80/24 Rule really enforced?

[pillowhead]

Except in NY.

Ed

I forgot--except New York. (Of course to many New Yorkers, there are no other states worth being in anyway I say this having married into a family of New Yorkers.)

---

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[Annette]

I'd say better to stand up now and let him know that you won't be treated like a bitch then to just put up with it because you are afraid of being harrassed.

Panda Bear, I'm right with you on protection of my sleep time! However, as other posters have pointed out, you WILL be thrown out on your a$$, 200K in debt, and not able to get a job at Walmart if you piss your PD off too much. Trust me, I've done it. By the grace of God, they decided to let me finish, since I had about 7 months to go. I also had evidence that would make a malpractice lawyer salivate. Meanwhile, they have put me through hell.

If your program is not follwoing the RRC rules, transfer out while you can(before your second year.) If it is an outside rotation, and you ABSOLUTELY KNOW your PD will back you up, tell him/her. If you don't want to be confrontational about it, or don't know how the PD will respond, just give the residency office a log of your hours. Keep a copy. You may even consider getting a signature on a copy of your log. This way, the PD can't come back and say that you are in trouble for not notifying him (which has happened.)

As for creative time keeping, on the log system my program uses, you have to document call time and post call time in different segments so it never looks as though you have worked over 24 hours. And, continuity clinic can consist of patients that no one in the clinic has ever seen, but were refered from the emergency department. Gotta love it!

 

[3dtp]

Panda Bear, I'm right with you on protection of my sleep time! However, as other posters have pointed out, you WILL be thrown out on your a$$, 200K in debt, and not able to get a job at Walmart if you piss your PD off too much. Trust me, I've done it. By the grace of God, they decided to let me finish, since I had about 7 months to go. I also had evidence that would make a malpractice lawyer salivate. Meanwhile, they have put me through hell.

If your program is not follwoing the RRC rules, transfer out while you can(before your second year.) If it is an outside rotation, and you ABSOLUTELY KNOW your PD will back you up, tell him/her. If you don't want to be confrontational about it, or don't know how the PD will respond, just give the residency office a log of your hours. Keep a copy. You may even consider getting a signature on a copy of your log. This way, the PD can't come back and say that you are in trouble for not notifying him (which has happened.)

As for creative time keeping, on the log system my program uses, you have to document call time and post call time in different segments so it never looks as though you have worked over 24 hours. And, continuity clinic can consist of patients that no one in the clinic has ever seen, but were refered from the emergency department. Gotta love it!

People, PLEASE pay attention to what Annette has said here! I cannot emphasize this enough! The program directors hold all the cards, they can pretty much fire you at will with little hope for legal redress in most, if not all states.

The US Supreme Court has just ruled (White v. Burlington and Santa Fe Railway) that whistleblowers are protected to a much greater extent than ever before in history, but many states do not allow physicians at any level to sue hospitals who fire them for any and whatever reason. Realize that program directors will blackball you with other program directors and what Annette has said will come true, then you are VSF.

Pandabear, I agree with you and in a normal profession and normal field, in the United States of America, this would not be tolerated. However, hospitals have so manipulated and rigged the system that residents have ZERO protections from malignant programs. If a program director decides that he doesn't like you, your race, your weight or the color of your armpit hair, they can and do fire you and when the lawyers come asking questions, the paper trail will say you are "disruptive" or "unprofessional" or "negligent" or any other thing they can come up with that has no clear meaning and hence cannot be readily proven nor disproven. Documents have been made up, memoranda falsified, evaluation files manipulated.

Make no mistake about it, a malignant program and dishonest program director can be the end of your medical career. I speak from first hand experience as does Annette. I nearly lost my subsequent matched position after I found out my TY program had lied to me and many others about the working conditions, the work rules and were in blatant disregard. As with Annette, but for the grace of God, personal connections in the community, and a very, very good and very, very well respected attorney with an extensive set of personal connections with my subsequent matched program, I would be working on the railroad right now instead of practicing medicine.

Annette speaks the truth. If your program is malignant, find another program and get out now. Before its too late. IF you are in a malignant program and you cannot get out, then keep your mouth shut, keep your records separate from the "official" records, ask for copies of your evals as they are written/reviewed and keep them in your file at home, get them notarized, just in case. Get everything notarized periodically, and if your hospital tells you to "adjust" your work hour sheets, smile and adjust, and after you have become board eligible, after you have PASSED your specialty board, and after you are licensed in the state where you want to practice, THEN and ONLY THEN take your notarized copies of the real work hours records and forward them to the ACGME.

Protect yourself and your career first. There are evil people in the world and some of them are program directors.

That being said, I am pleased to report that there are many programs who are not malignant, and are honest and are run by people of integrity. Had I not found this out, in a subsequent program, I would have feared greatly for the profession. As it happens, I think many programs are honest.

The problem is, how to separate the good the bad and the ugly. There is no safe way to create a rogue's gallery of bad programs and dishonest pds. If there were, then these programs would be forced to improve or fold.

Pandabear, again, I agree with your thoughts, but it cost me a year of my life to do just what you suggested. I write this knowing that the PD who screwed me is likely reading this and will redouble his efforts in the future.

 

[signomi]

If a program director decides that he doesn't like you, your race, your weight or the color of your armpit hair, they can and do fire you and when the lawyers come asking questions, the paper trail will say you are "disruptive" or "unprofessional" or "negligent" or any other thing they can come up with that has no clear meaning and hence cannot be readily proven nor disproven. Documents have been made up, memoranda falsified, evaluation files manipulated.

Absolutely true. My old program did this to a third year resident who was within 6 months of graduation. This person had issues, sure, but what made this person's issues worse than everyone else's? Complaining about the work load and violations did! I myself tried to leave my program after the internship from hell and they wouldn't write me a single letter, so I was trapped. Trust me, after you try to leave that late and can't get out, people hold a grudge!

That program had 2 suicides in a 5 year period...for a reason.

 

[angel80]

My IM Program is very concerned about compliance with the ACGME requirements. We have a day float team to help the post-call team get out by noon, and if we don't utilize the day float, and stay past noon to finish up our work, we get reprimanded. We are supposed to compulsively log in our work hours (truthfully). The main ACGME rule that I've seen get broken in several IM programs were I interviewed, is the 10 hour off program. Usually this occurs in the short call/night float system.

 

[8744]

Just a few comments. I'm not an expert but I did switch programs this year (but not for the reasons we are talking about).

1. You will need a Program Director's letter either to go through the match or to apply for an open spot in an another program. Your program director on whom you blew the whistle might be tempted to write a bad letter for you but he can't really do this if you are a performing to standard and have no formal reprimands. At worst he can damn you with faint praise, giving you a clean but unenthusiastic bill of health. He's not going to write that you are a trouble-maker because you alerted him to work hour violation, even if he knows it was you who ratted him out.

Someone correct me but I believe it is a violation of civil law to communicate private information about an employee (disciplinary actions, etc.) without the employees express consent. Whatever the case you can read the letter and if he lies about you you can take it up the chain of command whcih at most hospitals extends well above him.

As for other letters, you can get them form any attending who you work with and who will write you a letter. If you ask and they are willing, then you will get a good letter.

