80 Hour Workweek Restrictions

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dumbest premed

dumbest premed

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Hey guys. I'm writing a research paper on the 80 hour work week. I support it, and I basically need a three-part thesis on the matter and I have to discuss each part of the thesis. I agree with it since it will improve patient care with better rested physicians, and it will also make residency more tolerable (prevent depression, sleep related car accidents...). Does anyone have another reason for supporting the new workweek restictions?

I'm sure that you guys know a lot more on the matter than I do...and I'm just looking for a hint on a topic to research. I want to write about this since I'm interested in at and I would like to learn more about it, since it will eventually affect me. So if anyone has any input on the question I put up, I'd really appreciate it. Thanks.

(Why the heck didn't I take my second semester of english back when I was a freshman?:laugh: )
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be sure to include all the reasons that this restriction is not a good idea...

problems with enforcement, tracking of hours, special "exemptions"....

not to mention substantially less training time for many specialties (mostly surgical), which could mean less-well-developed skills, or the need to extend residency training. then there's the problem of continuity of care.
 
Originally posted by doc05
be sure to include all the reasons that this restriction is not a good idea...

problems with enforcement, tracking of hours, special "exemptions"....

not to mention substantially less training time for many specialties (mostly surgical), which could mean less-well-developed skills, or the need to extend residency training. then there's the problem of continuity of care.
Click to expand...

I'll definitely include a lot of that in the refutation section...you have some good points there.
 
Anymore volunteers?:p

(The search function is down:( )
 
I think it might be fitting to include at least a paragraph or so on what ignited this whole work week limitation thing--the Libby Zion case. Perhaps you could use it as an intro?
 
don't forget continuity of care issues with problems with workhours.
 
Thanks for the tips...I just looked up the Libby Zion case and I'll probably use it for the intro...I'll also put the continuity of care issues in the refutation section.
 
Useless scutwork.

One good reason to put some sort of limits on the work hours is that traditionally residents spend several hours a day doing tasks that aren't directly related to their education - things that could be done by any non-physician like fetching x-rays, wheeling a patient to radiology b/c transport services are too slow, just to name a few. Some hospitals are just totally inefficient and understaffed that residents spend half their day double checking that orders were done or drawing labs themselves, when if a few more nurses or ancillary staff were hired, they could do that work. Why don't they hire more ancillary staff? They'd have to pay them, and residents get paid the same no matter whether they work 50 or 120 hours a week, so it's easier for hospitals to just make residents pick up this slack in patient care b/c they are ultimately responsible for making sure the patient gets what is needed.

I am starting a surgery residency this year, and honestly I don't want to be forced to leave at noon post-call if there's an interesting OR case to be done on a patient I admitted on call the previous night - that would be compromising my education and continuity of care. So I think an absolute 80 hour limit and they kick you out the door could be bad for our training and patient care. However, if I'm staying till 7pm post-call to run around and catch up on the inefficiency of the hospital, I'll be happy when they force me to go home early.

As a student, I have done rotations at hospitals where there were very few RN's and every department was understaffed, and I have worked 120 hours/week doing scutwork tasks at least 30 hours/week of that time. I've also done rotations at places where they have hired PA's and NP's (physician assistants and nurse practicioners), in addition to having great RN's and ancillary staff - and I've seen much greater efficiency, reducing the resident and student hours on a very busy surgical service to under 100 hours a week of mostly things that contributed to our education and training. If the work hour limits force more hospitals to move to this model of greater efficiency, I'll be all for it.
 
Could anyone enlighten my uninformed soul about this case or any others? Just curious...links would be great.
 
I thought of more for the original poster -

There's some studies done (you'll have to find them, I don't have the references, but I remember the results) on sleep deprivation that measured things like memory, reaction time, judgement and found that sleep deprived people behaved like people with illegal blood alcohol levels in these tasks. You might want to find and use that data.

Also, you might want to point to work hour restrictions pilots and even flight attendants have to ensure the safety of people whose lives are in their hands. If our pilots were working 40 hours straight without sleep, you'd better bet people would be more scared to fly - why arent' they afraid of having surgery when the surgeons have all often been working for over 30 hours straight? - probably b/c they dont' even know.
 
