Winged Scapula

Cougariffic!
Staff member
Administrator
Lifetime Donor
15+ Year Member
Apr 9, 2000
39,607
28,106
forums.studentdoctor.net
Status
Attending Physician
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.
Of course not, but they also do several years more training than we do in the US. And there is a general consensus that it takes them longer, as students and trainees, to reach parity with their US counterparts because of the reduced hours and lack of autonomy.

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.
Actually I don't know many who would argue that. Is it in disarray? Sure, but the quality and availability of medical care and training in the US is excellent, hence the draw for many foreign nationals to train here.

You may think 48 hrs per week sounds great but are you willing to put in all the extra years that they do in the UK? Most residents, when polled, are not.
 

Haole

10+ Year Member
Jun 6, 2008
94
0
Status
Resident [Any Field]
Should I feel bad I have no desire to work 120 even 80 hours a week for 4 years so I can practice in a system where midlevel providers with half the educational commitment in years (likely less than 60hrs/week) are being rewarded with independent practice rights? Why should I be so devoted to a system that wants to cut my future earning potential while raising the cost of my education, denying me education-related deferrments for my student loans, all while causing me to go into forbearance with interest accruing so fast I might as well be paying tuition... :barf:

I'm tired of the older generation talkin' crap about the "lazy generation of young doctors". They had it pretty good in their day. Higher level of respect in the community, lower educational costs, better pay, less paperwork!, lower malpractice, all expenses paid vacations by drug reps, lunches, all kinds of free crap...I can't even get a free pen anymore!! So what if I dont want to work 80 hours a week!? Why should I continue to work 30 hour shifts? For what? What is the incentive? The general public could care less about level of training as long as they get their healthcare cheap.
 

exPCM

Membership Revoked
Removed
10+ Year Member
Apr 12, 2006
919
6
California
Status
Attending Physician
Should I feel bad I have no desire to work 120 even 80 hours a week for 4 years so I can practice in a system where midlevel providers with half the educational commitment in years (likely less than 60hrs/week) are being rewarded with independent practice rights? Why should I be so devoted to a system that wants to cut my future earning potential while raising the cost of my education, denying me education-related deferrments for my student loans, all while causing me to go into forbearance with interest accruing so fast I might as well be paying tuition... :barf:

I'm tired of the older generation talkin' crap about the "lazy generation of young doctors". They had it pretty good in their day. Higher level of respect in the community, lower educational costs, better pay, less paperwork!, lower malpractice, all expenses paid vacations by drug reps, lunches, all kinds of free crap...I can't even get a free pen anymore!! So what if I dont want to work 80 hours a week!? Why should I continue to work 30 hour shifts? For what? What is the incentive? The general public could care less about level of training as long as they get their healthcare cheap.
Good points. I am glad to see a resident such as yourself that is able to see the big picture and won't just blindly drink the koolaid that many oldtimer attendings try to feed residents and med students.
 

Substance

10+ Year Member
5+ Year Member
Jul 27, 2007
1,224
190
Status
Attending Physician
Should I feel bad I have no desire to work 120 even 80 hours a week for 4 years so I can practice in a system where midlevel providers with half the educational commitment in years (likely less than 60hrs/week) are being rewarded with independent practice rights? Why should I be so devoted to a system that wants to cut my future earning potential while raising the cost of my education, denying me education-related deferrments for my student loans, all while causing me to go into forbearance with interest accruing so fast I might as well be paying tuition... :barf:

I'm tired of the older generation talkin' crap about the "lazy generation of young doctors". They had it pretty good in their day. Higher level of respect in the community, lower educational costs, better pay, less paperwork!, lower malpractice, all expenses paid vacations by drug reps, lunches, all kinds of free crap...I can't even get a free pen anymore!! So what if I dont want to work 80 hours a week!? Why should I continue to work 30 hour shifts? For what? What is the incentive? The general public could care less about level of training as long as they get their healthcare cheap.
Amen.
 

