--and she'll be coming back to me for anything else.

 

[DrDre311]

Of course, since one of the alternatives will be to increase the number of years of training. That however cannot be construed as their acceptance of 30 hour shifts.

If 80 hour work weeks are so gravy, why stop at residents? Let everyone log 80 hours weekly so patients can get more continuity of care. Nurses need to stop that whole 3 days a week nonsense too.

This is the only thing approaching a valid counterargument.

 

[sirus_virus]

This is the only thing approaching a valid counterargument.

MY point is that residents are so few in number compared to the rest of the other staff in the medical community. If the argument remains "continuity of care", then why restrict it to such a small group of workers, and might I add, the most inexperienced group.

If you tell me residents have to work long hours because there is no other way to train residents, then I might buy in. If the argument is that residents help lessen the financial burden on the system, I might buy in. But I cannot buy into this "continuity of care" snake oil.

 

[JMC_MarineCorps]

Hi,

I'm a psychiatry intern...I was just wondering about this 'street cred' everyone is talking about. I'd like a little bit of it...is that possible?

Thank you,

JMC

 

[gutonc]

And if I'm lying, I'm dying. I am quite sure that most of the other residents on SDN could chime and confirm what I am saying about the nature of modern patients.

Oh yes, absolutely. The VA is basically patient after patient like this, it's hard to kill a vet. We have a scale we use to measure these guys based on their problem list.

10 items or less = VA healthy
10-15 items = VA moderately ill
15+ items = VA sick

I took care of a guy 2 weeks ago (not at the VA) who got a new heart in 1991, a new kidney in 2000, has had 13 melanoma resections over the past 10 years and had a left pneumonectomy a year ago for NSCLC. CC? Dyspnea and weakness. If he'd gotten sick 10y earlier he wouldn't have made it to 1991 which is where his saga begins. Now he's probably got another 5 years.

A patient with an isolated problem than can be treated is so rare on a Gen Med service that when I get one admitted I find myself looking for other things that are wrong because I just don't believe that PNA or pyelonephritis or whatever is the only thing that can be going on.

 

[Faebinder]

The reason we continue to sustain these is that we as physicians have stopped fighting useless interventions. Hospitals dont care, they always get their money... ALWAYS... one way or another. Journals need to start publishing more negative studies and we as physicians need to start taking zero value interventions seriously.

It comes back to the topic of the Price of Life.

 

[Tired]

Oh, we work pretty hard on our shifts. I hate to repeat the mantra which is nonetheless true but in Emergency Medicine, when you walk out the door you are done with nothing to do or worry about until your next shift.

But it can get really busy.

I know that. I also know it's part of the reason that many of you choose ER instead of Surgery.

What annoys me is when people who train under that type of schedule spend their time telling people like me what the "correct" way is to train surgeons.

 

[What the pho]

And as far as selling a hot stripper on lip injections, she'll tell you that she already got her breast aug from Dr. Dre--and she'll be coming back to me for anything else.

If I wanted to do some breast aug I'd just sign up with the American Board of Cosmetic Surgery and call myself a "cosmetic surgeon." Hell the most famous cosmetic surgeon/breast implanter on TV isn't even PRS boarded and still has tones of business.

Only thing is if the hot stripper invites you to have a threesome with her hot lesbian GF you'll be to tired to brakem off right from those Bilat TRAMs you do or those fibular jaw reconstructs. You'll probably say can I take a nap while you 2 get it on, and wake me when you want me to join in. Me having been rested will brakem off right each time, and when they want to party like a rockstar and f*#k like a pornstar will have all the free time and energy to do so.

 

[elwademd]

Yes...I think we forget that none of these diseases existed back then. Nobody smoked or drank, nobody was fat, everybody exercised and everything was easier on those jackass old school guys--they're just picking on us.

I bet I could find some old-schoolers (from the dark ages of, say, ten years ago) with stories about nonstop admits/sick-as-snot patients/all night cases followed by another full day of work and then call again the next day. And if patients are sicker now because we have improved treatment modalities to keep them alive, then by definition we should be able to manage those comorbidities.

By the way, residency training has changed. It changed 5 years ago and I personally don't think it needs to change again, at least not so soon. As far as your street cred goes, how many 100 hour weeks are you working now? In fact, how many times a month do you go over 80 hours? I've got no sympathy for q4 call when many residents have q3 call (and sometimes even q2 call), TICU/SICU/MICU/neuro ICU/burn ICU rotations, etc. Plus, as you yourself admit, you get to punt these sick patients off to various services at the end of your shift. Not everybody gets to do that.

