60 HR Work Week Caps Coming???

[medicinesux]

As if working 80 hrs a week was even remotely sane to begin with. If this ever comes to fruition, it will be way beyond overdue.

Check out the comments section for some interesting perspectives. Who would've thought that the lay public would rather not be treated by a resident who has been up all night? Check out the good clashing going on between the old timer physicians and the younger crop of docs who are viewed as "lacking commitment". One of these geezers even threatened to recommend his hospital stop taking residents if this were to go through

One of the major complaints being voiced is that the hours of clinical training will no longer be sufficient. Though I believe this has some merit, I also see sour grapes from those who want to continue the hazing process and also from admin who will be losing their cheap slave labor. Too bad. This wildly abusive system needs to be taken out of service once and for all. However, to make up the total hours lost, I would chop off the fourth year of med school (which would also save a whole year of egregious tuition costs on a fairly useless year) and transform it into a mandated internship for EVERYONE no matter what specialty they eventually pursue. This infusion of 20K extra bodies would also help cover the increased hours that would need to be covered. This internship would be done at the hospitals your med school is affiliated with so there would be no applying. During this internship you would than apply to your respective residencies. Of course, med schools and hospitals would pitch a fit over this proposal since they would be out our student loan money.

http://www.washingtonpost.com/wp-dyn/content/article/2010/03/17/AR2010031704006.html

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[Laryngophed]

Wouldn't it be possible to extend the training of residents by a half or full year to compensate for the decrease in clinical hours? I know most residents will hate the idea (I'm sure I will too) but if there is some threshold for clinical training, couldn't it be met by an extension of total training time? I know that Medicare funds for ~3 years (IIRC) but since hospitals get so much work done with residents at a cost cheaper than attendings, wouldn't they be willing to foot the bill?

I'm not certain beyond quality of life issues for residents that this will decrease the number of errors though. Someone has linked a study that showed no significant change in medical errors with the initial reduction in work hours versus the time before the change. Either we haven't met the threshold in reduction of hours or in our current system (given hand-offs, etc.) the work hours aren't the limiting factor in reducing errors. It's possible that consecutive hours worked may be a potential target and that total hours worked isn't as critical in the long run.

 

[Law2Doc]

...Either we haven't met the threshold in reduction of hours or in our current system (given hand-offs, etc.) the work hours aren't the limiting factor in reducing errors. ...

You are correct that no study has shown a reduction in patient errors since the 80 hour limit. There has been some suggestion that resident's traffic accidents have decreased by a nominal amount, but I don't know that that was the point of the limit.

The problem likely is that the fewer hours residents work, the more handoffs there are. Handoffs, unfortunately, are where most errors are made -- when you have someone trying to explain all the patient care details of a couple dozen patients to someone new in about a minute a patient. The shorter the work hours, the more new people get thrown into the mix. Once you have taken care of someone throughout the day/night, you have a pretty good idea of what to do/what not to do with them when things start going bad -- even if you are sleepy; at least you don't have that confused down time where you are trying to figure out who this patient is and what has already been done/tried, or worse, where you might order something without realizing that this patient hasn't done well getting X drug or it makes them too hypertensive, etc etc. Makes a huge difference, and I suspect that the more you decrease errors from tiredness you will replace them with errors from handoffs. An 80 hour average is actually pretty reasonable in terms of minimizing handoff errors while ensuring that everyone gets out of the hospital to sleep most nights, particularly if a night float system is incorporated. Dropping it further is probably simply unrealistic in many specialties. And while everybody would love more time out of the hospital, it's pretty reasonable and from my personal experience you rarely find yourself so exhausted that you cannot think straight (as I suspect you would get if hours were uncapped and regularly ran into the 100 range).

Some residencies already had to expand the number of years to accomodate the reduced learning encompassed in the 80 hour work week, most are resistant to this, but probably to the detriment of the training. I think most residents would rather get things done as quickly as possible, rather than draw out the training to sleep a bit more. Additionally, as you decrease resident hours, you increase fellow and attending hours -- somebody has to pick up the slack, and these folks aren't protected by hour limitations. Some programs have had attendings have to step up the hours already when the limitation was imposed at 80 hours/week.

You can't just say decrease resident hours and let them sleep more in a vacuum -- residents fill a role and if you decrease their hours somebody has to fill that role. So either you have more handoffs or attendings who have to work 20 additional hours/week. Neither is a great solution if reducing errors is the goal.

 

[Bobblehead]

Additionally, as you decrease resident hours, you increase fellow and attending hours -- somebody has to pick up the slack, and these folks aren't protected by hour limitations. Some programs have had attendings have to step up the hours already when the limitation was imposed at 80 hours/week.

Fellows are considered trainees and must follow the same ACGME work hour regulations. In general they can do incrementally more than they do now, but that's because they're not maxed out on work hours already.

Now attendings on the other hand are NOT subject to any work hour regulations. I suspect that there's a limit on how much people can be asked to work though before they'll go to a grass-is-greener hospital on the other side of town.

 

[Law2Doc]

...Now attendings on the other hand are NOT subject to any work hour regulations. I suspect that there's a limit on how much people can be asked to work though before they'll go to a grass-is-greener hospital on the other side of town.

They as a group have clout and can push back. This is a big reason why I don't see lowering the hours as realistic unless the feds are going to open up the coffers and allow places to stockpile more residents to handle the extra shift. But I don't see anyone ponying up money for this in the near term. So this idea is probably a non-starter.