2. If they haven't documented anything bad about you, then it didn't happen. Your program director can't just make up infractions and surreptitiously include them in your file as something to spring on you when you ask for a letter. If he's going to accuse you of something it's going to be in the open and on paper which is the only advantage you have against the bureaucracy. The fact that you're a whistleblower makes it very difficult for you to be offically harrassed unless you are indeed a total piece of **** (which is another problem). Since you're not living with the program director and will see him only very rarely, what does it matter if he's mad at you? If you keep your nose clean, remain enthusiastic, and do your job like you're supposed to what's he going to do?

Jack.

3. You'll probably be a hero to your fellow residents if your actions lead to compliance with the work hour rules so don't sweat that.

4. The former program director of my former program is being sued in federal court for an alleged EEOC violation against a resident who was fired. You can take legal action if you are being harrassed. Stipend or not, whatever your classification as either an employee or a student, you have some legal protections.

Like I said, you just have to ask yourself what it's worth to not be somebody's bitch. Unfortunately the price of pointing out corruption is usually too high for most people who prefer not to make waves. Still, I believe that guy who almost shut down medicine at Hopkins did pretty well in the end.

 

[sepsis]

....Stipend or not, whatever your classification as either an employee or a student, you have some legal protections...QUOTE]

In 1999 the (NLRB) national labor relations board decided 3-2, in a reversal of the 1976 decision, that residents are employees, NOT students!

 

[Annette]

2. If they haven't documented anything bad about you, then it didn't happen. Your program director can't just make up infractions and surreptitiously include them in your file as something to spring on you when you ask for a letter. If he's going to accuse you of something it's going to be in the open and on paper which is the only advantage you have against the bureaucracy. The fact that you're a whistleblower makes it very difficult for you to be offically harrassed unless you are indeed a total piece of **** (which is another problem). Since you're not living with the program director and will see him only very rarely, what does it matter if he's mad at you? If you keep your nose clean, remain enthusiastic, and do your job like you're supposed to what's he going to do?

Jack.

Hmmm, ever raised your voice even a tad? Unprofessional. Ever have a student complain that you did not teach enough? Lazy. Ever make a nurse mad? Difficult to work with. Looked at anyone the wrong way? Condescending. Ever not read an article because you are post call, got no rest, and are extremely tired? Does not self-direct study, doesn't pursue systems based learning. Ever break a "rule" that everyone else breaks every single day? Uncooperative, does not take direction. It doesn't take much for them to "document" problems. With the core competencies, which are so vauge, they can damn you 9 ways to Sunday without you even doing anything. As for going up the chain of command, using the (binding) appeal process (check your hand book) forget it. They are to proctect the program director, not you.

Thank goodness most program directors are decent human beings.

 

[spalatin]

Just a few comments. I'm not an expert but I did switch programs this year (but not for the reasons we are talking about).

... At worst he can damn you with faint praise, giving you a clean but unenthusiastic bill of health....

And damning with faint praise is exactly what they do. There are a series of codewords known to PDs that must not be in every letter. I am working with an attending who had this happen to her when she was a resident. She grovelled, became the PD's pliant little girl (you use a different term) and played the game after they added four months to her residency. She was unable to find another residency after she got a mediocre letter.

Someone correct me but I believe it is a violation of civil law to communicate private information about an employee (disciplinary actions, etc.) without the employees express consent. Whatever the case you can read the letter and if he lies about you you can take it up the chain of command whcih at most hospitals extends well above him.

At honest programs and honest hospitals you are correct. There are numbers of programs and hospitals where the "chain of command" is the policy setting body that tells a program it is just fine to abuse residents. They could care less about civil law. The Health Care Quality Improvement Act and a ruling in the DC District Court Shulman v. Washington Hospital Ctr 222 F. Sup 59 (D. DC, 1962), 121 US App DC 64; 348 F2d 70 (1965) ruled that hospitals medical staffing decisions are not reviewable by a court.

Many of the state courts have followed Shulman. Sue a hospital and they get it bounced because of Shulman. My own beloved California has created a chink in this armor, but it is a very small one. In the east, there's a case pending before the Michigan Supreme Court. In Feyz v. Mercy Memorial, 264 Mich App 699; 692 NW2d 416 (2005), the trial court ruled that an attending had no right to a lawsuit because of this doctrine of judicial non-review. The Michigan Supreme Court is expected to rule soon on the hospital's appeal in this case.

You may be correct that it may indeed be a violation of civil law, but if hospitals have immunity from judicial review, then who in the world can enforce this law? How can you enforce a law if the courts will not allow you to bring a complaint? Hospitals nationwide rely on this and send their PDs to classes on how to screw residents without having to deal with the outfall.

2. If they haven't documented anything bad about you, then it didn't happen. Your program director can't just make up infractions and surreptitiously include them in your file as something to spring on you when you ask for a letter.

Can and do. See Annette's response.

The fact that you're a whistleblower makes it very difficult for you to be offically harrassed unless you are indeed a total piece of **** (which is another problem).

And that is precisely why they can and do get away with it. The aggrieved program director hopes the world will think that about you. When the next PD calls him, the telephone conversation goes something like this:
"I've got an app from Dr. Bear, I understand he was in your program?"
"Yes, Dr. Bear had some issues and was very defensive in dealing with them. Of course you understand I am not at liberty to discuss these issues but lets just say Dr. Bear was very unprofessional and well, despite our best efforts he was disruptive and just wouldn't work with us."
"Thank you doctor."

3. You'll probably be a hero to your fellow residents if your actions lead to compliance with the work hour rules so don't sweat that.

You will also be unemployed and potentially unemployable. Something to take very seriously.

4. The former program director of my former program is being sued in federal court for an alleged EEOC violation against a resident who was fired. You can take legal action if you are being harrassed. Stipend or not, whatever your classification as either an employee or a student, you have some legal protections.

Ibid. above. Do you have a citation? This is information that would be very useful to all in the event there's trouble. A case can be followed since it is a public proceding. I hope he wins since so few do.

Like I said, you just have to ask yourself what it's worth to not be somebody's bitch. Unfortunately the price of pointing out corruption is usually too high for most people who prefer not to make waves. Still, I believe that guy who almost shut down medicine at Hopkins did pretty well in the end.

He, Annette and 3dtp are some of the rare ones. They were fortunate enough to be able to overcome huge obstacles, which in itself is a testament to them and their abilities. The ACGME was under intense congressional scrutiny at the time this was happening. When the Congress is watching less carefully, will those who follow make out as well?

Many others are not so fortunate.

 

[Apollyon]

Still, I believe that guy who almost shut down medicine at Hopkins did pretty well in the end.

Hopkins stuck it up his ass, but Ohio State stepped up and did the right thing - created a spot for him, and funded it 100%, too. However, he was not listed as a resident in their program last year (when he would have been an EM-2). I don't know what happens after this.

 

[sepsis]

The Health Care Quality Improvement Act and a ruling in the DC District Court Shulman v. Washington Hospital Ctr 222 F. Sup 59 (D. DC, 1962), 121 US App DC 64; 348 F2d 70 (1965) ruled that hospitals medical staffing decisions are not reviewable by a court.

this is very scary.