I don't notice a great deal of surgery residents--the people that get their asses worked on trauma and ICU months for a big chunk of their training--advocating further reductions in work hours.

there are so many things that have changed in society and medicine in the last 10, 20, 30 40, 50 years; its really hard to compare medicine today to "back then".

1955, president eisenhower had an mi. he spent something on the order of 3 months cooped up in a hospital. went home with coumadin and a low fat diet.

we do more for patients with chest pain in the first hour these days then the president received 50 years ago.
even in the 1980s, beta blockers were thought to increase mortality in acute mi... now, unless someone's bp precludes it, acs patients are receiving this within the first few hours.

so, even 20 years ago, what was being done for acs? maybe heparin and aspirin (low molecular weight heparin was just being developed, gp 2b3a inhibitors didn't exist)... there weren't many decisions in the decision tree.

hepatitis c... discovered 20 years ago

c dificile... was just an afterthought for something on the boards, and within the past few years is now an organism that can have fatal outcomes.

resistant organisms, again, something that wasn't really seen 10, 15 years ago. mrsa was seemingly theoretical, now it would seem that most hospitals assume its mrsa until proven otherwise.

again, less knowledge, less things to complicate the decision tree... one could say that decisions were easier because things were much more straightforward.

while i understand both sides of the argument, its hard to sit there with a straight face listening to an attending complain about how he had 20 admissions every 3 days 30 years ago when there was a 2 slice ct scanner, no mri, no hiv, no hep c, no c dif, 1 antifungal, minimal blood thinning medication outside of aspirin/coumadin/heparin... and docs made more... and docs were sued less... you admitted patients for physicals that are now done as an outpatient... if someone had a stroke (whether acute or subacute), there wasn't even a chance at doing anything for it...

again, there were so many medications/interventions/imaging modalities that didn't exist, one could argue that there wasn't much to do besides do a physical exam! of course, i jest, but it is something to think about when an attending tells you about "back in my day".

since i finished residency yesterday, i guess i'm now one of those attendings!

 

[DrDre311]

there are so many things that have changed in society and medicine in the last 10, 20, 30 40, 50 years; its really hard to compare medicine today to "back then".

1955, president eisenhower had an mi. he spent something on the order of 3 months cooped up in a hospital. went home with coumadin and a low fat diet.

we do more for patients with chest pain in the first hour these days then the president received 50 years ago.
even in the 1980s, beta blockers were thought to increase mortality in acute mi... now, unless someone's bp precludes it, acs patients are receiving this within the first few hours.

so, even 20 years ago, what was being done for acs? maybe heparin and aspirin (low molecular weight heparin was just being developed, gp 2b3a inhibitors didn't exist)... there weren't many decisions in the decision tree.

hepatitis c... discovered 20 years ago

c dificile... was just an afterthought for something on the boards, and within the past few years is now an organism that can have fatal outcomes.

resistant organisms, again, something that wasn't really seen 10, 15 years ago. mrsa was seemingly theoretical, now it would seem that most hospitals assume its mrsa until proven otherwise.

again, less knowledge, less things to complicate the decision tree... one could say that decisions were easier because things were much more straightforward.

while i understand both sides of the argument, its hard to sit there with a straight face listening to an attending complain about how he had 20 admissions every 3 days 30 years ago when there was a 2 slice ct scanner, no mri, no hiv, no hep c, no c dif, 1 antifungal, minimal blood thinning medication outside of aspirin/coumadin/heparin... and docs made more... and docs were sued less... you admitted patients for physicals that are now done as an outpatient... if someone had a stroke (whether acute or subacute), there wasn't even a chance at doing anything for it...

again, there were so many medications/interventions/imaging modalities that didn't exist, one could argue that there wasn't much to do besides do a physical exam! of course, i jest, but it is something to think about when an attending tells you about "back in my day".

since i finished residency yesterday, i guess i'm now one of those attendings!

Having an IQ somewhere north of legally ******ed, I am aware of all this. Whether or not medicine today is more difficult/complex, or patients tend to have more comorbidities, or whatever, is not my point.

My point is that we don't really have it that bad. Although residency is far from a cakewalk, we're not used/abused nearly to the degree that some SDN posters seem to think we are. Residents are protected from 120 hour weeks and literally living in the hospital. I'm not saying we should go back to doing things the way they were done in the "Golden Age" of medicine when docs were real men who never slept a wink and still knew everything under the sun, because that viewpoint is just as wrongheaded as the idea that all residencies should be limited to 60 hour weeks.