J ROD

Watch my TAN walk!!
Lifetime Donor
10+ Year Member
Aug 1, 2005
58,243
1,987
working on my tan......
Status
Resident [Any Field]
Should I feel bad I have no desire to work 120 even 80 hours a week for 4 years so I can practice in a system where midlevel providers with half the educational commitment in years (likely less than 60hrs/week) are being rewarded with independent practice rights? Why should I be so devoted to a system that wants to cut my future earning potential while raising the cost of my education, denying me education-related deferrments for my student loans, all while causing me to go into forbearance with interest accruing so fast I might as well be paying tuition... :barf:

I'm tired of the older generation talkin' crap about the "lazy generation of young doctors". They had it pretty good in their day. Higher level of respect in the community, lower educational costs, better pay, less paperwork!, lower malpractice, all expenses paid vacations by drug reps, lunches, all kinds of free crap...I can't even get a free pen anymore!! So what if I dont want to work 80 hours a week!? Why should I continue to work 30 hour shifts? For what? What is the incentive? The general public could care less about level of training as long as they get their healthcare cheap.
Sticky this!!

100% agree.....:thumbup::thumbup:
 

Raggaman

Member
10+ Year Member
Jul 19, 2004
163
1
Status
Attending Physician
Should I feel bad I have no desire to work 120 even 80 hours a week for 4 years so I can practice in a system where midlevel providers with half the educational commitment in years (likely less than 60hrs/week) are being rewarded with independent practice rights? Why should I be so devoted to a system that wants to cut my future earning potential while raising the cost of my education, denying me education-related deferrments for my student loans, all while causing me to go into forbearance with interest accruing so fast I might as well be paying tuition... :barf:

I'm tired of the older generation talkin' crap about the "lazy generation of young doctors". They had it pretty good in their day. Higher level of respect in the community, lower educational costs, better pay, less paperwork!, lower malpractice, all expenses paid vacations by drug reps, lunches, all kinds of free crap...I can't even get a free pen anymore!! So what if I dont want to work 80 hours a week!? Why should I continue to work 30 hour shifts? For what? What is the incentive? The general public could care less about level of training as long as they get their healthcare cheap.
Amen to the power N
 
Aug 19, 2009
186
1
Status
Suddenly I realized something. What difference does it make? None of us can do anything about it if things are changed. Only high level academic attendings with a prestigious position on one of these boards can make any changes. None of us in the training pipeline have the slightest say.

Ultimately, we just have to hope it works out. We all picked this route because it seemed like a good bet : worthwhile work with historically excellent pay. Fundamentally, the more educated a person is, generally the better their job prospects. This holds true for nearly all free market jobs in the United States. Thus medicine seemed like a good bet. For all of us in the training pipeline, we've given up too much to turn back.
 

Johnjonny21

10+ Year Member
5+ Year Member
Mar 21, 2009
19
0
Status
when is this meeting supposed to be regarding duty hours changes? will the decision be made right at this meeting or sometime afterward.
 

Law2Doc

5K+ Member
Moderator Emeritus
10+ Year Member
Dec 20, 2004
30,981
9,891
Status
Attending Physician
Good points. I am glad to see a resident such as yourself that is able to see the big picture and won't just blindly drink the koolaid that many oldtimer attendings try to feed residents and med students.
I'm not so sure that it's about blindly drinking the koolaid. Did you read the Post article at the top of this thread and actually find it bogus, or an old-timer conspiracy against the newbies? I think we all like the improved lifestyle duty hour restrictions bring, but I think most of us can see the attitude changes and hit to our training that it brought, and that was just to the 80 hour limit. Going to something lower would compound things. Honestly, I can see getting rid of the 30 hour shifts, and wider use of nightfloat as valuable changes to the system, but otherwise I don't know that I would talk about reducing total hours further unless you were also talking about some commensurate extension of residency years (which I am not desirous for). Heck, I'd personally rather shorten things up a year and push the hourly limits above 90.
 

drfunktacular

ANA ≠ SLE
10+ Year Member
Oct 5, 2004
555
176
Status
Attending Physician
Quote from an editorial in this week's NEJM by an expert on the history of medical education (highly worth the read):

Since the Libby Zion case in 1984, the medical profession and the public have been preoccupied with the subject of residents' work hours. However, this narrow focus on work hours has diverted attention from a more fundamental development affecting the quality of the residency experience: the changes in the learning environment resulting from the introduction of prospective payment to hospitals. With prospective payment, which also began in 1984, the average severity of illness of hospitalized patients increased, the number of patients house officers admitted per admitting night skyrocketed, and the average length of hospital stay fell precipitously. For house officers in all fields, this meant busier days and nights, less time to read and sleep, and greater stress, tension, and fatigue.1 The long-overdue regulations implemented in 2003 limiting resident duty hours have had the unintended consequence of worsening this situation. House officers now spend fewer hours in the hospital but their workload has not decreased, resulting in an even more frenetic pace of work — a phenomenon known as work compression. In this environment, education often seems marginalized.
Ludmerer KM. "Redesigning Residency Education — Moving beyond Work Hours." NEJM 2010;362:1337-8.
 