 

[J1515]

Ugh, enough bitching already. 80 hrs is NOT bad. We are doctors learning how to manage patients. We need 80 hour weeks. That's the only way this stuff will ever become second nature. I'm so sick of people complaining about every hardship in life. Wahhh, I wanna work fewer hours, I want free healthcare, I wanna make more money... enough already. Life isn't easy. When you need to learn everything from Prader-Willie syndrome to the management of chronic renal failure in diabetics, you need to spend as much time in the hospital as possible. So as residents we're tired, boo hoo. Cry me a river. There are plenty of non-medically related jobs out there where people put in >50-60 hour weeks in the office and work weekends. If there is any field where we need 80 hour work weeks it's medicine. You all knew what you were signing up for the first day of medical school. If you wanted an easier life you should've become a teacher...you could've had summers off.

And yes, I'm a resident who has worked 80 hour weeks in the past during certain blocks. I have felt too tired to drive home after a 30 hour overnight call and so I did the responsible thing which was take an hour nap in my car or the call room before driving home. Common sense.

 

[Winged Scapula]

Fellows are considered trainees and must follow the same ACGME work hour regulations. In general they can do incrementally more than they do now, but that's because they're not maxed out on work hours already.

Only fellowships that are accredited by the ACGME. There are plenty of non-ACGME fellowships that are accredited by other bodies (ie, Society of Surgical Oncology, osteopathic fellowships) and thus, are not subject to ACGME regulations.

 

[SmokD]

Only fellowships that are accredited by the ACGME. There are plenty of non-ACGME fellowships that are accredited by other bodies (ie, Society of Surgical Oncology, osteopathic fellowships) and thus, are not subject to ACGME regulations.

Wait, does that mean osteopathic residencies are not subject to 80hour restrictions?

 

[Laryngophed]

Wait, does that mean osteopathic residencies are not subject to 80hour restrictions?

No, it means they aren't subject to ACGME regulations. I believe the AOA (which oversees the residencies, but I may be incorrect) have adopted similar guidelines to the ACGME's with regard to work hour restrictions.

 

[konRAD 1]

At my institution nobody really follows the 80 hour limit as it is...the senior resident on IM was putting in 92 hours a week and the ortho residents put in close to 100 on average...then they just lie on their hour logs

 

[AnesNavy]

Ugh, enough bitching already. 80 hrs is NOT bad. We are doctors learning how to manage patients. We need 80 hour weeks. That's the only way this stuff will ever become second nature. I'm so sick of people complaining about every hardship in life. Wahhh, I wanna work fewer hours, I want free healthcare, I wanna make more money... enough already. Life isn't easy. When you need to learn everything from Prader-Willie syndrome to the management of chronic renal failure in diabetics, you need to spend as much time in the hospital as possible. So as residents we're tired, boo hoo. Cry me a river. There are plenty of non-medically related jobs out there where people put in >50-60 hour weeks in the office and work weekends. If there is any field where we need 80 hour work weeks it's medicine. You all knew what you were signing up for the first day of medical school. If you wanted an easier life you should've become a teacher...you could've had summers off.

And yes, I'm a resident who has worked 80 hour weeks in the past during certain blocks. I have felt too tired to drive home after a 30 hour overnight call and so I did the responsible thing which was take an hour nap in my car or the call room before driving home. Common sense.

Agreed....the thought of doing an extra year is silly. -anesnavy

 

[wholeheartedly]

Haven't studies shown that the biggest problem isn't really the 80+ hrs in a week but rather the 30 hrs at a time stretches that contribute most to medical errors?

 

[knockoutMice]

... I would chop off the fourth year of med school (which would also save a whole year of egregious tuition costs on a fairly useless year) and transform it into a mandated internship for EVERYONE no matter what specialty they eventually pursue. This infusion of 20K extra bodies would also help cover the increased hours that would need to be covered. This internship would be done at the hospitals your med school is affiliated with so there would be no applying. During this internship you would than apply to your respective residencies.

^^ That's the way how it works here in the Indian subcontinent.... and probably the UK (because our system is modeled on the UK system, not entirely sure though)

 

[Law2Doc]

Haven't studies shown that the biggest problem isn't really the 80+ hrs in a week but rather the 30 hrs at a time stretches that contribute most to medical errors?

No studies have shown this. Studies to date have shown that now that we have capped the number of hours in a row at 30, it really hasn't reduced any errors, nor has the 80 hour average done an iota of good. You have to realize that while something "intuitively" sounds like it ought to be helpful, statistically it may not be. The key reason -- you introduce more of another error-fraught part of the system -- the handoff. So as you decrease sleep deprived related errors, you increase handoff related errors. Is there a happy medium? Some would argue that it might be close to where we are at now, maybe even a few hours a week more.

Now I am all for folks getting to go home and spend time with family, be able to have a social life while they are still young enough to enjoy one and so on. But to do it under the guise that it's going to reduce errors is a bit too convenient. The data thus far suggests it isn't helping. And I think a lot of the younger folks who now get out of the hospital earlier thanks to the 80 hour cap are going out and doing fun things, rather than getting that extra sleep, which further inhibits the data.

 

[exPCM]

When the Institute of Medicine released a report last year recommending that on-call shifts be limited to 16 hours,many skeptics argued it couldn't be done, or that it would come at a cost—more signouts, and less continuity of care.
However, some residency programs have already made the transition to shifts of no more than 14 or 16 hours, with great results.
Here are three case studies from Washington State, Ohio, and New York, where programs have redesigned their work hours to fit the evidence that a 16-hour limit is safer for resident physicians and their patients.