The simple fact is this: we're not being overworked as much as we think we are--we need to get over it, learn our respective crafts, and take care of patients.

And even if medicine as a field has changed from what it was 20 years, 10 years, 5 years ago--and obviously it has--the people who have been in the game for decades may still, against all odds, be on top of their games and we might be able to learn something from them instead of focusing on their "antiquated" ideas about residency training.

The fact that it's the non-surgeons (and especially residents in lifestyle specialties, who don't work the killer hours, take trauma call, or have the 5-7 year residencies--before any fellowship) complaining about hours and trying to say that work hours should be reduced--which would obviously mainly affect longer residencies like surgery more than other fields--is just something that I find simultaneously ironic, irritating, and unwarranted.

 

[DrDre311]

If I wanted to do some breast aug I'd just sign up with the American Board of Cosmetic Surgery and call myself a "cosmetic surgeon." Hell the most famous cosmetic surgeon/breast implanter on TV isn't even PRS boarded and still has tones of business.

Only thing is if the hot stripper invites you to have a threesome with her hot lesbian GF you'll be to tired to brakem off right from those Bilat TRAMs you do or those fibular jaw reconstructs. You'll probably say can I take a nap while you 2 get it on, and wake me when you want me to join in. Me having been rested will brakem off right each time, and when they want to party like a rockstar and f*#k like a pornstar will have all the free time and energy to do so.

Rey is a joke. His success is the product of being in the right place at the right time combined with good business/marketing acumen--like a lot of successful businesspeople. There are a lot more PRS boarded surgeons doing augs than there are snake oil salesmen like Dr. 90210, but it does piss me off that there are inappropriately trained people trying to make a quick buck doing operations they're not qualified to do.

Also, you underestimate my energy level and stamina. I can operate all day, party all night, drum up future business, and come back for more the next day.

 

[Faebinder]

DrDre311 must be in the cushiest plastic surgery program in the US. Wonder if his opinion would not change if he was in general surgery or internal medicine.

Not everyone is single and some have children that they would like to know something about them other than their names.

Also, not all programs are the same. Some are well under 80 and some are lying through their teeth and calling it 80 and some are borderline. We all agree 56 is too low but we all agree that at after 16 hours of work your learning curve is a solid horizontal line and it's time to get some sleep, hopefully not on the road.

 

[Blade28]

DrDre311 must be in the cushiest plastic surgery program in the US. Wonder if his opinion would not change if he was in general surgery or internal medicine.

For most residents in integrated Plastics programs, the first 2-3 years of training are pretty identical to what the G Surg folks go though.

 

[deleted109597]

The simple fact is this: we're not being overworked as much as we think we are--we need to get over it, learn our respective crafts, and take care of patients.

I don't think [hope?] that most people think that we are working so hard that it interferes with our entire lives. Now residents actually have kids and see them, etc. I think where most people get pissed off is that we go to school 4x as long as most people in the hospital, work at least twice as many hours as them, and often earn less than they do. Simple because "that is how it is". I truly and honestly think that having residency be longer would be completely acceptable, as long as we made some changes in secondary education. Does the fact that I took middle english literature make me a better doctor? Unlikely. A better person? No, because I read that stuff before and after I took the class, so it didn't change my perspective on much, just made it more organized.
Do I make any decisions based on what I learned in my 8 weeks of mandatory psychiatry, family medicine, or the 4 weeks of derm I took in med school? No, I make decisions based on the rotations I make as a resident. Off-service medical school rotations are an absolute waste of time. Duke already does medical school in 3 years, it could easily be shortened down to 2-2.5 without being that much harder (ie, get rid of the useless parts, not make them happen at the same time). Then you would have 1.5-2 more years of actual training that is pertinent to your field, and still graduate at around the same time as we do now. Also, you would be getting paid for instead of taking out loans for that amount of time, so you still end up better. If this allowed people to not have to be q3 for months on end, then is it better training? Likely. Remember, everything we learn is by repetition, so the more we repeat stuff, the more we know.
I'm not for lengthening residency if we don't shorten some of the other crap we have to wade through, but I like longer residency better than longer medical school. Of course, this starts to get closer and closer to the "apprentice" model which is of course terrible. I mean, how dare anyone say apprentices aren't really good at their job? I bet there are neurosurgery PAs out there that will forget more about their job than some neurosurgery residents learn during their residency. Why? Simply because they have done it more times.