Law2Doc

5K+ Member
Moderator Emeritus
10+ Year Member
Dec 20, 2004
30,981
9,891
Status
Attending Physician
Quote from an editorial in this week's NEJM by an expert on the history of medical education (highly worth the read):

QUOTE]

Agree with this. Although a prior poster is going to say this is just more koolaid. :smuggrin:
 

aProgDirector

Pastafarians Unite!
Moderator
10+ Year Member
Oct 11, 2006
8,284
7,171
Status
Attending Physician
Quote from an editorial in this week's NEJM by an expert on the history of medical education (highly worth the read):

Ludmerer KM. "Redesigning Residency Education — Moving beyond Work Hours." NEJM 2010;362:1337-8.
Note that the editorial was commenting on a study in the NEJM looking at a new teaching service at the Faulkner. They created a teaching service with an average of 3.5 patients per intern. The result was happier interns who self reported that they learned more.

The question is whether taking care of 3.5 patients is "enough". A long standing tenet in residency is that you can't learn it without doing it, and that volume is key. There is no question that this is the case for procedural fields. I worry that 3.5 patients is not much more than we expect of our Sub-I's.
 

drfunktacular

ANA ≠ SLE
10+ Year Member
Oct 5, 2004
555
176
Status
Attending Physician
Note that the editorial was commenting on a study in the NEJM looking at a new teaching service at the Faulkner. They created a teaching service with an average of 3.5 patients per intern. The result was happier interns who self reported that they learned more.

The question is whether taking care of 3.5 patients is "enough". A long standing tenet in residency is that you can't learn it without doing it, and that volume is key. There is no question that this is the case for procedural fields. I worry that 3.5 patients is not much more than we expect of our Sub-I's.
My experience is that sub-Is often have more time to read about their patients and often catch small details, inconsequential or otherwise, that we as interns frequently miss when we have 8 or 10 patients to tuck in. I think they learn more per patient, as well.

With regard to 3.5 patients not being "enough" for a trainee, I do agree that more patients means more exposure. However, in my experience the argument justifying heavy patient loads more often involves appeal to the number of patients you'll have to deal with "in the real world." I've worked with general internists who see 40 patients a day in clinic, and hospitalists who round on 20 patients per day. This is simply too many. If we are training tomorrow's doctors to work under these kinds of loads, we are training them to perpetuate the medical errors and discontinuities of care that we already see today.

The biggest problem I see with the experimental inpatient service model they created at BWH was with the need to keep up with the hospital's patient volume. At my program, the teaching hospitals are utterly dependent on the residents to keep up the throughput, and our teams already are often capped 2 or 3 call shifts in advance (i.e., admitting tonight to tomorrow's night team), and the resources aren't available to hire enough non-teaching hospitalists to keep up with the load.
 

Integrity

Removed
Apr 6, 2010
72
0
Status
Resident [Any Field]
One of the major complaints being voiced is that the hours of clinical training will no longer be sufficient.
What is it about the US training that requires so many more hours than what is required of European doctors? What is it that requires you to have the status as a resident, in order to treat all types of patients? I call BS. :thumbdown:
 

Integrity

Removed
Apr 6, 2010
72
0
Status
Resident [Any Field]
Note that the editorial was commenting on a study in the NEJM looking at a new teaching service at the Faulkner. They created a teaching service with an average of 3.5 patients per intern. The result was happier interns who self reported that they learned more.

The question is whether taking care of 3.5 patients is "enough". A long standing tenet in residency is that you can't learn it without doing it, and that volume is key. There is no question that this is the case for procedural fields. I worry that 3.5 patients is not much more than we expect of our Sub-I's.
What is the problem?

If every resident only took half as many patients, double the interns. Allow hospitals to create their own models, like e.g paying residents according to how many patients they are able to supervise. Starting at 3-4, they could soon be moving upwards.

Let doctors have a free ticket to practice in whatever area they feel like, straight after med school, and let them prove their prowess by documenting work experience that can be gained by jumping from hospital to hospital, pgy1, pgy2, etc.

The safety insurance is the high risk of lawsuits by hiring docs who can't show work experience. This means that young doctors gain the advantage of having hospitals sell them educational positions, without being the hospitals slave dog for the entire residency period, risking a complete lock out from the profession if you don't get your tongue brown.