Virginia Mason Medical Center, Seattle, WA
Since 2007, Virginia Mason Medical Center
has operated a night float system in its Internal
Medicine residency program, enabling residents
in the ICU to achieve and maintain a maximum
shift of 13.5 hours. The internal medicine program
is made up of 35 residents – 10 per PGY
and an additional 5 preliminary medicine
interns.
The key to Virginia Mason's transition was
redesigning the resident rounds. According to
Program Director Dr. Alvin Calderon, the
redesign focused on two areas: 1) creating an
inpatient rounding schedule, and 2) defining
what happens in each rounding encounter.
For example, each bedside encounter was
designed to ensure that the patient's concerns
were talked over, the nurses' concerns were discussed,
and the resident's learning needs were
addressed.This enabled the physicians to use their
time efficiently, so that they were not trying to
squeeze more work into a shorter amount of time.
Dr. Calderon said residents' active participation
and investment in the redesign has been key.
"They understand patient-centeredness," he
said. "And it's not about trying to work less. It's
about doing the right work."

Summa Health System, Akron, OH
"Really, we just looked at various opportunities
to cut the number of hours that residents spent
here without reducing the amount of work they
were doing or the number of patients they were
seeing," said Dr. David Sweet, Program Director
in Internal Medicine at Summa Health System,
which runs Akron City Hospital. "So even today
on a 16-hour plan, we see more patients than we
saw in 2003-2004, and we have the same number
of residents that we had at that time."
The program gradually introduced night float,
and also addressed continuity of care concerns
through a team model.
Residents were enthusiastic about the move
away from 30-hour shifts. "We've become much
better about handing off patients," said Dr.
Jonathan Hlivko, a resident in the program. "I
don't feel like I'mmissing out on learning because,
even though I go home at 6:30 or 7 pm and the
night team comes and takes over, I'm back in to
round on those patients the next morning."

Dr. Hlivko and many of his fellow residents
said they feel like that they can go home and
read about a case, learn a little bit more, and
come back in the morning armed with fresh
information.
The internal medicine program at Summa
Health System was accepted into and recognized
by the ACGME's Educational Innovations Project
(EIP) for its creative approach to restructuring
work hours.

St. Luke's-Roosevelt Hospital Center, New York, NY
For several years, St. Luke's-Roosevelt
Hospital's internal medicine residents have
worked a maximum shift of 14 hours, and that's
only in very intensive rotations like ICU or the
"medical consult" done by third-years.
"Nothing is longer than 14 hours," said Dr.
Farbod Raiszadeh , a NY CIR Vice President and
recent alumnus of St. Luke's internal medicine
program. "There may be exceptional cases where
people stay longer, but the attendings and program
directors are committed to getting people
out on time," Dr. Raiszadeh said.
He credits Dr. Ethan Fried, Medicine program
director and head of GME, with making the
change. "Without Dr. Fried, these changes wouldn't
have happened," Dr. Raiszadeh said.
Like the other programs, introducing a night
float at St. Luke's was necessary in order to put
an end to 24-hour call.
St. Luke's-Roosevelt also continues to address
the challenges of improving signouts.Dr. Fried has
developed a template to standardize the signout
and make sure certain elements are included, Dr.
Raiszadeh said. "The second step he took was he
wanted to make sure signouts are done face to
face, between residents who are in a calm environment,
not rushed, and without interruptions."
http://www.cirseiu.org/assets/asset...d-487b-a7b4-d16d4976bcf3/1/CIR_News-12-09.pdf

 

[Impromptu]

Like many aspects of medicine, I think the transition away from 30 hours shifts and fewer weekly hours for residents will have growing pains as the system is refined. The problems were systemic problems, and can only be fixed by systemic fixes. As the above post shows, you can do the same amount of work in a less amount of time (be more efficient) if the system is adjusted to allow for more efficient work. It isn't about residents running around more frantically to get the extra work done, it is about making the system better.

 

[Law2Doc]

Like many aspects of medicine, I think the transition away from 30 hours shifts and fewer weekly hours for residents will have growing pains as the system is refined. The problems were systemic problems, and can only be fixed by systemic fixes. As the above post shows, you can do the same amount of work in a less amount of time (be more efficient) if the system is adjusted to allow for more efficient work. It isn't about residents running around more frantically to get the extra work done, it is about making the system better.

Depends how you measure better. If the goal is to reduce sleep related errors (which was the original point of the 80 hour work week stemming from the Libby Zion case), then it has failed miserably. No study thus far has borne that errors are, in fact, reduced after the change. If you measure better as better life for residents, then that's fine, but bear in mind it doesn't address that which was the whole point of the transition in the first place. And FWIW, attendings have seen their hours go up since this change, so it's not like you can do the same amount of work in less time, it's more like different people doing the same amount of work.

 

[NotAProgDirector]

As the above post shows, you can do the same amount of work in a less amount of time (be more efficient) if the system is adjusted to allow for more efficient work.

Actually, what really happens is you end up doing the same amount of work, but you do different work on shifts than with 24 hour call. That's not bad, but it's different. FWIW, I'm all for reasonable shifts. Slowly, my program is shifting. When you switch from 24 hour calls to shifts, you get a 15-20% inefficiency -- you need 15-20% more people, or 15-20% of the work needs to be shifted to someone else.