 

[DrDre311]

DrDre311 must be in the cushiest plastic surgery program in the US. Wonder if his opinion would not change if he was in general surgery or internal medicine.

Not everyone is single and some have children that they would like to know something about them other than their names.

Also, not all programs are the same. Some are well under 80 and some are lying through their teeth and calling it 80 and some are borderline. We all agree 56 is too low but we all agree that at after 16 hours of work your learning curve is a solid horizontal line and it's time to get some sleep, hopefully not on the road.

My perspective would be "I'm so bored I want to die, immediately" if I were in IM. But residency would be half as long as mine, so hey, there's that!

As a junior PRS resident my schedule is identical to a GS resident's, aside from a few months on PRS (which are some of the toughest months aside from trauma--long micro cases, hand call, face call, etc). I make sure my hours happen to be at 80/week for the month, just like every other surgery resident in the U.S. I work just as hard as any of the GS or ortho guys at my program and in fact, I'm always expected to be the best guy on service because I'm the integrated plastics guy.

I'm not in a "cushy" program--it's just that I choose not to bitch constantly about stuff I know nothing about.

You're not a surgeon, so again, you've even less room to talk than Panda. Get back to me when you've done a few more years of general surgery. I won't argue with someone who has no idea what he's talking about.

It may not be the popular viewpoint, but I stand by it. Residents do not have it as bad as some residents seem to think we do. There are unpleasant parts of residency, but you have to pay your dues to get where you want to be. If you're averaging 80 hours, there is enough protected time in a given month for you to exercise, read, and spend time with family. Nobody posting here is consistently working 100 hour weeks (Panda works half that and still bitches about it), and as a group we just need to stop whining so much and get over it.

 

[Tired]

We all agree 56 is too low but we all agree that at after 16 hours of work your learning curve is a solid horizontal line and it's time to get some sleep, hopefully not on the road.

Completely disagree. It may be subject to the laws of diminishing returns, but I'm hardly wiped out and exhausted after being up for 16hrs. What are you, like 70 years old? Next you'll tell us we need mandatory nap time.

 

[Raidergate]

Dre is just killing this thread.

 

[3dtp]

DrDre311 must be in the cushiest plastic surgery program in the US. Wonder if his opinion would not change if he was in general surgery or internal medicine.

Not everyone is single and some have children that they would like to know something about them other than their names.

Also, not all programs are the same. Some are well under 80 and some are lying through their teeth and calling it 80 and some are borderline. We all agree 56 is too low but we all agree that at after 16 hours of work your learning curve is a solid horizontal line and it's time to get some sleep, hopefully not on the road.

And this is the crux of the matter. I haven't a clue if 56 (or 80 or 40 or 90 or...) is too low, too high, or just right.

Contrast two programs: a very nice program with good people and excellent management. The program was very dilligent about the 80 hour rule and keeping call manageable and consistent with a reasonable life. Yes, it was hard work, and yes, occasionally we worked a few hours longer than 80 in a week (and I was probably one of the worst offenders since I never wanted to leave the OR), but with rare exceptions, everyone, for the most part, got a good night's (or day's) sleep. The program was designed with this in mind, it was planned for and it was executed. Without much ado. So, it is clear that it is possible to do this and do it well without compromising educational objectives or prolonging training time.

Another program in a galaxy not so far away. They publically stated that the rules didn't apply to them, the rules were "advisory" and "residents didn't work hard enough" and "the hospital's needs came above the residents." The call schedule was brutal, no one got sleep, and everyone was there the full 30 hours (24+6) or longer. 110 hours weeks were the rule. The program was miserable, people were miserable and everyone's goal was to get the heck out of it.

I know I learned more in the humane, program than I did in the other program, which was mainly an exercise in survival and getting out the door. The patients in the former program got better care, too, because the residents were happy, and although tired, reasonably well rested and recreated on their alternate golden weekends.

If programs had to be honest about their working conditions and residents didn't have to accept the concept that their health, well being, emotions and psyche would be stressed and jeopardized by excessive sleep deprivation, how long do you think programs that did this would last? Assumng alternatives exist. If residents who found they were in programs who were not honest were free to transfer because their credits/evaluations/references were centrally banked and not held hostage by the hospital, how long do you think it would take for them to clean up their act when their residents all transferred out in the first two months?