 

[8744]

Hmmm, ever raised your voice even a tad? Unprofessional. Ever have a student complain that you did not teach enough? Lazy. Ever make a nurse mad? Difficult to work with. Looked at anyone the wrong way? Condescending. Ever not read an article because you are post call, got no rest, and are extremely tired? Does not self-direct study, doesn't pursue systems based learning. Ever break a "rule" that everyone else breaks every single day? Uncooperative, does not take direction. It doesn't take much for them to "document" problems. With the core competencies, which are so vauge, they can damn you 9 ways to Sunday without you even doing anything. As for going up the chain of command, using the (binding) appeal process (check your hand book) forget it. They are to proctect the program director, not you.

Thank goodness most program directors are decent human beings.

That's why you have to be aggressive and not let anything bad go in your file without challenging it. For the record, of all the places where I interviewed this year and last, only one place called the program and asked to speak to the program director and this was only because I had forgotten to designate the program director's letter in ERAS.

I think if you are at a program in a very competative specialty you might have to either suck it up or blow the whistle and spend the next several years hated by your faculty. On the other hand, things like IM and FP are not very competative and as there are always open spots, you can probably get a position somewhere. You might even explicitely state to the new program that you are switching because your current program violates the work hour rules and that you called them on it. This will put things in perspective and they will either admire your guts or dislike you from the get-go. Either way, it's better to be a lion in the long run.

I'm not saying it's easy to buck the system but if you are brave, forthright, and cover your ass in a determined manner you can do it.

 

[8744]

By the way, seven or eight residents quit Duke Family Medicine in the two years before I showed up, many of whom were harrassed by the program, and they managed to find new positions.

It can be done.

 

[RuralMedicine]

I did my internship the last year before the work hour rules went into effect. Nothing miraculously changed overnight - I didn't have it easier. I went from 120 hour weeks where I worked shift averaging 38 hours on call without sleep every 3 days, carrying 15 patients from day one and admitting 8-15 per night...to watching interns work 80/30 with a cap of 4 patients. Blew me away.

Yes, work hour laws needed to happen. Did they really happen? Not everywhere. Where I did residency the interns got the 80/30 and the R2s worked more than that to do the intern work that the interns couldn't do because they had to leave. We didn't have to fudge our work hour logs because we never had any. It was made clear to us that complaining to the RRC when they came would cost the residency its accreditation and then we would be residents in an unaccredited program. So we lied like good soldiers. I blame the particular residency. They hid their heads in the sand and hoped the laws would blow over.

I recommend talking to interns and residents in any future program and seeing how many hours they are really working before you decide to go there. Not every program follows the new laws.

I was also in residency during implementation of work hour guidelines. My IM intern experience at our county hospital was somewhat similar hours wise to yours. (I'd say perhaps more like 110/36 than 120/38 and I did often get a 1-2 hour nap on call--which really helped a lot as far as being able to function). Obviously the fact that as Med-Peds intern I only did 4 months at our county hospital allowed me some less hour intensive, and less intense months to recharge. Our program I think made real efforts to adapt and change and tried to ferret out some creative solutions to work more efficiently. We struggled. There were definitely residents in some rotations who exceeded work hours because at the time it was what needed to happen for patient care. The program continued to adapt and revamp in response to residents exceeding work hour guidelines. [My impression is that exceeding work hours as a program is tolerated by ACGME if the program is genuinely making dilligent efforts to improve.] I think some of the work hours imposed changes really did improve things. There were also things that were necessary because of attempts to comply with work hours guidelines that were not necessarily a good thing for resident education.

Now I'm an attending in a rural area. I take more call than I did as resident. I often work longer hours. I do it because I don't have a choice we have a fixed number of physicians in our county and we do the best we can.

 

[toxic-megacolon]

Although hardly amusing, it is interesting to see what blinders people can put on.

I've found that many believe that the 30 hrs on call is up at noon. I've tried to explain to attendings (when I let interns go "early", ie, before noon), that noon assumes the intern came in at 0600 the day before. Since rounds on many services started at 0530 and the interns were in before that, it only makes sense that they would be over hours at noon.

One of my fellow senior residents got criticized on some evaluations (at an outside hospital) for leaving early - she never left before 30 hours were up, but since it was before NOON, she was leaving early.

New math, I guess.

This is so true... I've run into problems with leaving before noon, and now I've grown too tired to fight it. The other funny one is how they say "we're in compliance, we give you 4 days off a month." As if every month has 28 days???

 

[signomi]

That's why you have to be aggressive and not let anything bad go in your file without challenging it.

Ah, but that doesn't always work. The program I was in did all their evals on a computerized eval system. Once submitted they could not be edited or removed from your record. Brilliant on their part, I must say.
I had a royal supreme jack*ss attending fail me for leaving a patient's room when the patient's primary doc was talking to the patient and family about removing bipap and going CMO. Did he ask me why? Did he ask anyone else in the dept why? No. I have a failing month on my record because that assh*le "didn't remember" that my father had died after withdrawal of CPR (DNR) two weeks before. And I'm still bitter. I would kick that man to the curb if I could.

Xanax is your friend!

 

[8744]

...There were definitely residents in some rotations who exceeded work hours because at the time it was what needed to happen for patient care...

I apologize for harping on this but patient care is not your responsibilty 24 hours a day, 365 days a year. If violating the work hour rules is needed for patient care then your program needs to re-evaluate how much patient care they can do without violating the rules and structure things accordingly. Like I said, if patient care were a priority then your program director would pitch in and lend a hand...which he won't do because patient care is only a priority for your underpaid ass.

80 hours a week is plenty of time to train for anything.

 

[8744]

I was also in residency during implementation of work hour guidelines. My IM intern experience at our county hospital was somewhat similar hours wise to yours. (I'd say perhaps more like 110/36 than 120/38 and I did often get a 1-2 hour nap on call--which really helped a lot as far as being able to function). Obviously the fact that as Med-Peds intern I only did 4 months at our county hospital allowed me some less hour intensive, and less intense months to recharge. Our program I think made real efforts to adapt and change and tried to ferret out some creative solutions to work more efficiently. We struggled. There were definitely residents in some rotations who exceeded work hours because at the time it was what needed to happen for patient care. The program continued to adapt and revamp in response to residents exceeding work hour guidelines. [My impression is that exceeding work hours as a program is tolerated by ACGME if the program is genuinely making dilligent efforts to improve.] I think some of the work hours imposed changes really did improve things. There were also things that were necessary because of attempts to comply with work hours guidelines that were not necessarily a good thing for resident education.

Now I'm an attending in a rural area. I take more call than I did as resident. I often work longer hours. I do it because I don't have a choice we have a fixed number of physicians in our county and we do the best we can.

You certainly do have a choice. You can quit and get a different job somewhere else. It is, on the other hand, extremely difficult to switch residency programs, especially in something competative.

You are also making a whole hell of a lot more than you did as a resident. What make residency training so obnoxious is how little your time is worth to people who until recently have had little incentive to make things more efficient. I wouldn't work eighty hours a week for the rest of my life for any amount of money but it would be more palatable if I had to if I were making a decent salary, not the 10 bucks an hour I'm making now.

 

[spalatin]

I did often get a 1-2 hour nap on call--which really helped a lot as far as being able to function

There have been numerous studies going back to the 20s that demonstrate unequivocably that acute and chronic and acute on chronic sleep deprivation is not a good thing. The Air Force and the Federal Aviation Administration did a study on "cat naps" and power naps for pilots. The study showed that beyond 45 minutes in an acute on chronic sleep deprived subject that there was a "sleep lag" period lasting up to an hour where performance was substantially reduced over no nap at all. The 35-45 minute timed naps, however did improve performance substantially in acute and acute on chronic sleep deprivations. In my internship, we got zero sleep for up to 45 hours on duty. Unless you count the time sitting at the nursing station drooling in the chart pen in hand with your eyes struggling open trying to remember what order you were trying to write.