 

[Acherona]

I don't mind working 70-80hrs/week as much I mind being forced to stay awake for 30 hours straight. It's a cruel and barbaric form of human torture and should be put to a stop. Sleep is necessary for life. Overnight call is akin to depriving someone of food or shelter or air. It's really irrelevant whether errors are decreased or increased, this is about human rights for residents.

 

[wild0ne]

It's really irrelevant whether errors are decreased or increased, this is about human rights for residents.

Bingo.

It amazes me how many intelligent people allow the hospitals to frame the argument for them.

 

[wild0ne]

Like many aspects of medicine, I think the transition away from 30 hours shifts and fewer weekly hours for residents will have growing pains as the system is refined. The problems were systemic problems, and can only be fixed by systemic fixes. As the above post shows, you can do the same amount of work in a less amount of time (be more efficient) if the system is adjusted to allow for more efficient work. It isn't about residents running around more frantically to get the extra work done, it is about making the system better.

Exactly.

I'm sure that figuring how to get Mr. Jones discharged to a SNF is really contributing to your knowledge about Prader-Willi.

 

[wild0ne]

Handoffs, unfortunately, are where most errors are made -- when you have someone trying to explain all the patient care details of a couple dozen patients to someone new in about a minute a patient.

If that's the case, why do handoffs need, and I do mean absolutely need, to be limited to "about a minute"?

Is it because one cannot feasibly imagine a healthcare system where more than a few minutes cannot be spared on the systemic transfer of information to help minimize errors?

 

[tncekm]

So, why don't we just (a) increase the length of residency (b) keep the shift long? (And, kill the 30hr shifts altogether). We can even keep the costs low by reducing our pay proportionately. Just allow us to defer our loans during training, and it's no problem. We can live off of a 25% reduction in pay if our loans are deferred.

 

[filter07]

So, why don't we just (a) increase the length of residency (b) keep the shift long? (And, kill the 30hr shifts altogether). We can even keep the costs low by reducing our pay proportionately. Just allow us to defer our loans during training, and it's no problem. We can live off of a 25% reduction in pay if our loans are deferred.

increase length of training, reduce pay, and work greater than 30 hrs straight. sounds like a great plan.

 

[tncekm]

increase length of training, reduce pay, and work greater than 30 hrs straight. sounds like a great plan.

I didn't say work greater than 30hrs straight. I said to abolish the 30hr shifts.

And, yeah, pay is reduced. But, I'd be much more comfortable getting my loans deferred and working an extra year at a lower wage than putting in 90hrs/wk constantly worry about killing a patient or myself as I drive home (yeah, yeah... take a nap, right? Well, maybe it works for you, but after I'm up 30hrs a few hour nap isn't enough.)

If we want to cut resident hours, we can't expect our pay to go up and our residency term to decrease.

 

[Winged Scapula]

If that's the case, why do handoffs need, and I do mean absolutely need, to be limited to "about a minute"?

Is it because one cannot feasibly imagine a healthcare system where more than a few minutes cannot be spared on the systemic transfer of information to help minimize errors?

Well if you're handing off a list with 60 or more patients on it, even a minute per patient is an hour...and that doesn't count the sign-out being interrupted by pages etc. Longer sign out makes sense but its not realistic given the volume some hospitals and services have.

Frankly, the quality of the sign out is often a function of the quality of the resident and their attention to detail. However, at some point you just cannot keep every little detail about dozens of patients straight.

I used to know to keep an extra close watch on the ones I was told, "he's going home tomorrow, no problems, nothing to do."

 

[filter07]

If we want to cut resident hours, we can't expect our pay to go up and our residency term to decrease.

by the same token we can't decrease salary and increase residency length... resident salaries are depressed as it is. don't discount how much knowledge you get after graduating medical school. you are worth a lot more than they pay you. we just put up with it because residency is a finite amount of time, and our salary will get better as attendings. we don't need anyone giving president obama any more crazy ideas.

 

[tncekm]

by the same token we can't decrease salary and increase residency length... resident salaries are depressed as it is. don't discount how much knowledge you get after graduating medical school. you are worth a lot more than they pay you. we just put up with it because residency is a finite amount of time, and our salary will get better as attendings. we don't need anyone giving president obama any more crazy ideas.

Oh, I don't disagree that residents are underpaid. And, I definitely won't be discounting the level of knowledge I'll gain as a resident--I'm counting on it, in fact. As an MS1 I'd be scared to death to be responsible for patients. LOL

But, assuming that nobody actually cares what doctors get paid (which they don't), I don't think we'll see any increases in pay until we can find a way to unionize (a necessary evil and idea that I absolutely loath). Because of that, I was just trying to be realistic

 

[Looking4Info]

LONG POST BUT WORTH THE READ!!!

Reduce work hours for HUMAN RIGHTS sake since 30hr shifts (even 20hr shifts) are BARBARIC. (Could you imagine the scrutiny the government would get if they kept the POWs at GITMO awake for 30 hours straight without having "time" to eat or pee in an attempt to uncover the next terrorist plans???!!! - Arguable a noble cause, however do you know the criticism the government would receive for "abusing" the "rights" of these terrorists???!!! There would be angry campaigns in front of the Washington Monument for thousands of tax dollars to be spent on defending the rights of these POW criminals! Or what about foreign factories? Everyone screams and yells that it is shameful that "Made in X" is printed on everything since we are making these poor, uneducated mothers/fathers work 15+ hours/day (weekends off) in a factory for unreasonable compensation (which is twice what they would make in their poor countries to begin with) just to be able to put food on the table for their children. "Cheap labor" they are called, and we are blamed.