In these programs, it's not about education, it's all about the Benjamins! There are some hospitals out there who will do anything, say anything to make its bottom line look better. These are the ones that give all the rest a bad name and lead to a deterioration in overall health care. And this is why Congress, JCAHO and the ACGME are increasingly involved and aware. Some hospitals have abused and gamed the system for decades. This is becoming known and society is becoming increasingly intolerant of this type of abuse. And we should be too. None of us, not a single one of us is here because we are lazy or underachievers. Choosing a reasonable, healthy lifestyle over an unhealthy lifestyle does not make one lazy, it makes one intelligent.

 

[3dtp]

It may not be the popular viewpoint, but I stand by it. Residents do not have it as bad as some residents seem to think we do. There are unpleasant parts of residency, but you have to pay your dues to get where you want to be. If you're averaging 80 hours, there is enough protected time in a given month for you to exercise, read, and spend time with family. Nobody posting here is consistently working 100 hour weeks (Panda works half that and still bitches about it), and as a group we just need to stop whining so much and get over it.

Residents do have it much better. My first year out, I was in a program that consistently worked residents 110-120 hours a week. Calls were every 3/4 and you worked 36-40 hours on call. No sleep. Until you've worked those hours for a year, you cannot know what it is like. This is why we are under serious scrutiny in the profession. You argue that lack of sleep appears to be necessary to medical training. Where is your data? You argue also that it is necessary to pay your dues, so suck it up. Again, where is your data?

My great grandmother had ice delivered to her house in straw covered wagons pulled by draft horses. As for me, the automatic icemaker in my refrigerator and the nuclear reactor down the road making ice for me is a better deal than the good old days.

 

[Tired]

Choosing a reasonable, healthy lifestyle over an unhealthy lifestyle does not make one lazy, it makes one intelligent.

No matter how many hours they make the "limit" there will be one more person whining about how inhumane it is to work that long. We went to 80, will soon go to 56. In ten years we'll all be doing 14hrs a week with a 10hrs mandatory online training a month. We will transfer to DNP programs to get adequate clinical time . . .

 

[Faebinder]

You're not a surgeon, so again, you've even less room to talk than Panda. Get back to me when you've done a few more years of general surgery. I won't argue with someone who has no idea what he's talking about.

Did 1 year of colorectal surgery and now switched out to psych... thank you for asking. It doesn't make me a surgeon but I suppose to you if you have not worked 80+ hours for 5 years then you are not qualified to talk hours.

 

[Faebinder]

No matter how many hours they make the "limit" there will be one more person whining about how inhumane it is to work that long. We went to 80, will soon go to 56. In ten years we'll all be doing 14hrs a week with a 10hrs mandatory online training a month. We will transfer to DNP programs to get adequate clinical time . . .

 

[DrDre311]

You argue that lack of sleep appears to be necessary to medical training. Where is your data?

This is not my argument. I have never made such a statement.

In any event that information will not be available for some time, when the bulk of practicing physicians trained under the 80 hour model.

Residents do have it much better.

This is my argument.

You argue also that it is necessary to pay your dues, so suck it up. Again, where is your data?

Paying your dues is a necessity for success in most things in life, not just medicine. It isn't something I need data to prove. If you don't believe me, then don't pay your dues. Sit on your ass and wait for somebody to hand you the world on a platter.

All of us in medicine stand on the shoulders of giants who have come before us. If you want to whine and cry about how tough your seniors are on you, fine with me. Go for it. I'm through arguing about why we should pay more attention to patient care and learning from our elders' experience instead of bitching and moaning about work hours--when we're already protected and have it much better than residents as recently as ten years ago.

 

[DrDre311]

Did 1 year of colorectal surgery and now switched out to psych... thank you for asking. It doesn't make me a surgeon but I suppose to you if you have not worked 80+ hours for 5 years then you are not qualified to talk hours.

I'm qualified to not complain about working 80 hours. You're also qualified to not complain about it, although that hasn't stopped you yet.

It's funny that the 2 people bitching the most about needing reduced work hours are an EM resident and a psych resident (who somehow did just one year of colorectal surgery...hmmm).

 

[Tired]

Did 1 year of colorectal surgery and now switched out to psych... thank you for asking. It doesn't make me a surgeon but I suppose to you if you have not worked 80+ hours for 5 years then you are not qualified to talk hours.

How do you do one year of colorectal surgery? Isn't that a fellowship you do after Gen Surg?