While you may be trying to make the best of your situation, how is a medical error causing injury caused by sleep deprivation any less significant than allowing a sleep deprived pilot make headlines by driving his 800,000 pound airplane into a ditch? Except sleepy docs do it one case at a time and don't make headlines?

What make residency training so obnoxious is how little your time is worth to people who until recently have had little incentive to make things more efficient. I wouldn't work eighty hours a week for the rest of my life for any amount of money but it would be more palatable if I had to if I were making a decent salary

I have no problem working 80 hours a week or for that matter 7 days a week. This is not the major issue. I do have problems with programs keeping people up 30+ hours sans sleep. I think that there is no excuse for this. Given that studies have shown a wide awake drunk has the same effectiveness and judgement as someone awake for 24 hours, the fact that this continues to be "standard of care" is troubling. The fact that it took a death in New York, the Bell Commission, and work hour laws that were ignored by hospitals for over a decade and finally, the threat of Congressional legislation to move GME off dead center is even more troubling.

Like I said, if patient care were a priority then your program director would pitch in and lend a hand...which he won't do because patient care is only a priority for your underpaid ass.

Very well put. Hospitals justify it by saying, the country can't afford to take care of the indigent without resident slaves.

 

[seldomseen]

Can anyone give me more info or a link to the story about the guy from hopkins and the compliance issues? I've heard a little about it, but would like to get more info, as i'm thinking about applying there. (MS IV student currently).

thanks

 

[njbmd]

Can anyone give me more info or a link to the story about the guy from hopkins and the compliance issues? I've heard a little about it, but would like to get more info, as i'm thinking about applying there. (MS IV student currently).

thanks

Hi there,
That "guy" is Troy Madsen, M.D. who has a blog on ResidentDiary (one of the sister sites of SDN). You can read about this issue there. He is very objective about his experience at Hopkins and after Hopkins. He is also a wonderful writer.

njbmd

 

[RuralMedicine]

You certainly do have a choice. You can quit and get a different job somewhere else. It is, on the other hand, extremely difficult to switch residency programs, especially in something competative.

Yes I could leave the underserved area that I'm currently practicing in and go elsewhere. Of course that would merely leave my remaining colleagues now working even longer hours. It seems like a rather short sighted solution, but you're right technically I do have a choice. I should have chosen my words more carefully.

You are also making a whole hell of a lot more than you did as a resident. What make residency training so obnoxious is how little your time is worth to people who until recently have had little incentive to make things more efficient. I wouldn't work eighty hours a week for the rest of my life for any amount of money but it would be more palatable if I had to if I were making a decent salary, not the 10 bucks an hour I'm making now.

I suppose this is where we differ on the issue. You see it from a financial/prestige issue (and I suppose it can be). My concern is more how this impacts on quality of care.

 

[Apollyon]

Hopkins stuck it up his ass, but Ohio State stepped up and did the right thing - created a spot for him, and funded it 100%, too. However, he was not listed as a resident in their program last year (when he would have been an EM-2). I don't know what happens after this.

The Ohio State website was updated, and he's there, now. Apparently, he graduated last month.

 

[Faebinder]

Yes I could leave the underserved area that I'm currently practicing in and go elsewhere. Of course that would merely leave my remaining colleagues now working even longer hours. It seems like a rather short sighted solution, but you're right technically I do have a choice. I should have chosen my words more carefully.



I suppose this is where we differ on the issue. You see it from a financial/prestige issue (and I suppose it can be). My concern is more how this impacts on quality of care.

Err.. doesn't that bring you back to the same issue? Which is having longer hours than what the residents are currently doing makes the quality of care worse.

Listen, if someone tells me that after 30 years of being an attendant he still has to work 80+ hrs a week... to keep the quality of care high... I begin to question this argument. Panda Bear makes great points though the execution of how you would go about changing the system is a bit spontaneous.. (sorry PB, I agree with others on that).

Best I would imagine doing is collecting all the info and submitting it AFTER I have a job contract signed AFTER residency or fellowship if I wanted to finish one. Attempting to actively change the system before that is a suicide unless you are an AMG with high USMLE grades and superb record that would make attempting to transfer while under pressure a simple task for you.

 

[RuralMedicine]

I apologize for harping on this but patient care is not your responsibilty 24 hours a day, 365 days a year. If violating the work hour rules is needed for patient care then your program needs to re-evaluate how much patient care they can do without violating the rules and structure things accordingly. Like I said, if patient care were a priority then your program director would pitch in and lend a hand...which he won't do because patient care is only a priority for your underpaid ass.

80 hours a week is plenty of time to train for anything.

I'd hardly say that my program director was perfect or my residency program was perfect. I certainly had my complaints along the way, although some of them when presented as a group changed the way things were done for our class in later years and subsequent classes which I think is the first step to being a workable residency program. I'd also argue that patient care was/is a priority.

If I look at times where I exceeded work hours it was situations where crises happened and there wasn't really a great other option than staying an extra hour or 90 minutes. Yes there is an on call team but if both on call residents are admitting ICU patients (and we never did soft ICU admits it was more likely to have patients on our progressive care unit on the ventilator because they got intubated there and there weren't ICU beds) then you're kind of stuck dealing with your own crumping patient. Obviously this doesn't happen every day or perhaps even every week but it does happen and perhaps you can't completely plan away emergencies in medicine all the time. One thing our program did do was try to build in additional system buffers which did help. One thing they created was an ICU supervising resident which was a call-free month (which was nice) and you worked with the medicine teams / Pulmonary-CC attending and fellow on all ICU level patients. When I did that month as a fourth year I really tried to make myself available to my colleagues and help them get out on time if they were post call, provide supervision to their interns for procedures if they had a lot else going on, etc. I stayed late a few nights to take care of ICU transfers, or do lines etc that the team hadn't gotten to and I still was well under the work hours (and usually getting 8+ hours of sleep) so it worked well. Our hospital also asked the attendings to follow some patients without resident involvement (they could not be ICU patients and were supposed to be selected as low acuity, likely to not have unique learning opportunities--they seemed to get a lot of Chest Pain rule outs, awaiting ECF placement etc) this decreased the total patient pool some but unfortunately the county hospital where I did part of my residency serves a growing and increasingly uninsured population.

Another thing that changed with work hours was a very rigorous approach to caps. In the past at our institution ICU admissions post cap were still admitted to the on call team because it was felt that patient care was best served that way. (There was an attempt at buffering by artificially capping the team at 1 below presuming that there would be a critical admission to fill that gap. If it never happened then one intern came through call under cap. Of course if you had three post cap critical admissions you were obligated to admit them all)Non critical admissions were held for distribution to other teams. (Orders could be written by the ED and the patient could go to the floor if a bed was available--if there were patients deemed unsuitable for this but not truly critical then the home call resident was called in to admit. This also happened if there was a big bolus of patients deemed too many to hold). This was the process during my intern year and one of my resident years. I definitely had a little bit of a black cloud but I think the most patients we ever got in a call was 13 (of course 9 of them were ICU admits so it was interesting my attending came in at 8 that evening to see if we could staff out a few to have less to do in the morning he ended up going and doing a floor diabetic foot admission by himself and then brought back dinner). From my third year on we enforced caps rigidly so then the home call resident would come in and admit these patients and turn them over to the team in the morning. From being on both sides of this I do think we lost something in the process.