But everyone turns a blind cheek to residents being used in the same way. The solution? Simple: Go to more of an EM shift-work system with CONSCIOUS efforts regarding handoffs.

Now, as for the "time lost" in residency by decreasing 25% of work hours?

One of two viewpoints:

1. add some time to residency (6m perhaps?) or implement MSIV time as residency time for the second half (easily accomplished if MSIV finished in December and match was over in December similar to non main match)

or

2. does seeing 25% less cases of pancreatitis, less cholecystectomies, less STAT cesareans trully lower our fund of knowledge? (honest question here since I truly don't know yet)


If the above could be figured out, moving on to resident salaries...

They are grim as it is. Just a few dollars above minimum wage to be exact! It's terrible. WE are "cheap labor" and nothing more. The person above who stated that we only put up with it because residency is a finite amount of time and thus we know the light at the end of the tunnel is approaching is right on. However, that does NOT make it right.

IT DOES NOT MATTER IF WE ARE WORKING 60 OR 80 HOURS PER WEEK. WE CAN STILL INCREASE COMPENSATION. HOW??????????

Here's a "novel idea":

President Obama, you know that $3,000,000,000,000 deficit we have because banks (a private business) could not "go under" so the government had to rescue them for the sake of the American economic enterprise (good theory if it actually went the right way), but instead ended up paying bonuses to BIGTIME CEOs and people like me with excellent credit STILL CAN'T OBTAIN A MORTGAGE?

President Obama, you know that $3,000,000,000,000 deficit we have because automotive industries (private business) could not "go under" or we would thus be left with merely foreign imports from which the sales would not benefit our economy so the government had to rescue them?

President Obama, you know that $3,000,000,000,000 deficit we have because X, Y, & Z (all private businesses) could not "go under" so the government had to rescue them for the sake of the America?

Well... PRESIDENT OBAMA, SINCE I AM PERSONALLY PAYING FOR YOUR $3,000,000,000,000 DEFICIT VIA TAXES SINCE I AM CONSIDERED ONE OF THE "WEALTHY MEMBERS OF SOCIETY" MAKING OVER $12,000/YR, HOW ABOUT HEARING MY VOICE?!

How about using some of that funding (again, a majority of which I and my colleagues will be repaying when we are wealthy attendings making 6-fugure salaries)... even a mere 0.1% of it (which would still be 3 BILLION DOLLARS!!!) and dedicating it to the PUBLIC HEALTHCARE WORKERS???

Let me do quick math... on AVERAGE (forgive me if I'm off, but it is 4am), there are 25,000 resident positions available per year. The AVERAGE residency is 4 years in length, equating to a total of 100,000 residents (on average) working at any given time. Equally dividing that $3 Billion...

now wait... even I don't want to sound greedy... let's discount that amount by 50% and only ask the government to allocate 0.05% to PUBLIC SERVANTS!!!

Equally dividing $1.5 Billion among the 100,000 of us.... that's $15,000 more to each of us! OMG! Can you imagine decreasing from 80-60hr/wk (the equivalent of working only 1/2 again the normal 40hr work week rather than 2 full-time jobs) and getting paid a bit more?!

OK, for any of you who have seen some of my other posts, I matched unhappily into a position at a place my dean forced me to rank. Perhaps I missed my calling and medicine isn't for me... Look out Washington, here I come!

 

[Law2Doc]

Bingo.

It amazes me how many intelligent people allow the hospitals to frame the argument for them.

Um, it's not the hospitals framing the argument. The whole point of the 80 hour limitation was to reduce errors. It only happened because of a NY lawsuit stemming from the death of a child (Libby Zion) of a high profile news writer/lawyer. There's some debate as to whether tiredness really played a role (the jury found the patient partially to blame for using and lying about her drug use). But the profession basically caved to the public pressure related to this litigation and media barrage. But barring this litigation there was no way anyone was ever going to adjust residency hours for "human rights" or other reasons. This is a profession steeped in tradition, with virtually all the older players convinced that the hours they weathered made them into better doctors -- very hard to fight.

So now, as it turns out, nobody can show that errors have gone down since we capped duty hours at 80. Studies universally show no change. Which makes it a very hard argument to say, well hours should be 60. Why? So residents don't have to work as hard? I don't see it happening. It's not the hospitals framing the issue, it's the older professionals who are going to be asked to take up the slack if such a change were implemented that are your enemy on this. Also bear in mind that pretty much no other profession caps its workers hours, this tends to be reserved for things like airline pilots. As a lawyer I worked more than 80 hours quite a few weeks. Bankers sure do during big deals. Lots of folks do. It's hardly inhumane.

 

[Law2Doc]

...

2. does seeing 25% less cases of pancreatitis, less cholecystectomies, less STAT cesareans trully lower our fund of knowledge? (honest question here since I truly don't know yet) ...

You can't dictate what comes in. Missing 25% of the time means missing 25% of the cases, whatever they are, not just the routine stuff. Which also means missing 25% of the things that you hopefully will get to see during residency because they don't come around that often, but are critical to recognize when they do. FWIW, the biggest complainers about the 80 hour work week limitation tended to be surgery residents (the ones whose hours were most impacted) precisely because they were not allowed to scrub into something truly interesting because they were inevitably hitting their hour limitation. You only get to do residency once, and you need to see and do all you can in what amounts to a fairly short, albeit intense, period of time. Very few people have any appetite for longer residency. Most have the notion that you push through it painfully and fast. I actually think you'd have more than a few takers who would be willing to shorten it by a year and increase hours, rather than the drawn out plan you are floating.