Originally posted by Dr. Cuts
I think it might be fitting to include at least a paragraph or so on what ignited this whole work week limitation thing--the Libby Zion case. Perhaps you could use it as an intro?
Click to expand...

The Zion case was actually more of a case of an example of
1) little oversite of a junior medicine resident who made an incorrect diagnosis
2) the perils of shift work medicine (the patient was passed off between 3 different residents who all failed at multiple levels to question bad information on a sign out)
3) poly-substance abuse by the patient as a signifigant contributing factor


A better case for error directly related to work hours causing a patients' death was the suspension of the liver transplant program last year @ Mt. Sinai in New York
 
Thanks for all of the new info guys.
 
ITs going to be comical to see the neurosurgery and gen surgery programs violate the rule and get busted

numerous programs will get shut down before others learn a lesson
this is bound to happen!
 
Originally posted by droliver
The Zion case was actually more of a case of an example of
1) little oversite of a junior medicine resident who made an incorrect diagnosis
2) the perils of shift work medicine (the patient was passed off between 3 different residents who all failed at multiple levels to question bad information on a sign out)
3) poly-substance abuse by the patient as a signifigant contributing factor

It's interesting that when you pull the Zion case apart how much reality of the case veers from what it has come to symbolize. As our program has prepared to jump through hoops to meet the work hours rules I must admit I don't anticipate a smooth transition. I have often said that until you show me literature to support the learning enhancement benefits of sleep deprivation (and I know that literature to the contrary actually exists) that I can't fully endorse our current medical education system. However, quite honestly I think that the current ACGME guidelines will likely be detrimental to medical education and patient care at the same time. A colleague and I were discussing this issue recently and came to the conclusion that the issue truly is more one of supervision and backup (ironically the often quoted Zion case supports our theories) than an absolute number of hours. I agree that there are issues of medical errors attributed to fatigue but I doubt that merely restricting everyone to 80 hours/week will solve that problem. Additionally with frequent changeovers in some programs that have gone to shift work systems and or night floats we may see even more medical errors as we have information not being changed over and less associated physician responsibility.
Click to expand...
 
what's the deal with the Mt Sinai liver transplant program?
 
They had a split-liver donor (where a living person donates a part of ones liver) who died from infection (food poisoning from some shellfish I think) several days after a successful tranplant. It led to a systemic review of the practices of the program (one of the national leaders in liver transplant) which cited them with multiple organizational problems. One of those included having the surgical intern @ the time being first call on 38 patients on the transplant service & clearly violating the Zion laws for work hours. There was not neccessarily a correlation with the outcome from any of that, but it recieved extensive tabloid-like coverage in the media. The resulting witch hunt caused the closure of the program (one of a series of problems for MT. Sinai the institution in recent years). I believe they also had some other unexpected deaths on the transplant service which were also reviewed with more scrutiny and cited for the "lack of institutional control" as the NCAA would say.

Rather then this case truly being about the issue of work hours itself (which it isn't), I think it highlights the real potential of the new ACGME regulations to be used as a tort issue with ANY bad outcome by trial attorneys. It is going to become a frequent point of contention & neccessitate some kind of punch card system to accurately keep track of hours in order to protect the institution. It also very likely is going to lead to the formal prohibition of moonlighting by programs for the same reasons. At present there's a distinction by the ACGME on in-house vs. out of house moonlighting (the former counts, the latter does not) - this is clearly not going to pass the sniff test in court & force programs to ban moonlighting eventually outside of your vacations (ie. when you have no clinical responsibilities)
 
Originally posted by droliver
They had a split-liver donor (where a living person donates a part of ones liver) who died from infection (food poisoning from some shellfish I think) several days after a successful tranplant.
Click to expand...
Did this take place at the local Red Lobster or at the hospital? And the correlation to any aspect of provision of medical care is...what again?
 
as my new and improved signature says, I think it's absolutely comical that I now work longer hours than the residents.

some old fart attending can pull 48 hrs in house over the weekend, but the 20 something intern can't

what are these grads gonna do when they finish residency and actually have to work more hours?/:laugh: :laugh: :laugh:
 
HiFi, if the attendings are working 48hrs, they need more attendings. NO ONE -not even superhero surgeons!- can function properly if they are sleep deprived.