The good thing for patients is that hospitals need to think of how they can educate residents, in order to get residents. Residents don't galore in the US, the number of docs per capita is lower in the US than in any european country. Med graduates go from zero to hero, like whoooooooosh!!
 

Law2Doc

5K+ Member
Moderator Emeritus
10+ Year Member
Dec 20, 2004
30,981
9,891
Status
Attending Physician
What is the problem?

If every resident only took half as many patients, double the interns.
With what money? The problem is that each intern is only affordably trained by the hospital because the government gives the hospital about $100k per funded slot to train them. That plus whatever benefit the intern provides to the hospital sweetens the deal enough for it to be worth it for the hospital to (1) front the liability insurance, (2) pay the intern, (3) train them, and (4) other benefits. Most of the work the typical resident does doesn't translate into something the hospital can bill a patient for, notwithstanding that it's administratively necessary. Admission notes, progress notes, discharge summaries, dictations, daily rounding, daily lectures, M&M, Grand rounds, sign-outs -- these are all integral to a resident's daily life and yet very little of this gets billed to the patient. So it's not like it's financially feasible to just hire more interns. On a national level, if the taxpayers wanted to fund more interns, that would be different, but that's a hard political sell if it's for training purposes more than for something like better access to care.
 

Law2Doc

5K+ Member
Moderator Emeritus
10+ Year Member
Dec 20, 2004
30,981
9,891
Status
Attending Physician
What is it about the US training that requires so many more hours than what is required of European doctors? What is it that requires you to have the status as a resident, in order to treat all types of patients? I call BS. :thumbdown:
It's driven by the liability risk here that doesn't exist in Europe. Mostly it's a longer training period because it's a lot less forgiving here if you screw up. But as a result, the folks who emerge from residency training programs here are among the best trained in the world, simply because they log so many more hours at it before they emerge as attendings. To the extent its accurate that you need 10,000 hours at something to have some expertise in it (per a recent Gladstone book), the US system makes residents hit that mark. Most of the European trained doctors I've met who've transitioned to the US post-residency usually candidly remark that they feel their US counterparts were significantly advantaged by having been trained so many more hours. It's hard to argue, for things like training, more is better. The only think you might argue is that perhaps less is sufficient. But in a litigious society, less generally puts you below the "reasonable expectation" level.
 

Integrity

Removed
Apr 6, 2010
72
0
Status
Resident [Any Field]
With what money? The problem is that each intern is only affordably trained by the hospital because the government gives the hospital about $100k per funded slot to train them. That plus whatever benefit the intern provides to the hospital sweetens the deal enough for it to be worth it for the hospital to (1) front the liability insurance, (2) pay the intern, (3) train them, and (4) other benefits. Most of the work the typical resident does doesn't translate into something the hospital can bill a patient for, notwithstanding that it's administratively necessary. Admission notes, progress notes, discharge summaries, dictations, daily rounding, daily lectures, M&M, Grand rounds, sign-outs -- these are all integral to a resident's daily life and yet very little of this gets billed to the patient. So it's not like it's financially feasible to just hire more interns. On a national level, if the taxpayers wanted to fund more interns, that would be different, but that's a hard political sell if it's for training purposes more than for something like better access to care.
Funny, in Germany, new "residents" do all the stuff you describe, all the administrative tasks, yet the hospitals receive 0 funding from the government. "Residents" are trained in their speciality as a part of the deal, working and learning. Give and take. Training vs working is an area of negotiation there as well, given that you need to complete a certain amount of e.g surgical operations to finish speciality training.

All the "problems" you mention seems to be artificially constructed due to the privileged position hospitals have in the US.

Like stated (by someone else): Cartels.
 

daru1

10+ Year Member
Nov 15, 2006
256
57
Status
Attending Physician
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.
#1 Are you a resident? Have you had to work 80 hrs a week? Have you been on a 30 hour shift?

#2 Moonlighting hours count towards duty hours.

If you're going to make statements like this, do a little research first please.
 

dilated

Fought Law; Law Won
10+ Year Member
Nov 4, 2004
1,023
11
NC
Status
The problem is that each intern is only affordably trained by the hospital because the government gives the hospital about $100k per funded slot to train them. Most of the work the typical resident does doesn't translate into something the hospital can bill a patient for, notwithstanding that it's administratively necessary. Admission notes, progress notes, discharge summaries, dictations, daily rounding, daily lectures, M&M, Grand rounds, sign-outs
One wonders how hospitals without residents make these things happen. Ah yes, they hire midlevels, for substantially more money, half the hours, and no Medicare GME funding. And yet somehow it STILL makes financial sense for them to do that.