 

[NotAProgDirector]

If we decrease the 80 hour work week further, one of the following has to happen:

1. We decide that less training is OK, and leave everything else alone.
2. We increase the length of training to offset the decrease in hours.
3. We switch to a true "competency" based system -- i.e. your training is as long as it needs to be. In order to do this, we would need some very reliable metric of competency, else it leaves PD's in a truly horrific role (for everyone).
4. We average the hours out. In my program, there are busy months which tend to run 70-75hrs per week, and then there are Electives which are 7:30AM - 4-5PM no nights or weekends. If we were to switch to a 56 hour week, I'd probably have to move some additional work (i.e. weekend coverage) into the electives. I personally think this would be a tragedy.
5. We hire more people. Not going to happen, Medicare can't afford it.
6. We get "more efficient". Might happen in the long run.

I think the interesting question for debate (lost in some of the dialog above) is whether residents should work 24 hour shifts. We could switch to an 16 hour shift system that is still 80 hrs per week. Why should residents work 24 hours?

1. Cool stuff happens at night, and residents are at the forefront of that "cool stuff"
2. Residents get more autonomy at night, which is a good learning experience.
3. Working night shifts means missing out on day activities -- conferences, etc.
4. Working on a team (Resident/Interns/Medical student) taking call together is a huge bonding event. It gets lost in a shift based system. For example, on Internal Medicine rotations medical students usually admit a patient in the evening, then "digest" it, then present to the resident usually after 11PM once the team has capped. In a shift based system, this all gets rushed and you can't let the student go and learn at their own pace, since you need to get out at shift's end.
5. A shift based system is inherently less "coverage efficient" than a call based system. In my calculations, you usually end up about 15% short in trying to fill all the shifts with the same people in an overnight call schedule.

Why shouldn't residents work 24 hour shifts?

1. Many, many objective studies in various fields demonstrate that critical thinking skills, reaction times, and attention all deteriorate with both acute and chronic sleep deprivation.
2. Whether or not this translates to poor patient outcomes remains unclear. If so, the effect will be small. Regardless, there are studies showing the chances of a post call resident being involved in an MVA are much higher post call, clearly a bad outcome.
3. Some people think they can do fine post call. Honestly, I thought I was one of those people. Now, I am pretty sure it's not true, much like people who think they can drive "just fine" after having a few drinks. You just can't see it when you're the one "driving".

In a maximum 16 hour shift based system, residents will still work night shifts, so you would still get night exposure. In those surgical specialties where either 1) a certain procedure is very rare and you might miss it because of duty hours or 2) a procedure is so long that it would cause a violation, exceptions would be made. Presumably, both of these events are relatively rare.

Many of the above "pluses" of a 24 hour call based system can theoretically be designed into a shift based system, but there is an inherent risk that these good things will be lost, either through neglect, lack of resources, or competing priorities. Or, some may only be available in a 24 hour call system and really not work in a shift based system.

I am an IM PD so I really have no idea about running a surgical program. So, I have a question for Dr. Dre (or anyone who would like to chime in). Assuming that the hour limit stays at 80/week, could you realistically design your surgical residency to limit work to 16 hour shifts, or would that kill surgical training? Again, there could be rare exceptions for exceptional cases.

 

[Tired]

I am an IM PD so I really have no idea about running a surgical program. So, I have a question for Dr. Dre (or anyone who would like to chime in). Assuming that the hour limit stays at 80/week, could you realistically design your surgical residency to limit work to 16 hour shifts, or would that kill surgical training?

I don't know, so I won't comment on that portion of your question.

I think though, that you're coming at it from the wrong direction. The better question is why the hell should we design such a system? I read your list of "pros" above, and honestly, it's pretty weak. Basically, it sounds like you're saying we should redesign the structure of residency that has functioned well for the last 50 years because people get tired when they stay up late, and sometimes residents get in car accidents. It sounds like a reason to build more call rooms, not to pass federal legislation.

 

[elwademd]

I don't know, so I won't comment on that portion of your question.

I think though, that you're coming at it from the wrong direction. The better question is why the hell should we design such a system? I read your list of "pros" above, and honestly, it's pretty weak. Basically, it sounds like you're saying we should redesign the structure of residency that has functioned well for the last 50 years because people get tired when they stay up late, and sometimes residents get in car accidents. It sounds like a reason to build more call rooms, not to pass federal legislation.

just because we've been doing it that way doesn't mean we should continue to do it that way either.

as more states begin to release data about hospital's & surgeon's operative mortality (california already does this for http://oshpd.ca.gov/HID/Products/Clinical_Data/CABG/2005/ExecutiveSummary.pdf]vabgcabg: http://oshpd.ca.gov/HID/Products/Clinical_Data/CABG/2005/ExecutiveSummary.pdf ; http://www.theheart.org/article/801811.do), perhaps there will be a little more interest/push from the right (or wrong) people to truly look at how many hours are worked. and if its an issue for attending surgeons, it will be an issue for resident surgeons.