 

[Parietal Lobe]

http://opinionator.blogs.nytimes.com/2010/03/18/at-midnight-all-the-doctors/?ref=opinion

 

[TysonCook]

Get rid of the 30hr mega shift. I have no horse in this race, but I can say that as an attending I regularly work 60-80hrs a week, and so do my colleagues in other fields.

With the new "obamacare" I think that we ALL should be prepped for ~80hr work weeks, as we now have 32,000,000 more patients with "access"

Regardless, if you can't work 60hr/wk, you most likely will have a hard time being an attending.

 

[Bobblehead]

So, why don't we just (a) increase the length of residency (b) keep the shift long? (And, kill the 30hr shifts altogether). We can even keep the costs low by reducing our pay proportionately. Just allow us to defer our loans during training, and it's no problem. We can live off of a 25% reduction in pay if our loans are deferred.

Just to understand where you are coming from as an MS-1 in this discussion, are you a traditional medical student without a break in your education from high school to college to medical school? Have you ever had to work a job to pay all of your basic living costs without loans, grants, gifts, supported family/children or done the math on what 4-10 years of deferred/reduced earnings will do to your overall ability to retire on an adequate nest egg?

There have been rumors floating around for a while now on increasing residency lengths. Reducing work hours further will likely prompt some type of serious discussion for an overall increase in training program length and that should be of real and financial concern to anyone that's still in the training pipeline.

Oh, I don't disagree that residents are underpaid. And, I definitely won't be discounting the level of knowledge I'll gain as a resident--I'm counting on it, in fact. As an MS1 I'd be scared to death to be responsible for patients. LOL

But, assuming that nobody actually cares what doctors get paid (which they don't), I don't think we'll see any increases in pay until we can find a way to unionize (a necessary evil and idea that I absolutely loath). Because of that, I was just trying to be realistic

There are already resident unions in existence, i.e. CIR. All you'd have to do is get enough signatures from your institution's trainees to force a collective bargaining vote.

 

[tncekm]

Just to understand where you are coming from as an MS-1 in this discussion, are you a traditional medical student without a break in your education from high school to college to medical school? Have you ever had to work a job to pay all of your basic living costs without loans, grants, gifts, supported family/children or done the math on what 4-10 years of deferred/reduced earnings will do to your overall ability to retire on an adequate nest egg?

I'm a non-trad, worked through my whole education, my adolescence was lived at poverty-level income, and am totally independent right now. I know what it will cost to extend my residency a year, approximately $100-150k. I understand all of that just fine. But, after 11-16 years of undergrad + med + residency (+ fellowship), an additional year isn't going to kill me financially or spiritually. In fact, I think it does the exact opposite. My quality of life throughout the entire 3-8 year residency + fellowship would be vastly increased, and that's priceless.

In addition, my suggestions to a drop in income reflective of our reduced hours (which I'd prefer not to see, but it would be a possibility under that hypothetical situation) was offset by my suggestion that loans be deferred until your formal training is over in terms of standard of living while in residency + fellowship.

Oh, and thanks for the info on resident unions!

 

[wild0ne]

Longer sign out makes sense but its not realistic given the volume some hospitals and services have.

Of course it's unrealistic under the current system, where a resident covers 60 patients. That's a straw man argument.

The question is: Is it unrealistic if your time is protected somehow? If you're given 1-2 hours to sign out, while another team handles emergent pages, would that not work? (If it's not another team, pick whatever solution you want. The point is, imagine a system where you can sign out for 1-2 hours). And please, don't tell me it's not financially feasible.

Frankly, the quality of the sign out is often a function of the quality of the resident and their attention to detail. /QUOTE]

The same can be said of patient care in general - it's a function of the quality of the resident and attention to detail (among many other factors). The whole point of systemic processes is to eliminate this variability.

Having a systematic, thorough sign out that is free from time constraints - would that not be at least a potential avenue to investigate? I don't see how having this would take away from your learning.

 

[Winged Scapula]

I'm not sure it has anything to do with being "financially feasible" but rather technically.

Now I am willing to hear a sample schedule but my first question is: who is this team who is answering emergency pages (let's imagine we live in a fantasy world where the nurses, other allied health professionals and outside calls from patients can differentiate between an emergency call and something that can wait)? If they are answering pages for 1-2 hours while you are signing out, when do they get to sign out? Its not fair to make them stay while you are signing out. That's what happened in the old days - you didn't go home until the Chief was out of the OR, you rounded and then signed out.

Another issue is that its not so much that it takes a long time to sign out a heavy census, but that people generally want to leave ASAP when their day is over. So it probably wouldn't matter if you had 60 patients or 6 - the sign out is going to be equally crappy because the resident knows that once they're done, they're out. 60 takes longer than 6 of course, but the end result is the same - you'll get a crappy sign out in many cases because the focus is on leaving the hospital, especially if you're post call.

So I'm not here to argue about it - if you have a solution which is technically feasible, I'd like to hear it but it would seem very difficult to do in small programs (ie, few residents) with a high census.

 

[wild0ne]

Likewise. I'm not arguing. I'm honestly asking. And, I respect your candid answers.

And, I completely agree that it would be technically difficult, but not exceedingly so. My point is that it can be done, and it's likely not being done because it would require staff, which requires money.