Seriously, how can you even say that with a straight face? It's not particularly subtle as to what GME payments really are: a money transfer to safety-net academic hospitals that treat large numbers of uninsured patients so they stay afloat.
 

aProgDirector

Pastafarians Unite!
Moderator
10+ Year Member
Oct 11, 2006
8,284
7,171
Status
Attending Physician
What is the problem?
I'm always looking for creative solutions

If every resident only took half as many patients, double the interns. Allow hospitals to create their own models, like e.g paying residents according to how many patients they are able to supervise. Starting at 3-4, they could soon be moving upwards.
Twice as many interns can be a problem for programs. You need primary care clinics, electives, plus core requirements (like neuro and geriatrics in IM). IN addition, it's much more expensive to hire 2 people to do 1/2 a job -- benefits, vacations, etc.

Paying interns for census is an interesting idea. It would need to be under the program's control -- else interns would simply try to increase their census to get paid more whether or not they could handle it. I have considered trying to pay interns/residents per discharge summary, or per admission, in order to 1) incent shorter LOS's and 2) compensate residents with "black clouds"

Let doctors have a free ticket to practice in whatever area they feel like, straight after med school, and let them prove their prowess by documenting work experience that can be gained by jumping from hospital to hospital, pgy1, pgy2, etc.
This is similar to the old UK system, where residents did "attachments" for 6-12 months per stint, rather than a true residency. (The UK has now changed to a 2 year foundation system). This would give residents more flexibility and portability. However, the attachments in the UK system were often very specialized (working on a "liver unit" for 6 months) and may not give residents a well rounded education. Also, this type of system would definitely allow someone with "problems" to filter through -- doing 3-6 months at a time, moving from program to program.

Another problem would be that programs could get rid of residents easily. I could easily drop the bottom 1/2 of any group, since I wouldn't be required to keep anyone for full training.

There would also be limited quality control in such a system. If a resident did an attachment for 2-3 years with a primary care doc, how would you really know that they have learned IM? And this would change the way we license docs, as if you spent 2-3 years doing only outpatient medicine you might not be qualified to do inpt medicine. Currently, we have a "you must be trained to do it all" type of system. No reason this can't change.

You'd also need to have some way to decide when someone was "ready" to practice alone.

The safety insurance is the high risk of lawsuits by hiring docs who can't show work experience. This means that young doctors gain the advantage of having hospitals sell them educational positions, without being the hospitals slave dog for the entire residency period, risking a complete lock out from the profession if you don't get your tongue brown.
Are you suggesting that residents would pay, rather than be paid, for educational experiences?

The good thing for patients is that hospitals need to think of how they can educate residents, in order to get residents. Residents don't galore in the US, the number of docs per capita is lower in the US than in any european country. Med graduates go from zero to hero, like whoooooooosh!!
I think you're suggesting that if anyone was able to train a resident, there would be many, many more potential residency spots than actual residents. Hence, only programs that offer a quality program would be able to retain residents. Again, we'd have to be willing to give up the broad training currently mandated in IM.

One wonders how hospitals without residents make these things happen. Ah yes, they hire midlevels, for substantially more money, half the hours, and no Medicare GME funding. And yet somehow it STILL makes financial sense for them to do that.

Seriously, how can you even say that with a straight face? It's not particularly subtle as to what GME payments really are: a money transfer to safety-net academic hospitals that treat large numbers of uninsured patients so they stay afloat.
I agree. If the feds never started funding GME spots, I bet we'd have a similar arrangement to what we have now. Hospitals have become dependent on federal GME dollars because it exists.

Hospitals without residents make things happen by doing business differently. Not so long ago, there were no mid levels, and physicians basically didn't work at night. Nurses would care for patients without physician coverage, except by phone. "Increase the dopamine to 4" would be a common telephone order -- no exam, no evaluation, except by the nurse. Admissions from the ED get orders written by the ED physician, not seen by IM until the next AM. Nurses don't call silly things to faculty at night. It could be done, whether it's better or not is unclear.
 

Integrity

Removed
Apr 6, 2010
72
0
Status
Resident [Any Field]
Twice as many interns can be a problem for programs.
Then hire just the same amount, and let them do the double work, if you find residents willing, and capable of doing work at your place, if the residency requirements were lifted, and my suggestion introduced.