As for less time in the hospital=bad handovers, I don't believe it. Bad handovers are just a result of bad management/bad training. A non-sleep deprived resident has a better chance of doing a proper hand over than a sleep deprived one. There will always be handovers (unless you want residents to be forever on call for the rest of their lives!). If bad hand overs are a problem, educate the residents on how to do it properly, don't whine about the frequency. Practice makes perfect.

As for moonlighting, I agree the courts aren't likely to appreciate the difference of in- vs. out of house. That's the breaks. 80 hours is plenty long to be working anywhere. If money is the trouble, maybe you should join the suit against the match people so residents are paid wages sufficient to cover student loan payments.

P.S., HiFi, I like your signature about Russian roulette, but I'd change it to: I've worked over 120 hours this week and I haven't killed anyone yet, therefore I conclude it is safe.
 
Originally posted by Annette
HiFi, if the attendings are working 48hrs, they need more attendings.
Click to expand...

well that's easy to say unless of course you happen to join a small neurosurgery group, or go on faculty in a critical care dept, and one weekend a month you are on primary call for the weekend.

will you get lucky and get some rest? maybe. But if it's hoppin', you'll be working the entire weekend......all while you go through 2 sets of residents and fellows.

some people will be in for a shock when then finish residency and all of a sudden, are no longer coddled. you will encounter very little sympathy amongst established physicians that did residency when giants walked the earth
 
It's one thing to say you were in house WITH residents and Fellows than it is to say I worked 48 hours ALONE WITHOUT ANY MD HELP. Then I'd call you a giant. ;) If you have residents and fellows you have it cush. Anyway, I wouldn't want you treating my family at the 47th hour with or without coverage. I think it's dangerous for patients and there should be a better system 48 hours in a row for one physician. I bet you'd have plenty of juries who agree in case you are not willing to make changes in the coverage system. Lastly, I bet some of the fresh fellows and residents "helped" you out quite a bit during your 48 hour stint.

I had to walk 5 miles in 4 ft high snow drifts to get to school suffering frostbite and loosing some toes and fingers , but hey I'm a giant!
 
80 hours= coddled?

I don't understand the macho BS. Why do doctors continue to believe that they are superhuman?

Would you fly in a plane piloted by someone who BOASTS that they have been up more than 24hours? I certainly wouldn't. Why should I trust my life or that of a loved one to someone who hasn't slept? To do so is negligent.
 
I got an A on the paper and presentation:clap: :clap:

Just a comment....during the presentation, there were a lot of shocked faces and I had a lot of questions at the end. This was an English class that I never took as a freshman, so there are many non-science and non-premeds in the class. Most people have trouble comprehending the amount of time that residents must put into their work week. Many people even found the new 80 hour rule unbearable...and couldn't see how anyone could go that long without a mistake. It's amazing how most people are completely clueless about graduate medical education.

Thanks for all the helpful input everyone!!!
 
So far, I'm not liking the 80 hour restriction much. Take today, for example. I was on call, 7a-7p covering my service plus 2 others. Night float comes on at 7p, and I must leave.

So the two scheduled admissons for surgery tomorrow show up at about 3. I put the orders in, but find I've been left with insufficent information to do so quickly, so I have to make some phone calls (eg to order blood on call to the OR you must enter into the computer what operation the pt is going to have. I have a note telling me to order the blood but it dosen't tell me what operation the pt will have. I cannot find a scrap of paper anywere telling me what the pt is having done, and, naturally the pt doesn't know.) So I'm just about to go start the H&P's when my pager starts going crazy. The ID fellow is concerned about a pt with fungemia, wants me to look at a wound and change antifungals. A pt gets transferred from the unit off insulin drip without sliding scale. I don't know how to get the sliding scale into the computer. Several pts can't poop and want laxatives, etc, etc....until it's 6:45, and my night float finds me getting rather frazzed, my previously organized list now in total chaos and he gets a rather crappy sign out with 2 H&P dumped on him.