 

[RuralMedicine]

Err.. doesn't that bring you back to the same issue? Which is having longer hours than what the residents are currently doing makes the quality of care worse.

I've always said that until you show me a study that shows that sleep deprivation improves the practice of medicine that our GME programs need to change. That said I think you can't throw the baby out with the bathwater. (Especially not in pediatrics programs --yeah it's lame) Ideally you're looking at system wide changes and that is not a rapid (or often linear process)

Best I would imagine doing is collecting all the info and submitting it AFTER I have a job contract signed AFTER residency or fellowship if I wanted to finish one. Attempting to actively change the system before that is a suicide unless you are an AMG with high USMLE grades and superb record that would make attempting to transfer while under pressure a simple task for you.

I think you can work within the system to change the system. That definitely happened in our residency program over the course of our training.

 

[Annette]

I've always said that until you show me a study that shows that sleep deprivation improves the practice of medicine that our GME programs need to change. That said I think you can't throw the baby out with the bathwater. (Especially not in pediatrics programs --yeah it's lame) Ideally you're looking at system wide changes and that is not a rapid (or often linear process)

So, you think residents have lost something by not doing the cp r/o's and the diabetic foot admissions? What exactly is the baby we're so blithely tossing out? I understand that change is not rapid, but it took the threat of government interference (And Hopkins getting smacked) for anything to change at all! There is something about learning to function under pressure, but the 80/24-36 rules still aren't enough.

I applaud your dedication to your collegues and patients. They, however are not in a position to ruin all that you have spent >8 years and heavy debt to gain.

I think you can work within the system to change the system. That definitely happened in our residency program over the course of our training.

Unfortunately, not everyone has/had a program director who wants to hear from the residents. I hope they are in a minority, but there are PD's out there who only want what is best for the hospital (and their political lives).

You also mentioned that you don't have a choice, or that it would leave your fellow collegues out on a limb. Residents do have a choice- take it without complaint or be professionally and economically ruined. Plus, our collegues will stuck out on a limb taking up the slack from a terminated resident.

 

[8744]

Yes I could leave the underserved area that I'm currently practicing in and go elsewhere. Of course that would merely leave my remaining colleagues now working even longer hours. It seems like a rather short sighted solution, but you're right technically I do have a choice. I should have chosen my words more carefully.

If your colleagues have to work longer hours then that's their personal problem. The solution is to see fewer patients, unless of course the material or philosophical benefits of supporting the entire health care system of an underserved area outweigh the desire for some free time. I don't see what's short-sighted about finding a better job based on criteria which you find important. In this case, every man must secure his own happiness. This is not the military where you should throw yourself on a grenade.

Whatever the case, the key point is that you have the option. You do not have this option as a resident as you well know. I would have left Duke Family Medicine in August if I could have but I had to grind on for a year until I could switch.

You are obviously committed to your patients but you have to draw the line somewhere or we'd all work 24/7.

 

[njbmd]

Unfortunately, not everyone has/had a program director who wants to hear from the residents. I hope they are in a minority, but there are PD's out there who only want what is best for the hospital (and their political lives).

You also mentioned that you don't have a choice, or that it would leave your fellow collegues out on a limb. Residents do have a choice- take it without complaint or be professionally and economically ruined. Plus, our collegues will stuck out on a limb taking up the slack from a terminated resident.

Hi there,
Some program directors are crazy, some are powerless, some are spineless and some just plain do not care about residents or resident eduction. Many residency applicants do not know what they are getting into because they meet the PD on interview day, get sunshine blown into various places and may make a mistake by blindly believing everything they are told on interview day. Couple that with desperate FMGs who are willing to work 24/7 for a chance at the "holy grail of Amercan medical practice" and you can wind up in a very poor situation as some folks have outlined here.

Your colleagues won't be out on a limb because there is always someone willing to come in (read FMG) and replace you at moments notice. There are always PDs who realize this fact and take full advantage of it. There are also PDs and other attendings who will lie if there is a personality conflict with a resident. Guess who loses? The resident. In short, you can find yourself in a very bad working situation with 80 hours the least of your problems.

My advice: Check and double check the programs before you believe everything fed to you on interview day or any other time. Be wary of residents who are too happy and residents who choose their words too carefully. Use your instincts! Talk to everyone and come back for a second look. Ask questions of upperclassmen who matched at programs that interest you. Try to get folks to give you the positives and negatives because every program has some. If they cannot do this for you, don't rank that program no matter how wonderful you think it might be.

As much as I love my program, it isn't 100% wonderful all the time. I don't expect that practice is going to be 100% wonderful all of the time. There are days when I feel like "throwing in the towel" but most of the time, I actually LOVE what I do. I am very fortunate to be in a program with a PD that is straight with the residents and seeks out their input when problems arise but make no mistake, we DO have problems from time to time. Any time and any place diverse people interact, there WILL be problems.

When folks come to interview, I try to answer questions as honestly as possible. I was fortunate when I interviewed that most of the residents did the same for me. I also interviewed at more than a few places that made the hair on the back of my neck stand up. I also did plenty of second looks being sure to give myself time when flying in and out. In the end, I did OK but I have classmates and colleagues who have struggled.

My educated guess is that 95% of residency programs in this country try very hard to offer a good educational and working experience for their residents but that remaining 5% or so can be he-- if you are caught in one of them. It's just "buyer beware". For something that is so crucial to the rest of your career, try to get as much information up front as you can and be realistic.

njbmd

 

[toxic-megacolon]

Making residents responsible for recording their own hours is one of the biggest problems with the 80 hour rule. As an intern you are "lazy"if you work less than 80, and in trouble if you record more. The only way to stay on the good side of the program is to "work more, record less." Most programs know this, I'm sure, and take full advantage.

 

[EctopicFetus]

This rule is around but reality is that residents dont report when they violate it. If you really think about it would you want your program to go on probation? It makes you look bad.. It seems like the people who report the abuse are the ones who are at the end of their rope.

 

[kbrown]

This rule is around but reality is that residents dont report when they violate it. If you really think about it would you want your program to go on probation? It makes you look bad.. It seems like the people who report the abuse are the ones who are at the end of their rope.

here's my two cents...
my program STRICTLY (not kidding), enforces it. BUT, my personal take is this: If 5PM rolls around, and I am not ready to sign out b/c I haven't tied up loose ends, I am not gonna sign that out to the call team. So sometimes I end up sticking around a bit longer (sometimes until 630P) tomake sure that my collegues don't have to do scutwork of mine. Secondly, and this has happened often, I am NOT signing out a procedure or a physical exam (DRE, pelvic, etc..), so that being said, I will stick around for that also.

Now b/c I am an intern who has only been on offservice rotations thus far I dont' know how this will all level out in the end. But what I know now is this: many times, the best learning comes (for whatever reason) after everyone has gone home and it's only the overnight, after hours team. This is when pt's decide it's good to crash, spike fever, alter mental status, etc...This is not something that I want to miss out on. I want to learn first hand the work up, treatment, procedure to take care of these issues. So in short, I have stayed MANY times, well past when I was supposed to go home, to do all of the aforementioned things.