You need primary care clinics, electives, plus core requirements (like neuro and geriatrics in IM).
No, you don't. In Germany, you can become a specialist in IM without doing any neurological training. You have your clinical year after 5 years of med school, and off you go!

IN addition, it's much more expensive to hire 2 people to do 1/2 a job -- benefits, vacations, etc.
Yeah, but that will be your problem as a program director, if the traditional system giving you the upper hand is removed.

Paying interns for census is an interesting idea. It would need to be under the program's control -- else interns would simply try to increase their census to get paid more whether or not they could handle it.

I have considered trying to pay interns/residents per discharge summary, or per admission, in order to 1) incent shorter LOS's and 2) compensate residents with "black clouds"
This is an area with mutual benefits, pretty much regardless of system change. If I could trade fear of not meeting my program directors requirements in for reduced wages/ higher security feeling for less wages, I'd do it, it is just a question of amount.

However, the attachments in the UK system were often very specialized (working on a "liver unit" for 6 months) and may not give residents a well rounded education. Also, this type of system would definitely allow someone with "problems" to filter through -- doing 3-6 months at a time, moving from program to program.
Working at a liver unit makes you good at liver, and that is what you would sell. If you dumped me, then I would find a program elsewhere, and sell my liver knowledge. If I wouldn't find a program, I'd become a GP (family doc).

There would also be limited quality control in such a system.
In a free system, you trade the lower end quality control, for more availability and affordability of care. Besides, this is not a downside for physicians.

You'd also need to have some way to decide when someone was "ready" to practice alone.
Yep. After med school. I'd pick a gp who had his years of experience on his homepage.

Again, we'd have to be willing to give up the broad training currently mandated in IM.
Yep, everything moves towards specialization. Both in direction of field separation, and many-levels-of-education separation. It is more efficient, and gives more care per $$$.
 

aProgDirector

Pastafarians Unite!
Moderator
10+ Year Member
Oct 11, 2006
8,284
7,171
Status
Attending Physician
In a free system, you trade the lower end quality control, for more availability and affordability of care. Besides, this is not a downside for physicians.
Here's where we disagree. I think it's a huge downside. I can't support this.
 

Arcan57

Junior Member
15+ Year Member
Nov 21, 2003
2,860
1,301
Visit site
Status
Attending Physician
My experience is that sub-Is often have more time to read about their patients and often catch small details, inconsequential or otherwise, that we as interns frequently miss when we have 8 or 10 patients to tuck in. I think they learn more per patient, as well.

With regard to 3.5 patients not being "enough" for a trainee, I do agree that more patients means more exposure. However, in my experience the argument justifying heavy patient loads more often involves appeal to the number of patients you'll have to deal with "in the real world." I've worked with general internists who see 40 patients a day in clinic, and hospitalists who round on 20 patients per day. This is simply too many. If we are training tomorrow's doctors to work under these kinds of loads, we are training them to perpetuate the medical errors and discontinuities of care that we already see today.

Hospitalists that round on 20 pts/day? Given a 10 hr day, that's 30 minutes per patient. Even in an ICU setting, that would be an unusually long mean time/pt as an attending. Our hospitalists (without midlevel support) are probably averaging a census of 30-40/day. The problem becomes that there is no cap on the number of patients that can get sick on any given day. So as an attending you're either going to get killed occasionally, or you're going to be paying someone (possibly multiple someones) to take jeopardy call when you "cap". Most attendings freely elect not to select the second option.
 

Law2Doc

5K+ Member
Moderator Emeritus
10+ Year Member
Dec 20, 2004
30,981
9,891
Status
Attending Physician
Funny, in Germany, new "residents" do all the stuff you describe, all the administrative tasks, yet the hospitals receive 0 funding from the government. "Residents" are trained in their speciality as a part of the deal, working and learning. Give and take. Training vs working is an area of negotiation there as well, given that you need to complete a certain amount of e.g surgical operations to finish speciality training.

All the "problems" you mention seems to be artificially constructed due to the privileged position hospitals have in the US.

Like stated (by someone else): Cartels.
Not cartels, medmal. The reason this works in Germany and not here is because when a resident screws up there, nobody hits the hospital with a multi-million dollar (or euro) lawsuit. Residents are a huge financial risk here, far more than midlevels.

There's a reason most of the existing but unfunded slots don't get internally funded and filled -- it's simply not financially profitable to the hospital without getting that six digit government payout. If it were as lucrative as some of you guys suggest, there would be no such thing as an unfilled, unfunded spot. And yet there are.
 