As for the fear of inadequate sign outs due to an urgency to get home ... I agree. Who wouldn't want to haul @ss after 30 hours. But, if you knew that same @ss would be held accountable for lapses in the transfer of information, you'd be less likely to sign out sloppily. And besides, if we're all professionals who know someone's life is on the line, especially when it comes to the transfer of essential information, I'm betting the majority of residents would act ethically.

I don't have the answers to the "How to make handoffs secure" question. My point is that the answer to that question is not: Eliminate them or reduce them because they are the source of errors. Change the way they are done instead.

 

[thedrjojo]

You can't dictate what comes in. Missing 25% of the time means missing 25% of the cases, whatever they are, not just the routine stuff. Which also means missing 25% of the things that you hopefully will get to see during residency because they don't come around that often, but are critical to recognize when they do. FWIW, the biggest complainers about the 80 hour work week limitation tended to be surgery residents (the ones whose hours were most impacted) precisely because they were not allowed to scrub into something truly interesting because they were inevitably hitting their hour limitation. You only get to do residency once, and you need to see and do all you can in what amounts to a fairly short, albeit intense, period of time. Very few people have any appetite for longer residency. Most have the notion that you push through it painfully and fast. I actually think you'd have more than a few takers who would be willing to shorten it by a year and increase hours, rather than the drawn out plan you are floating.

My thought to this is, has there been any studies showing any detrimental effect of the 80 hour week? Have they proved that residents aren't learning as much, getting enough experience/education, and becoming worse doctors? Have they shown that residents aren't as prepared to be doctors under the new system? Has board pass rates changed at all? Have we had any worse outcomes (that I am guessing is no since all have said no studies has shown an improvement)? Just like there are people claiming 80hours will reduce errors and it makes logical sense but the data doesn't produce it, there are people saying that decreasing hours waters down the resident experience, costs them cases etc which will hurt their training, and while that makes logical sense, does that necessarily have the data to back it up? And if it doesn't, then it boils down to a wash as far as those topics go, and it boils down to now residents aren't as much slave labor, have more time to be humans, and are doing just as good, and so it should stay. And then, the question goes to since we know they still can get the education/training with 80 hours a week, what will 60 hours do? It would be nice to instead of blanket changing the whole system, set up pilot programs and use some evidence based decisions like we all love in medicine, and unlike healthcare reform, this is something that pilot programs can be setup with to see effects of change (they could even do it within a single program: half a year, half the residents are 60h/w, then the other half of the year the remaining residents get 60h/w and can compare... do this at several programs, for a few years, and look at the results.)

 

[calvinNhobbes]

I have no problem with 80+ hour weeks, or 24+ hour shifts, as long as there is an educational reason for them. And if there is not, then I want to be paid for what my labor is worth.

You start paying residents for 40 hours plus 40 hours of overtime at the same rate as a nurse, PA, or NP and there will be a lot less complaining.

That's the difference between any other professional (business, law, etc.) and medical residents. It's not the hours, is the compensation for the work.

 

[Path or bust]

No study thus far has borne that errors are, in fact, reduced after the change

Well I don't know what the heck is happening when people say "studies do not show any patient benefit" with reduced work hours. As posted by another poster elsewhere, here are just a few:
Perhaps you've seen some papers that we haven't run across? Please post if so.

1) Impact of the 80-hour work week on mortality and morbidity in trauma
Morrison CA, Wyatt MM, Carrick MM.
J Surg Res. 2009 Jun 1;154(1):157-62. Epub 2008 Jul 9

2) Impact of duty hours restrictions on quality of care and clinical outcomes.
Bhavsar J, Montgomery D, Li J, Kline-Rogers E, Saab F, Motivala A, Froehlich JB, Parekh V, Del Valle J, Eagle KA.
Am J Med. 2007 Nov;120(11):968-74.

3) Changes in outcomes for internal medicine inpatients after work-hour regulations.
Horwitz LI, Kosiborod M, Lin Z, Krumholz HM.
Ann Intern Med. 2007 Jul 17;147(2):97-103. Epub 2007 Jun 4.

4) Mortality among hospitalized Medicare beneficiaries in the first 2 years following ACGME resident duty hour reform.
Volpp KG, Rosen AK, Rosenbaum PR, Romano PS, Even-Shoshan O, Wang Y, Bellini L, Behringer T, Silber JH.
JAMA. 2007 Sep 5;298(9):975-83.

(This one shows no difference - provided for different conclusions)

5) Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform.
Volpp KG, Rosen AK, Rosenbaum PR, Romano PS, Even-Shoshan O, Canamucio A, Bellini L, Behringer T, Silber JH.
JAMA. 2007 Sep 5;298(9):984-92.

6) The 80-hour resident workweek does not adversely affect patient outcomes or resident education.
de Virgilio C, Yaghoubian A, Lewis RJ, Stabile BE, Putnam BA.
Curr Surg. 2006 Nov-Dec;63(6):435-9; discussion 440.

7) Changes in hospital mortality associated with residency work-hour regulations.
Shetty KD, Bhattacharya J.
Ann Intern Med. 2007 Jul 17;147(2):73-80. Epub 2007 Jun 4.

 

[PostLessOne]

Law2Doc has spread this misinformation in every single thread he's been in. "There's no evidence" that going to 80 hours a week has helped".