I would much rather be able to stay and finish what I started while the pages start going to the night float. However, I must leave at 7 lest I go over hours. I would have felt much less frazzled had I just been able to take care of the pages knowing I would be able to finish the admission paperwork uninterrupted.

I know it's bad for pt care to be overly tired, but it's equally bad to have a bunch of doctors who really don't know what's going on with the pts. That's what I believe is happening.
 
Hifi

circular reasoning completely.. .yeah i can stay awake for 2 straight days,, and i have done it... but does it make it right.. i can put in a central line blind folded . do i do it? NO!!!!! just because it can be done that does not mean its the right way of doing things....... the macho bull **** that medicine is pulling is what is bringing medicine down.... this is a business.... clearly.. if it were not medical education would be completely funded by the states..... so residents and fellows have aright to organize and demand reasonable working conditions with reasonable compensation.. Once medical profession becomes so undesirable that no one will be entering it.... thats when things will change because thats where its headed chief
 
I for one am glad that this 80-hour rule will be in effect by the time I start residency, and am hoping the hours will be reduced even further in the near future. It would be great if we could get residency hours down to 50-60 hours per week like most other countries.
 
Originally posted by ArrogantSurgeon
I for one am glad that this 80-hour rule will be in effect by the time I start residency, and am hoping the hours will be reduced even further in the near future. It would be great if we could get residency hours down to 50-60 hours per week like most other countries.
Click to expand...

Are you then willing to extend your training by several years?
 
Originally posted by Kimberli Cox
Are you then willing to extend your training by several years?
Click to expand...

Do you have evidence showing that shorter training times hurt patient care?

I know that seems logical but we dont know that to be the case.

HRT lowers LDL and raises HDL, thats a fact. So using your logic one would have to conclude that its automatically better for cardiovascular health.

Ooops.. it turns out when we measure HRT vs heart disease DIRECTLY, instead of INDIRECTLY, its WORSE for you.
 
MacGyver,

actually there is a fair bit of experience with abbreviated training programs in the US & UK & the consensus has been that a signifigant # of them subjectively needed clinical retraining to be deemed competent as well as they objecively had higher failure rates on board certification exams. This comes from experiments with shorter residencies in the 1970's in the States & more recently in the U.K.

The take home message is that there's no free lunch when trying to trim the fat from surgery training. Less hours @ work will mean fewer patient contacts and operative experience & its pretty easy to see that a number of newly trained surgeons will be less well trained then their forebears. How much of a dropoff we're willing to accept and what part of a surgical curriculum will be more or less emphacized for general (& the subspecialties) are the questions being generated by these new parameters
 
Originally posted by droliver
MacGyver,

actually there is a fair bit of experience with abbreviated training programs in the US & UK & the consensus has been that a signifigant # of them subjectively needed clinical retraining to be deemed competent as well as they objecively had higher failure rates on board certification exams. This comes from experiments with shorter residencies in the 1970's in the States & more recently in the U.K.
Click to expand...

Link please.


The take home message is that there's no free lunch when trying to trim the fat from surgery training. Less hours @ work will mean fewer patient contacts and operative experience & its pretty easy to see that a number of newly trained surgeons will be less well trained then their forebears.
Click to expand...

If thats true then why not make surgical residency 10 years long?
 
Originally posted by MacGyver
Do you have evidence showing that shorter training times hurt patient care?

I know that seems logical but we dont know that to be the case.

HRT lowers LDL and raises HDL, thats a fact. So using your logic one would have to conclude that its automatically better for cardiovascular health.

Ooops.. it turns out when we measure HRT vs heart disease DIRECTLY, instead of INDIRECTLY, its WORSE for you.
Click to expand...

No, other than familiarity with the "experiments" mentioned by droliver in the post above.

At any rate, I was merely asking A.S. a question, not advocating a particular position on work hours/residency length.
 