I don't routinely go over 80, I don't know if I ever have. But I am most certainly not clockwatching and closely counting my hours. I am here to learn w/in reasonable limits. never again will I get the opportunity afforded to us in residency. when you walk out those hospital doors for the last time as a resident, people EXPECT you to know, not to learn. So I have made the personal decision not to pass up "opportunities" if I have the energy left at the end of the day.

Just my point of view

 

[3dtp]

I am NOT signing out a procedure or a physical exam (DRE, pelvic, etc..), so that being said, I will stick around for that also.

I don't routinely go over 80, I don't know if I ever have. But I am most certainly not clockwatching and closely counting my hours. I am here to learn w/in reasonable limits.

kbrown, I don't think there are many here would would in any way disagree with you. I've stayed scrubbed in long cases way past the daily deadline myself and been very happy about it, but then I'm the kind of person who can stand in the OR for five hours and think its five minutes. None of us watch the clock or we would have been engineers or something else. But that too is part of the problem, and hospitals in the past have taken increasing advantage of it.

Your institution strictly enforces the rules and that is a good thing. That means that they do regard you as more than a dictation machine and a revenue generator. Not all programs are like this. As njbmd pointed out these programs will blow sunshine up every orfice come recruiting days and after the match, they hand you a stick and tell you where they're going to put it, and you'd better smile.

Fortunately you have found a great program and one to be admired and treasured. I suspect that your words here will make it a highly competative and respected program in the future. Other programs, please get the message, and you know who you are!

 

[3dtp]

This rule is around but reality is that residents dont report when they violate it. If you really think about it would you want your program to go on probation? It makes you look bad.. It seems like the people who report the abuse are the ones who are at the end of their rope.

Martin Niemoeller was a German Naval Officer of some distinction in WW-I and a fervent anti-semite. After the war, he became a pastor of the Evangelische Kirche Deutschland. In the US, this is known as the Lutheran Church. By the time of the rise of the National Socialist Party, (Nazi), he had reformed his ways. He wrote a poem which I've included below.

The implicit message is that if we do not enforce rules and report abuse of rules there will be creep (and I admit I am occasionally guilty myself), and we will be right back where we started. These rules were put in place first and most importantly for the protection of patients from medical errors and secondly to protect you from excessive fatigue. Chronic fatigue makes you a poorer learner, with poorer recollections and ultimately a poorer practitioner of the art. This is not a macho thing, this is a physiologic need. Panda Bear said this very eloquently in his comparison to a field solder on patrol to the intellectual demands of our profession.
------------------------------------------

Niemoeller wrote this:

Als die Nazis die Kommunisten holten,
habe ich geschwiegen;
ich war ja kein Kommunist.

Als sie die Sozialdemokraten einsperrten,
habe ich geschwiegen;
ich war ja kein Sozialdemokrat.

Als sie die Gewerkschafter holten,
habe ich nicht protestiert;
ich war ja kein Gewerkschafter.

Als sie die Juden holten,
habe ich nicht protestiert;
ich war ja kein Jude.

Als sie mich holten,
gab es keinen mehr, der protestieren konnte.

[English translation]
When the Nazis came for the communists,
I remained silent;
I was not a communist.

When they locked up the social democrats,
I remained silent;
I was not a social democrat.

When they came for the trade unionists,
I did not speak out;
I was not a trade unionist.

When they came for the Jews,
I did not speak out;
I was not a Jew.

When they came for me,
there was no one left to speak out.

 

[toxic-megacolon]

here's my two cents...
my program STRICTLY (not kidding), enforces it. BUT, my personal take is this: If 5PM rolls around, and I am not ready to sign out b/c I haven't tied up loose ends, I am not gonna sign that out to the call team.

Of course you aren't going to sign that out. That's why the rule allows for you to "average" 80 hours per week. Its your responsiblity to anticipate those days you are going to stay late over a 4 week period, and sign out at appropriate times on days when you don't have a pelvic waiting. Time management SHOULD be your responsiblity, not the programs. If you know you have to leave by noon post call, don't pick up a gyn patient at 11:50. If you really want to work more, go volunteer at a free clinic or something. But just because you want to work more, its not fair to force your patients to deal with an overworked resident. That's selfish.

 

[DRDARIA]

Of course you aren't going to sign that out. That's why the rule allows for you to "average" 80 hours per week. Its your responsiblity to anticipate those days you are going to stay late over a 4 week period, and sign out at appropriate times on days when you don't have a pelvic waiting. Time management SHOULD be your responsiblity, not the programs. If you know you have to leave by noon post call, don't pick up a gyn patient at 11:50. If you really want to work more, go volunteer at a free clinic or something. But just because you want to work more, its not fair to force your patients to deal with an overworked resident. That's selfish.

My understanding of the rules (based on my chief resident's explanation) is that while the 80 hour per week rule is an average. However, the 30 hour rule is hard and fast. We were told a minute beyond 30 hours is a violation. Which actually makes sense. Lots of people work close to 80 hours. That's not the killer. It's the 30 consecutive hours without sleep that makes you dangerous (in my humble, and currently sleep-deprived, opinion).

 

[KidDr]

My understanding of the rules (based on my chief resident's explanation) is that while the 80 hour per week rule is an average. However, the 30 hour rule is hard and fast. We were told a minute beyond 30 hours is a violation. Which actually makes sense. Lots of people work close to 80 hours. That's not the killer. It's the 30 consecutive hours without sleep that makes you dangerous (in my humble, and currently sleep-deprived, opinion).

It's not only your opinion, it's also been extensively studied--and the studies consistenly are showing a big drop off in functioning after 16 hours on duty. And, as others have pointed out, by 24 hours awake you're functioning no better than a drunk person, and you're also more likely to be in a MVC. Which is why, in my humble opinion, the current work hours regulations leave a LOT to be desired. To my knowledge, only one study has looked at the effect of working a cumulative number of hours per week (in this study's case, an average of 80-90), and found that these residents functioned like someone with a blood EtOH level of 0.04-0.05.

Here's a few of the recent studies, in case anyone hasn't seen them yet:
http://content.nejm.org/cgi/content/short/351/18/183
http://jama.ama-assn.org/cgi/content/full/294/9/1025
http://www.hourswatch.org/images/NEJM Car Accidents.pdf
http://www.hourswatch.org/images/Philibert - Sleep metaanalysis MDs and non-MDs.pdf

What gets me is that, as residents, we're expected to know the latest research concerning, for example, the most appropriate pharmacologic therapy post-MI. Quoting a recent article might even score you extra points in a morning report. BUT, in some places, if one tries to quote the above articles (published in the SAME well-known, peer-reviewed journals) in support of more reasonable work hours for residents, they look at you like you're an idiot, and resort to their same old, "well when I was a resident...."
Can you imagine if I tried to pull that in regards to patient care? "Well, we always used to use penicillin to treat pneumonia, so I thought I'd give it a try." I'd be sued. Give me a break.

 

[toxic-megacolon]

Lots of people work close to 80 hours.

The only people I ever hear say this is med students/residents/attendings. I know there are random stock brokers and lawyers, etc. that do it, but it is really more the exception rather than the rule.