 

[Tired]

just because we've been doing it that way doesn't mean we should continue to do it that way either.

So your argument is that we show throw away a system that works in favor of a yet-to-be-determined system based on the supposition (rather than evidence) that being tired may adversely affect patient outcomes? And all this before we even talk about whether the shorter clinical training time will have an effect on patient well-being?

But yeah, my argument is something to be laughed at.

 

[Faebinder]

How do you do one year of colorectal surgery? Isn't that a fellowship you do after Gen Surg?

Didnt i explain that to you (yes you) in the intern forum like 6 months ago? Yes it was a one year fellowship and no I am not board eligible as a result of it. It's a research fellowship where I got to play CRS intern + do research on the side. You can actually do that in any field. You got any specific questions on the program, ask me private, I would be happy to give you the names, university, and numbers.

 

[Faebinder]

I don't know, so I won't comment on that portion of your question.

I think though, that you're coming at it from the wrong direction. The better question is why the hell should we design such a system? I read your list of "pros" above, and honestly, it's pretty weak. Basically, it sounds like you're saying we should redesign the structure of residency that has functioned well for the last 50 years because people get tired when they stay up late, and sometimes residents get in car accidents. It sounds like a reason to build more call rooms, not to pass federal legislation.

Just because it functions well, doesn't mean it can't be better. If it aint broke then don't fix is not a good motto unless you are an old car.

 

[3dtp]

Paying your dues is a necessity for success in most things in life, not just medicine. It isn't something I need data to prove. If you don't believe me, then don't pay your dues. Sit on your ass and wait for somebody to hand you the world on a platter.

Due paid. In full. Contract signed, credentialed, and the platter has been placed at my door. Non sequitor.

All of us in medicine stand on the shoulders of giants who have come before us. If you want to whine and cry about how tough your seniors are on you, fine with me. Go for it.

Again, non sequitor. My seniors were not inappropriately tough on me. Nor as a senior was I inappropriately tough on my juniors. Nor as a chief was I inappropriately tough on all the young 'uns. Life worked out better that way for everyone. We took care of each other. And, we learned better. How tough my seniors were on me or I on the juniors has no place in this discussion as it is not about the malignancy or lack thereof, but rather, is it appropriate and necessary to sleep deprive to educate young physicians? That you have been abused or are the abuser (or are not as the case may be) is a different thread and a horse of a different color.

I'm through arguing about why we should pay more attention to patient care and learning from our elders' experience instead of bitching and moaning about work hours--when we're already protected and have it much better than residents as recently as ten years ago.

You have it better. Not necessarily much better. I've lived in both systems. I know from this first hand experience. That work hours have been a problem is clear, a fact that you have consistently refused to acknowledge. That this problem has become less so in the past 4-5 years appears to be true, but as AProgDir has insightfully noted, it is about the contigous on-duty time. As far as I recall from this thread, not a single person has advocated paying less attention patient care nor failing to learn from our elders' experience.

Were we not learning from our elder's experience, we would not be having this discussion on this topic. It is precisely because we have learned from those experiences that we know that there is a need to improve the system.

The objections center around the inappropriate use of highly trained labor for non-educational purposes, and the expenditure of costly resources in a system which severely undervalues those resources during "graduate medical education." Adam Smith identified this in his landmark work, "An Inquiry into the Nature and Causes of the Wealth of Nations."

I know how to clean a latrine. I have cleaned many latrines in my day. If I need a clean latrine and there is no one around to clean it, I will clean it myself. It takes 15 minutes to learn how to clean a latrine. Less if the DI is from South Carolina. If my decade of training and education allows me the ability to cure a life threatening illness, and there is only so many hours in a day to do this, then I have no business cleaning latrines when I can have someone else whose level of training and talents makes cleaning latrines the highest and best use of their abilities.

If your goal is to produce those who work by rote repetition, then the present (and former) system is just fine. If your goal is to produce intelligent thoughtful physicians, then let's clean up our act. If there are dues to be paid, I would like to see the generations coming up behind me and who will be taking care of me get something valuable for those dues, and not just paying for payments' sake.. And that includes being on one's feet for 30 hours because our elders did it. We no longer stick our dirty ungloved hands in our patients open bellies, either.