I can understand that you need a certain amount of patient contact/interaction to be competent, but seriously, don't you think that being tired all the time is a good learning environment? And, alot of time we spend is wasted.

Time spent inputing sliding scale orders into a computer isn't time spent learning or becoming competent. I spent half an hour waiting for the lab to send up a stupid hemoccult card before I could start a patient on heparin. What did I learn during that half hour? The stupid lab phone number. Provide people to input the orders in the computer and stock the units appropriately, and we'll have plenty of learning time, and more time for patient contact. The 80 hour restriction will help the hospital realize that our time is valuable, and to "use" us appropriately.
 
The 80 hour work week doesnt seem to have done much for medical education. I spend much of those 80 hours doing paperwork and other things not really requiring an MD (like calling pcp offices to set up f/u appointments, or calling pcp offices to fax over charts). It would be nice if we could have an assistant to take care of such things.
I'm an intern who just started a few weeks ago. But I am pretty unhappy and have thought several times about just quitting this whole residency thing.
 
Y'all talk about this 80 hour work week thing as if it were going to happen. Pfffftttt!!!

I remain skeptical. I've been pushing 100 hours per week, and I must say I'm pretty damn efficient. There's just THAT much work (I mean, paperwork and other non-medical crap) to do.
 
Originally posted by Annette
As for less time in the hospital=bad handovers, I don't believe it. Bad handovers are just a result of bad management/bad training. A non-sleep deprived resident has a better chance of doing a proper hand over than a sleep deprived one. There will always be handovers (unless you want residents to be forever on call for the rest of their lives!). If bad hand overs are a problem, educate the residents on how to do it properly, don't whine about the frequency. Practice makes perfect.
Click to expand...

Just wanted to comment on the handover issue... I'm an EM resident, and sign-out is a fact of life for us. We generally try to tie things up and have a dispo for people before we leave so that people don't fall through the cracks. Sign-outs, no matter how good, have an inherent problem... the next person is NEVER going to know your patient as well as you do. They are not going to spend as much time talking to your patient, they are never going to know the details as well as you did, and they were not there when the patient arrived so they won't really know what the original exam was.

Just a tangent...
 
I thank my lucky stars for these new laws everyday. The overnight call at my Prelim Med program has been effectively reduced from Q4 last year to about Q8 this year... and that is a humongous difference in terms of the lifestyle one leads in PGY-1.

I guess I just broke the law today though... I was overnight call yesterday starting at 10am and I just got out... at 4:30pm! That's 30 1/2 consecutive hours!!! Oh my! :eek:
:p
 
Technically, 30.5 hours only breaks the regulations by 1/2 hour. You are allowed to have 6 hours after a 24 hour work shift for "sign-out", continuity of care, etc. During this time you are not supposed to be seeing new patients, consults, etc. Of course, that rule is broken all the time.

However, while it seems great to only have call q8 you really learn a lot on-call, especially if you're in a program which allows you a fair bit of independence. I dislike call as much as the next guy, but I find that now that we have less, I dislike it MORE (seems you get used to going home at night and sleeping in your own bed) and I feel like I'm learning less as the weeks go by.

Just my two cents...
 
The work week restrictions are working out pretty well in our program. We instituted a day float system where the day float residents come in the morning of our call (q4) to cover our patients. Thus, we get to sleep in before a long night on call, and the day float coverage gets a fairly diuresed patient list. We come in at noon, start taking our admissions, and can follow up on any tests initiated by the day float for the pre-existing patients. We admit until 7 am, at which time we round (there is a strict policy for attendings arriving early on our postcall days) and any new patients after that time will be worked up by day float and passed on to the on call team when they arrive at noon. Then we can see our patients for the whole post-call day (since we don't have to be out until 6) which is when the bulk of the diagnostics are done for the new admits. I've flirted with the 6:00 deadline almost every call, but have never gone over it, and am very close to 80 hours/week. I don't feel that my education has suffered as a result of this system whcih gives me time for patient care as well as morning report and noon conference every day.

As an internal med guy I will say this however, I can't imagine trying to accomplish all the things I do and still get all the technical training required of surgeons in the same amount of time.
 
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