 

[Faebinder]

The only people I ever hear say this is med students/residents/attendings. I know there are random stock brokers and lawyers, etc. that do it, but it is really more the exception rather than the rule.

Are they also...

1) Handling human lives like physicians?

2) Getting paid 10 dollars an hour for it?

I agree that I rather work 7 days a week over having to do a 36 hour shift but I am sure I am a minority in that regards.

 

[8744]

here's my two cents...
my program STRICTLY (not kidding), enforces it. BUT, my personal take is this: If 5PM rolls around, and I am not ready to sign out b/c I haven't tied up loose ends, I am not gonna sign that out to the call team. So sometimes I end up sticking around a bit longer (sometimes until 630P) tomake sure that my collegues don't have to do scutwork of mine. Secondly, and this has happened often, I am NOT signing out a procedure or a physical exam (DRE, pelvic, etc..), so that being said, I will stick around for that also.

Now b/c I am an intern who has only been on offservice rotations thus far I dont' know how this will all level out in the end. But what I know now is this: many times, the best learning comes (for whatever reason) after everyone has gone home and it's only the overnight, after hours team. This is when pt's decide it's good to crash, spike fever, alter mental status, etc...This is not something that I want to miss out on. I want to learn first hand the work up, treatment, procedure to take care of these issues. So in short, I have stayed MANY times, well past when I was supposed to go home, to do all of the aforementioned things.

I don't routinely go over 80, I don't know if I ever have. But I am most certainly not clockwatching and closely counting my hours. I am here to learn w/in reasonable limits. never again will I get the opportunity afforded to us in residency. when you walk out those hospital doors for the last time as a resident, people EXPECT you to know, not to learn. So I have made the personal decision not to pass up "opportunities" if I have the energy left at the end of the day.

Just my point of view

Are you not signing out DREs and pelvics because you like them or because you don't want to make your collegues do them?

I hope it's for the latter reason.

Seriously though, I agree completely with your post. I don't mind at all staying past "quitting time" for something useful, interesting, or meaningful. I don't think any of us does. And since I'm in Emergency Medicine and our program does 14 twelve hour shifts a month, it is highly unlikely that I will ever even get close to the EM 72 hour maximum much less the 80 hour limit.

That' one reason I went into Emergency Medicine and ranked this program high on my list.

 

[8744]

...None of us watch the clock or we would have been engineers or something else...

Hey...low blow.

P. Bear, MD PE Civil Engineering
Emergency Medicine Resident
Somewhere in the Midwest

 

[supercut]

Hi there,
Some program directors are crazy, some are powerless, some are spineless and some just plain do not care about residents or resident eduction. Many residency applicants do not know what they are getting into because they meet the PD on interview day, get sunshine blown into various places and may make a mistake by blindly believing everything they are told on interview day. Couple that with desperate FMGs who are willing to work 24/7 for a chance at the "holy grail of Amercan medical practice" and you can wind up in a very poor situation as some folks have outlined here.

Your colleagues won't be out on a limb because there is always someone willing to come in (read FMG) and replace you at moments notice. There are always PDs who realize this fact and take full advantage of it. There are also PDs and other attendings who will lie if there is a personality conflict with a resident. Guess who loses? The resident. In short, you can find yourself in a very bad working situation with 80 hours the least of your problems.

My advice: Check and double check the programs before you believe everything fed to you on interview day or any other time. Be wary of residents who are too happy and residents who choose their words too carefully. Use your instincts! Talk to everyone and come back for a second look. Ask questions of upperclassmen who matched at programs that interest you. Try to get folks to give you the positives and negatives because every program has some. If they cannot do this for you, don't rank that program no matter how wonderful you think it might be.

As much as I love my program, it isn't 100% wonderful all the time. I don't expect that practice is going to be 100% wonderful all of the time. There are days when I feel like "throwing in the towel" but most of the time, I actually LOVE what I do. I am very fortunate to be in a program with a PD that is straight with the residents and seeks out their input when problems arise but make no mistake, we DO have problems from time to time. Any time and any place diverse people interact, there WILL be problems.

When folks come to interview, I try to answer questions as honestly as possible. I was fortunate when I interviewed that most of the residents did the same for me. I also interviewed at more than a few places that made the hair on the back of my neck stand up. I also did plenty of second looks being sure to give myself time when flying in and out. In the end, I did OK but I have classmates and colleagues who have struggled.

My educated guess is that 95% of residency programs in this country try very hard to offer a good educational and working experience for their residents but that remaining 5% or so can be he-- if you are caught in one of them. It's just "buyer beware". For something that is so crucial to the rest of your career, try to get as much information up front as you can and be realistic.

njbmd

Amen. I recall being on the interview trail and whenever I got to talk to the residents, all I heard was all the good things about the program. Know that it is in the best interest of the current residents to try to recruit as good as possbile people for the upcoming year's intern pool. So I made sure that I always asked what they didn't like about the program, as welll as some questions about potential problems

I wound up in a surgery program that is very compliant with 80 hours. Our PD is serious about enforcing the rules. He also knows that when we have an attending who is not supportive of the rules and expects us to like, we can jepordize ourselves by speaking up. So he regularly meets with us, in addtion to having us self report our hours. There have been several times when he has spoken to attendings on our behalf. There have even been some changes in rotations and schedules to improve compliance on the problem services.

 

[RuralMedicine]

So, you think residents have lost something by not doing the cp r/o's and the diabetic foot admissions? What exactly is the baby we're so blithely tossing out? I understand that change is not rapid, but it took the threat of government interference (And Hopkins getting smacked) for anything to change at all! There is something about learning to function under pressure, but the 80/24-36 rules still aren't enough.

I think you missed my point entirely. I actually thought that the plan to turf some patients away from direct resident care was a good idea and didn't compromise education. On the other hand I did think that the on call team taking truly critical admits after cap was in the best interest of the patients and when we switched to having those patients admitted by our home call resident we did lose something in the process. My comment to Faebinder that you extracted more referred to the relative physician shortage for uninsured/ underinsured in the city I trained. Our county hospital used residents as one strategy to fix that shortage (and did it in a reasonably responsible fashion).

I applaud your dedication to your collegues and patients. They, however are not in a position to ruin all that you have spent >8 years and heavy debt to gain.

I think now it's my turn to misunderstand what your saying. I'm not sure exactly what you're getting at. Feel free to expound if you feel like it.

 

[RuralMedicine]

If your colleagues have to work longer hours then that's their personal problem. The solution is to see fewer patients, unless of course the material or philosophical benefits of supporting the entire health care system of an underserved area outweigh the desire for some free time. I don't see what's short-sighted about finding a better job based on criteria which you find important. In this case, every man must secure his own happiness. This is not the military where you should throw yourself on a grenade.

Yes we all have choices as I mentioned earlier my word choice was less than literally accurate. Thank you for taking me to task on it twice now. You are also right that if I chose to leave this underserved community my colleagues could refuse to accept any new patients. They could all resign their hospital privileges as well so as to avoid the extra call rotation and the extra unassigned admissions (as a result of all of my current patients being doctorless).

Whatever the case, the key point is that you have the option. You do not have this option as a resident as you well know. I would have left Duke Family Medicine in August if I could have but I had to grind on for a year until I could switch.