Johnjonny21

10+ Year Member
5+ Year Member
Mar 21, 2009
19
0
Status
bump.
isnt the ACGME at the end of april. that should be this week or next. Does anyone know the exact day? I am interested in how it will turn out
 

Guyton

Internist Psychiatrist
10+ Year Member
7+ Year Member
Dec 11, 2006
101
98
Virginia
medicine.vtc.vt.edu
Status
Attending Physician
Folks, we are physicians. Hard as administration, lawyers, and the government would like to try and pigeonhole our profession in with the shift workers, it is not what the practice of medicine is about. I hope that we all knew going into this that 60-100 hour work weeks were our lot, at least during residency. A physician in training lives in the hospital. That is why it is called residency and not "on the job training."

None of us were drafted that I am aware of, and anyone can walk away and get a nice cush job pushing paper with the nine to fivers. Work hour restrictions defy the entire purpose of a residency- preparing a physician for successful transition into the profession. If an internist or surgeon comes out of a residency program with scheduled nap/thumb sucking time, capped 60 hour week, and five weeks leave a year they will get a harsh reality check when they go out into the adult world.
 

Parietal Lobe

Junior Member
10+ Year Member
5+ Year Member
Apr 16, 2006
161
2
Status
Just curious about something. I don't understand the Foundations system linked above. In the UK, how many years in training would someone going into surgery have to complete? What about something like derm?
 

Winged Scapula

Cougariffic!
Staff member
Administrator
Lifetime Donor
15+ Year Member
Apr 9, 2000
39,607
28,106
forums.studentdoctor.net
Status
Attending Physician
Just curious about something. I don't understand the Foundations system linked above. In the UK, how many years in training would someone going into surgery have to complete? What about something like derm?
I don't know about Derm but for Surgery in the UK:

Foundation Training: 2 years

Core Surgical Training: 2 years (during this time you apply for the Specialty training)

Specialty Surgical Training: about 6 years (will vary, depending on field and trainee's progression)

Additional Consultant/Fellowship training:1 or more years
 

45408

aw buddy
10+ Year Member
7+ Year Member
Jun 14, 2004
16,976
47
Status
Resident [Any Field]
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.
Word. I think it was beyond ridiculous to have people work 100-120 hours per week. I read one blog post by a former neurosurgery resident who did Q2 call and didn't go home until 10pm on his post-call day. Great. 41 hours on, 7 hours off. Makes perfect sense.

Exactly.

I'm sure that figuring how to get Mr. Jones discharged to a SNF is really contributing to your knowledge about Prader-Willi. :rolleyes:
Hahahaha, brilliant. There are so many systems errors in health care that it just boggles the mind. I watched a great YouTube video called "If the airline industry were like health care," and it was really eye-opening as to how mismanaged all the different aspects of health care really are. Having a resident trying to find a SNF for some complicated patient with all sorts of social issues is a total misallocation of resources. Sure, it might be good for that patient's care, but it's bad for just about everything else.
 

MJB

Senior Member
Moderator Emeritus
10+ Year Member
Apr 12, 2005
2,848
24
Status
Attending Physician
Should I feel bad I have no desire to work 120 even 80 hours a week for 4 years so I can practice in a system where midlevel providers with half the educational commitment in years (likely less than 60hrs/week) are being rewarded with independent practice rights? Why should I be so devoted to a system that wants to cut my future earning potential while raising the cost of my education, denying me education-related deferrments for my student loans, all while causing me to go into forbearance with interest accruing so fast I might as well be paying tuition... :barf:

I'm tired of the older generation talkin' crap about the "lazy generation of young doctors". They had it pretty good in their day. Higher level of respect in the community, lower educational costs, better pay, less paperwork!, lower malpractice, all expenses paid vacations by drug reps, lunches, all kinds of free crap...I can't even get a free pen anymore!! So what if I dont want to work 80 hours a week!? Why should I continue to work 30 hour shifts? For what? What is the incentive? The general public could care less about level of training as long as they get their healthcare cheap.
Hoo-Rah..

Very well said.

My 400K in debt coming out of residency is gonna be awesome...

Many of the older docs I hear complain were able to pay out of pocket for med school in the "good ole days".
 