 

[DrDre311]

Due paid. In full. Contract signed, credentialed, and the platter has been placed at my door. Non sequitor.

Again, non sequitor. My seniors were not inappropriately tough on me. Nor as a senior was I inappropriately tough on my juniors. Nor as a chief was I inappropriately tough on all the young 'uns. Life worked out better that way for everyone. We took care of each other. And, we learned better. How tough my seniors were on me or I on the juniors has no place in this discussion as it is not about the malignancy or lack thereof, but rather, is it appropriate and necessary to sleep deprive to educate young physicians? That you have been abused or are the abuser (or are not as the case may be) is a different thread and a horse of a different color.


You have it better. Not necessarily much better. I've lived in both systems. I know from this first hand experience. That work hours have been a problem is clear, a fact that you have consistently refused to acknowledge. That this problem has become less so in the past 4-5 years appears to be true, but as AProgDir has insightfully noted, it is about the contigous on-duty time. As far as I recall from this thread, not a single person has advocated paying less attention patient care nor failing to learn from our elders' experience.

Were we not learning from our elder's experience, we would not be having this discussion on this topic. It is precisely because we have learned from those experiences that we know that there is a need to improve the system.

The objections center around the inappropriate use of highly trained labor for non-educational purposes, and the expenditure of costly resources in a system which severely undervalues those resources during "graduate medical education." Adam Smith identified this in his landmark work, "An Inquiry into the Nature and Causes of the Wealth of Nations."

I know how to clean a latrine. I have cleaned many latrines in my day. If I need a clean latrine and there is no one around to clean it, I will clean it myself. It takes 15 minutes to learn how to clean a latrine. Less if the DI is from South Carolina. If my decade of training and education allows me the ability to cure a life threatening illness, and there is only so many hours in a day to do this, then I have no business cleaning latrines when I can have someone else whose level of training and talents makes cleaning latrines the highest and best use of their abilities.

If your goal is to produce those who work by rote repetition, then the present (and former) system is just fine. If your goal is to produce intelligent thoughtful physicians, then let's clean up our act. If there are dues to be paid, I would like to see the generations coming up behind me and who will be taking care of me get something valuable for those dues, and not just paying for payments' sake.. And that includes being on one's feet for 30 hours because our elders did it. We no longer stick our dirty ungloved hands in our patients open bellies, either.

You do realize that you're not actually disagreeing with me about anything, right? You aren't producing anything contrary to a single thing I've said. I do, however, disagree with your spelling (and usage) of non sequitur. An example of a true non sequitur would be if your wife said to you, "Oh, honey, I love you," then you looked at your watch and said "Oh, bout a quarter til five."

Your last few posts have begun by restating my point of view and then gone off on weird allegorical tangents about latrines, horse-drawn carriages, and icemakers.

 

[DrDre311]

I am an IM PD so I really have no idea about running a surgical program. So, I have a question for Dr. Dre (or anyone who would like to chime in). Assuming that the hour limit stays at 80/week, could you realistically design your surgical residency to limit work to 16 hour shifts, or would that kill surgical training? Again, there could be rare exceptions for exceptional cases.

I'm not a PD, but my gut feeling on the matter is that a 16 hour limit would not work for surgical specialties. It's tough enough to get in on the cases I want to do as it is, and as you mention, I get to do the most operating on nights and weekends. I don't particularly enjoy getting my sleep cycle all screwed up by being up all night on call, but I do like making treatment decisions and operating with increased autonomy. Even though I don't like being in the ER all night, I've become much quicker, more skilled, and more efficient by being the guy on call for hand or face.

The problem with such a short limit on hours is that there's no way to predict how long a given case will last, and they don't often go off back to back in a nice neat package; so a 16 hour limit would cut down on the number of cases anyone could do which necessitate increased training time (in years) for residents and all programs would become even more top-heavy than they currently are. The proposed limit would also cut down on clinic time, which (although most surgery residents detest clinic) is also an important component of education.

Operative skill can't be learned from a book or a lecture; it's learned from doing hundreds and even thousands of cases. Specifically limiting "shifts" to 16 hours doesn't seem like a good idea in an unpredictable field like surgery to me. I think it would result in added years and I don't really want to be a resident for 9 or 10 years.

However, that's just my personal feeling on the matter. I can't know how such a change would really affect training because it hasn't happened. I could be completely wrong, but I think most surgery residents and attendings would have similar viewpoints.