Kinda looks like there's a lot of evidence that this was a good idea. Doesn't mean going to 60 will be, though. Personally I agree with the others here : if you were to work for 12 hours every day of the week, and then sleep for 8, working out and eating in the other 4, you'd feel pretty recharged every day you went to work. It would suck not ever getting a break, but you'd work 84 hours a week no problems.

But instead the schedules have crazy 30 hour shifts followed by a few hours off followed by another work day.

One logical thing to do would be to split the nights up. Have a schedule where each resident works 6 days a week for 12 hours a day. Some nights, the resident would either work 6 hours after the end of his or her shift or start 6 hours before. (dividing the night between residents so that no one has to work all night). On a night where the resident had to work til midnight, he or she would be allowed to skip morning rounds and come in at 8 or 9 am. Residents who had to start at midnight would be allowed to leave the hospital early at 3pm or so.

Only problem with my idea is that it puts the handoff at midnight...maybe not such a good idea. Then again, you'd be handing off to someone fresh, and it would be quiet then.

This schedule would minimize the length of shifts and yet allow for plenty of hours on the job. (a full 80 or 88 a week)

So, I am for them reducing the absolute maximum (exception for a mass casualty call) shift length to 24 hours, with 18-20 hours of patient contact being the limit. And they should boost the enforcement of the duty hour limits.

 

[ranmyaku]

Of course it's unrealistic under the current system, where a resident covers 60 patients. That's a straw man argument.

The question is: Is it unrealistic if your time is protected somehow? If you're given 1-2 hours to sign out, while another team handles emergent pages, would that not work? (If it's not another team, pick whatever solution you want. The point is, imagine a system where you can sign out for 1-2 hours). And please, don't tell me it's not financially feasible.

Frankly, the quality of the sign out is often a function of the quality of the resident and their attention to detail.

The same can be said of patient care in general - it's a function of the quality of the resident and attention to detail (among many other factors). The whole point of systemic processes is to eliminate this variability.

Having a systematic, thorough sign out that is free from time constraints - would that not be at least a potential avenue to investigate? I don't see how having this would take away from your learning.

lol, 1-2 hours for a sign out? wtf. Do you really need 2 hours to sign out?

I usually crosscover 45-50 patients. Takes 20-30 minutes max to get sign out.

 

[VA Hopeful Dr]

Law2Doc has spread this misinformation in every single thread he's been in. "There's no evidence" that going to 80 hours a week has helped".

Kinda looks like there's a lot of evidence that this was a good idea. Doesn't mean going to 60 will be, though. Personally I agree with the others here : if you were to work for 12 hours every day of the week, and then sleep for 8, working out and eating in the other 4, you'd feel pretty recharged every day you went to work. It would suck not ever getting a break, but you'd work 84 hours a week no problems.

Show us the evidence then, if you're so sure that there is lots of it.

 

[exPCM]

Anyone who posts that there are no adverse effects from 30 hour shifts is FOS.
It is obvious from numerous studies that fatigue adversely affects judgement and performance.
The military has done extensive studies on the effects of fatigue.
Military pilots in general are a physically fit group of individuals in which adverse effects from fatigue are well documented.
Does anyone really believe your typical couch potato resident physician handles fatigue and sleep deprivation so much better than a well trained military pilot?
http://www.dtic.mil/cgi-bin/GetTRDoc?Location=U2&doc=GetTRDoc.pdf&AD=ADA487169

 

[AD28]

if residents' work weeks were reduced to 60 hours, my gut tells me that there would be a lot of residents who would end up moonlighting more with the extra time, which would sort of negate much of the purported benefits anyway.

plus, i think the 80 hour work week is important to resident education. its important to learn how to focus and do your job no matter what.

 

[Substance]

if residents' work weeks were reduced to 60 hours, my gut tells me that there would be a lot of residents who would end up moonlighting more with the extra time, which would sort of negate much of the purported benefits anyway.

plus, i think the 80 hour work week is important to resident education. its important to learn how to focus and do your job no matter what.

The major difference is that moonlighting pays well, as opposed to the slave labor which is residency.

 

[dutchman]

1) 30 hours work without sleep is ABUSE.

2) Justifying any type of ABUSE by saying it is less ABUSIVE than before is ridiculous.

3) Trying to measure improvements in work performance between an era of lots of abuse and an era of less abuse, is like trying to measure the difference in behavior between women raped a lot and women raped a little. It is idiotic, because abuse is abuse, you either stop it or you dont.

4) Abusive elements almost always threaten their victims in one way or another. In this case residents are threatened with more years of training, and lack of job security. It often works.

5) This is a civil rights issue, and ACGME should not be the one to determine if human rights are protected. Contact aggressive pt advocacy groups, call up civil right journalists and activists, call up folks that care in congress.

Side note: Victims of abuse sometimes turn into perpetrators, hence the "I did it so you ought to do it" crew. More importantly, with a workforce trained on how to give and recieve abuse, are you surprised physicians are often not capable of standing up for themselves, even years out of training? This is why lawyers, insurance companies, mid-levels, etc. will always have an upper hand in any struggle against physicians.

 

[alittlestory]

Well then-- how do you all feel about the Jr. Docs in the UK
(i.e. residents/fellows) having a 48 hour work week?

Does that mean they are less competent to those who pursue training in the US? I think not. But I do think that they are happier residents.

 

[Looking4Info]

DUTMAN... AMEN! You are right on and we all need to come together to fight this and make change. 48h work weeks in the UK are making me drool! We do twice that and many would argue that the US has one of the worst health care systems.