RustedFox

Go to the ER now, or you'll have a stroke.
Lifetime Donor
10+ Year Member
Aug 21, 2007
4,222
3,852
On a box.
Status
Attending Physician
Folks, we are physicians. Hard as administration, lawyers, and the government would like to try and pigeonhole our profession in with the shift workers, it is not what the practice of medicine is about. I hope that we all knew going into this that 60-100 hour work weeks were our lot, at least during residency. A physician in training lives in the hospital. That is why it is called residency and not "on the job training."

None of us were drafted that I am aware of, and anyone can walk away and get a nice cush job pushing paper with the nine to fivers. Work hour restrictions defy the entire purpose of a residency- preparing a physician for successful transition into the profession. If an internist or surgeon comes out of a residency program with scheduled nap/thumb sucking time, capped 60 hour week, and five weeks leave a year they will get a harsh reality check when they go out into the adult world.
- While I agree that hours spent in TRAINING are critically important, one has to look at the PRACTICE of it and not the PRINCIPLE of the matter. I'm a resident right now, and in some (a lot) of my off-service rotations, my day is largely "do this irrelevant task" and "hurry up and wait" sandwiched between "being shouted at by jerk attending"... which adds up to a whole lot of WASTED TIME.

This dovetails nicely into my next point... why is Jerk Attending always so unhappy? Could it be because he/she is so terribly overworked to the point where they can't enjoy life outside of the hospital? Most likely.

... Thus, the system of abuse gets perpetuated. Residents who are miserable grow up to be attendings that are twice as miserable, and whose only relief comes in the form of making the next batch of residents miserable.

Bottom line: there's so much more to life than just the hospital. Since there are only so many hours in a day/week, if you spend 60+ hours at the hospital, that's a whole hell of a lot less time you can spend living a healthy lifestyle, or actively enjoying your life. If anyone can HONESTLY say that they LOVE every second that they spend in the hospital, then I truly feel bad for them for missing out on the rest of life.

Keep this in mind next time you're sitting through a "stress management" or "substance abuse" lecture that highlights the scary rates of abuse/suicide/other unhealthy habits amongst physicians. Maybe we wouldn't spend so much time Monday-morning quarterbacking and wondering why Dr. Johnny drank himself to the gun-in-mouth blues if we would not just "promote" a healthy lifestyle, but actually alot the time to live one.
 
Apr 27, 2010
1
0
Status
Resident [Any Field]
While I could see a 60 hour limit for medicine specialties, it simply doesn't make sense for surgical residency. Typically we manage more patients than medicine residents, all while operating, performing procedures, and running our clinics. I don't think it is possible to get adequate surgical training in 60 hours a week.

Should we switch in and out of Surgery like the Anesthesiologists taking their coffee and crossword puzzle breaks?
 

thedrjojo

10+ Year Member
Jun 20, 2008
23,959
16,324
Status
Attending Physician
While I could see a 60 hour limit for medicine specialties, it simply doesn't make sense for surgical residency. Typically we manage more patients than medicine residents, all while operating, performing procedures, and running our clinics. I don't think it is possible to get adequate surgical training in 60 hours a week.

Should we switch in and out of Surgery like the Anesthesiologists taking their coffee and crossword puzzle breaks?
Maybe... would lead to less fatigue and better outcomes likely... the pride in surgery would never allow this (although I have seen residents switch out mid case before)...

This is also being addressed with streamlining/tracking of residents. The arguments have been made pro and con, but if I am going into vascular surgery, why not only train in vascular surgery and not worry about breast, oncology, transplant, etc (which they are actually doing now with vascular residencies). They have CT surgery residencies now too... pretty soon the only people going into general surgery are going to be General Surgeons (or as they now are being called, Acute Care Surgeons or Laparoscopic Surgeons), Trauma, Transplant, or Oncology... or adopt an approach where you have 3 year GS residency but no certification afterwards (or a limited certification) and then you pick a track after those 3 years to focus your senior/chief years on your specialty of choice (like all IM subspecialties)...
 

FutureInternist

10+ Year Member
Aug 23, 2007
1,390
405
Where Bugs Bunny should have made a left turn
Status
Attending Physician
While there has to be some minimum number of hours spent learning the trade, I wonder whether the combined specialty people are any worse than the single specialty....from my understanding Med/Peds is 4 yrs with alternating 6 months b/w kids & adults (i.e. 2 yrs per specialty) while each of IM and Peds is 3 years....so are these guys really losing anything by skipping out on 2 years of residency.
I can see it making some sense in procedure based specialties since practice makes perfect, but for stuff like IM/Peds etc, I don't think it matters.