Interesting weren't you earlier in this thread arguing that residents could have more power if they would only take it. I'm guessing that you could have left the FM program at Duke last August if you truly desired. However, that move would have had consequences and you chose not to do that. Obviously you signed some type of an employment contract with Duke which spelled out some of those consequences. (Although I'm guessing perhaps incorrectly that they wouldn't have truly pursued legal reprocussions.) Leaving abruptly two months into a twelve month contract would have also raised red flags with your potential EM program directors (or really any potential employer I would think). Sure you could have opted to challenge and defend them but you chose not to take that route.

You are obviously committed to your patients but you have to draw the line somewhere or we'd all work 24/7.

Sure--and we all draw the line in different places and should have that right. I will never work 24/7 but if I practiced in suburban area I'd certainly work a lot less. But yes I chose to come to a rural area and practice here because the need was there. We all make our own choices.

 

[3dtp]

Hey...low blow.

P. Bear, MD PE Civil Engineering
Emergency Medicine Resident
Somewhere in the Midwest

[removing foot from mouth and checking tongue for footprints]
Hey, now, I wasn't referring to all engineers! After all we gotta have the CEs otherwise it would flow at all, let alone have it all flow down hill. But, unless you're COE, you get paid by the minute.

 

[pruritis_ani]

There is one glaring part you left out - you can also go to clinic post-call for up to 6 hours - as long as you don't have any new patients. I've seen medicine residents do that, and that SUCKS, in my book.

My program is good about the 80/30 rules, but we do clinic post call as well. And, Ob call is rough. You do NOT see the call room overnight as an intern. To go to clinic to do prenatal visits for 6 hours post call is cruel and unusual punishment......

 

[DRDARIA]

The only people I ever hear say this is med students/residents/attendings. I know there are random stock brokers and lawyers, etc. that do it, but it is really more the exception rather than the rule.

Well, try any job that has mandatory overtime. Frighteningly enough, city bus drivers can come pretty close. Of course they don't do 30 hours straight. You're going to say that there are federal rules against this-- well public transporation is exempted from the rules because it is considered critical. Trust me, I have a family member who drives a city bus, and not only are the hours long, their work schedules are nuts.

Also add to your list military and other public servants. I agree it is the exception, not the rule (obviously not all of America works those hours), but there are more people who approach 80 than you would think. The key difference is they aren't also pulling regular 30 hour "shifts".

 

[8744]

Yes we all have choices as I mentioned earlier my word choice was less than literally accurate. Thank you for taking me to task on it twice now. You are also right that if I chose to leave this underserved community my colleagues could refuse to accept any new patients. They could all resign their hospital privileges as well so as to avoid the extra call rotation and the extra unassigned admissions (as a result of all of my current patients being doctorless).



Interesting weren't you earlier in this thread arguing that residents could have more power if they would only take it. I'm guessing that you could have left the FM program at Duke last August if you truly desired. However, that move would have had consequences and you chose not to do that. Obviously you signed some type of an employment contract with Duke which spelled out some of those consequences. (Although I'm guessing perhaps incorrectly that they wouldn't have truly pursued legal reprocussions.) Leaving abruptly two months into a twelve month contract would have also raised red flags with your potential EM program directors (or really any potential employer I would think). Sure you could have opted to challenge and defend them but you chose not to take that route.



Sure--and we all draw the line in different places and should have that right. I will never work 24/7 but if I practiced in suburban area I'd certainly work a lot less. But yes I chose to come to a rural area and practice here because the need was there. We all make our own choices.

1. One of the beauties of the medical profession is that you can, generally speaking, work anywhere. Not knowing your situation, I would guess that if the staffing situation is so dire, you can pretty much slap your rural hospital around like a biach if you wanted to. they threaten to revoke your priveleges because you don't want to work 120 hours a week, you say "fine," here's my two weeks notice (or six months or one year or whatever your contractual obligation) and move on to greener pastures. Sayonara. Have a nice day. Find another ho'. Sure, this entails logistical complications for you but this is no different than for anybody in any other profession looking for a better job. I have quit several good jobs for better ones.

2. I could have left Duke in August but then what would I have done? I had a limited license (good only for residency) so working at an urgent care would have been out of the question. Residency programs don't start until July 1st so what would I have done for money for ten months? Worked at Burger King? Tried to get back into the engineering business after being out of it for five years? These were not realistic options.

That's my point. As a resident you are for all pratical purposes stuck for at least a year. Sure, you can quit but as you pointed out, this will kill your chances of matching somewhere else, especially in as competative a specialty as Emergency Medicine. Not to mention contractual obligation which Duke does take seriously, by the way. The consequences of quitting a residency program are a lot more dire than switching jobs as a physician. Attending switch jobs all the time.

But I did it so this should be an inspiration to you.

3. "Choice" is the key phrase. You have a choice where and how much you want to work. Residents don't, except the initial choice of ranking a program for the match. Come on now. Isn't this obvious? Surely you haven't forgotten.

 

[CANES2006]

You do NOT see the call room overnight as an intern.

So true. There was a mix up in the beginning of the year that messed up our keys for our call rooms. To make the story short we don't have our keys to our call room yet. I thought that this would be a problem, however I haven't missed the darn key as of yet. If I had my key now, I still would not know what the inside of our call room looks like.

 

[RuralMedicine]

1. One of the beauties of the medical profession is that you can, generally speaking, work anywhere. Not knowing your situation, I would guess that if the staffing situation is so dire, you can pretty much slap your rural hospital around like a biach if you wanted to. they threaten to revoke your priveleges because you don't want to work 120 hours a week, you say "fine," here's my two weeks notice (or six months or one year or whatever your contractual obligation) and move on to greener pastures. Sayonara. Have a nice day. Find another ho'. Sure, this entails logistical complications for you but this is no different than for anybody in any other profession looking for a better job. I have quit several good jobs for better ones.

You really are not understanding where I'm coming from. As I've pointed out several times I realize that I had a choice in coming here in the first place and I could certainly go elsewhere, work less, and make more. The point you are missing is that it isn't all about me. My departure (or any physician's departure) would have significant adverse effect on the community. If we had more physicians in this community (and more competent EM providers but that is another thread entirely) my colleagues and I would all work less. At the moment we are choosing to continue to practice in this community because don't believe that your right to health care should be dependent on living in a urban or suburban area, being affluent, or having connections. I enjoy what I do. I believe that health care is a right not a privilege and that there are more important things than how much money you can make.

2. I could have left Duke in August but then what would I have done? I had a limited license (good only for residency) so working at an urgent care would have been out of the question. Residency programs don't start until July 1st so what would I have done for money for ten months? Worked at Burger King? Tried to get back into the engineering business after being out of it for five years? These were not realistic options.

That's my point. As a resident you are for all pratical purposes stuck for at least a year. Sure, you can quit but as you pointed out, this will kill your chances of matching somewhere else, especially in as competative a specialty as Emergency Medicine. Not to mention contractual obligation which Duke does take seriously, by the way. The consequences of quitting a residency program are a lot more dire than switching jobs as a physician. Attending switch jobs all the time.

But I did it so this should be an inspiration to you.

Please do not be offended when I say that your career path has no influence on my life and is not a source of inspiration. Your ability to match into an EM residency after realizing that your FM program was not what you wanted is in not inspiring to me because as you have very aptly pointed out our situations are very different. Now if I was currently in a FP program that I had scrambled into after not matching in EM and was realizing that I had no desire to do FP then your path might serve as an inspiration.