How did you hear of the survey? Just curious. As a med student, I didn't get any e-mail or snail mail notification of this survey.
As a PD, the ACGME oversees my program. They emailed me. I assumed they somehow distributed it to students. Apparently not.
So are residencies just going to get longer then?
Nope. Costs too much for the Fed Gov't. And, if IM went to 4 years and FP stayed at 3, it would be bad for IM. And, there is no way that the fellowships would tolerate another year delay. So this ain't happening -- at least not in IM.
Unless and until such time as programs/hospitals no longer maintain their schizophrenic attitude toward residents (ie nearly free labor v. physicians in training), institutions who are so inclined will not willingly do this. The more malignant programs will encourge in subtle or perhaps not so subtle ways, dishonesty in hours reporting.
I'd like to think that I happen to run one of those programs that actually cares about residents and doesn't just abuse them, but I agree that if programs see residents as simply free labor, they will get as much work out of them as possible regardless of the rules.
One of the suggestions of the IOM task force, not talked that much about, is developing an independent monitoring body -- recognizing that the ACGME shouldn't really be the watchdog for duty hours, as they are somewhat conflicted.
Yet, this is precisely what needs to happen. I could care less about 80 hours and 1:7 off. My body on the other hand, insists on a reasonable sleep period on a daily basis. One institution was able to accomplish close to this by splitting the night between intern teams. One intern took the "early" shift and worked 11-3 then went to sleep, and the other picked up the 3-7 "late" shift while the first slept. Then the regular daily routines began. There are solutions.
It's a great idea, assuming that the number of patients covered by each intern is reasonable. If each intern is assinged to cover 30-35 patients, but then when they sleep they each cross cover 70 patients, you've just traded one problem for another.
I agree with you that 24 hour call is bad. I have been trying to move to a more night float type system, with much resistance. From the residents themselves.
But, the IOM is correct in this case. I think the easiest fix is to give hospitals the incentive to properly assign value to their labor pool. The only way to do this is to allow residents to change residencies in a reasonable manner if they find themselves in a bad program, and vice versa. Then, there would be less need for direct rule making since bad programs will quickly become known and if they want to attract the residents they want, they will have to clean up their act and make it known. The end result will be an improvement in working conditions for everyone, and I believe a happier, healthier, more motivated residency corps.
What exactly is stopping residents from changing programs?
1. Contracts -- most contracts have some sort of "notice" clause. Requiring 60-90 days notice seems reasonable, although an argument for 30 days notice could be made.
2. Funding -- programs are funded and credentialed for a specific number of spots. I can't just take an extra person if I want to, unless I have an open spot. So if you want to leave your position, you can't simply be hired anywhere else. Since most spots are filled, there is a very low "open jobs" rate which makes it difficult to change programs.
3. Fear -- this is probably the biggest problem. If a resident leaves another program midstream, and tells me it's the program's fault, I think of two things: 1) It's really the resident's problem, and 2) if the program is really that bad, this resident is going to be way behind. Either way, these cases can be a huge problem, since once the resident starts in my program they're now my problem
These recommendations are not pulled out of hats. They are the result of some knowledge of sleep hygiene and have been tested over the past 100 years or so. These recommendations are generally nearly the same as the requirements listed in 14 CFR 135 Subpart F. (135.265, 135.266, 135.267).
These rules require time on duty not to exceed 8 hours for a crew of 1, 10 hours for a crew of 2, and rest periods of 10 hours between on-duty times.
These regulations do contain provisions for exceeding work rules limitations if delays or duty requirements cause the hours to be exceeded beyond the control of the organization, but they also carry a sanction: if duty hours are extended beyond the maximums, even if beyond the control of the company, then the rest periods are appropriately extended.
What this amounts to is a cumbersome and complicated set of record keeping and duty hours monitoring. This is the downside and its a royal pain. The upside is that since we enacted these regulations in this sector, the "mistake/accident" rates plummeted.
The comparison to aviation is made often, and is somewhat reasonable. There is no question that duty hours for pilots and other safety changes (i.e. checklists) have greatly decreased accidents and errors. However, the comparison has some problems: The main problem is basically this: Pilots interact with the plane, whereas physicians interact with patients. If I'm in a plane, I really don't need to meet the pilot, nor do I care if it's a different pilot who flys my return flight. Since the plane is very standardized, the pilot can do his or her job basically the same way each day. Medicine doesn't work that way -- doctors interact with patients. Patients and their families are all unique, and unpredictable. Standardization doesn't really work, and continuity is important.
Example:I was on a plane once that was delayed, and then finally the crew announced that they were going to be over their hours. So what happened? The flight was cancelled, and I was rebooked the next day.
Problem is, that doesn't work as well in medicine, as people get sick and they can't just wait until the next day. An example is this: I was just on the inpatient service with one of my teams. We were working a shift -- supposed to admit until 7P, home by 9P. All was going well, until a family came in at 6:30P and wanted to talk about their loved one. We spent quite a while talking to them, and then ended up leaving late. What should be done? We could tell families that we can only talk to them between 3-5P. The team could come in later the next day, but then they miss morning report and their discharges/patient care are all delayed (or someone else starts rounding on their service and their autonomy is undermined). Or we have the night float, who doesn't know the patient well at all, try to answer their questions so we get home on time.
I'm not sure what the right answer is, and I agree that if people are working too many hours and are too tired, then care gets compromised also.
Example #2: Birth of my first child. Wife goes into labor. Very excited. Come to hospital. Seen by MD #1. Told all looks good, get ready to be new parents. About 4 hours later, seen by MD #2. Examines wife, her exam is completely identical. Get told that her reflexes are brisk, worried about pre-eclampsia. MD #2 starts Mg. All contractions stop, Pit gets started. 4 hours later, MD #3 comes in. I suggest that maybe she doesn't really need the Mg. I get told that he can't tell me, since he didn't see her on admission. But now her reflexes are fine, so we have to assume that the Mg is needed. Pit's causing her contractions to be more painful, so she gets an epidural. MD #4 arrives (next shift), examines her, says she can't have the epidural because it's somehow interfering with her contractions. But she's not fully dilated yet, so not ready to push. I wonder why the last MD, here just an hour prior, ordered the epidural. MD #4 says they didn't really discuss it, he was just told that she had an epidural and he was here to check it. So the epidural is off. Pain is back for hours. MD #5 arrives and wonders why the epidural is off. Our baby was delivered by MD #7. We had a healthy girl, and all is well.
But it sucked. Shifts signing out to each other, and knowledge gets lost. There's no way to sign out everything perfectly. And most importantly, it would have been SO NICE to actually see one person in continuity for our baby. Maybe not 24 hours in a row, as everyone need sleep. But I think that in this discussion we can lose the importance of patients bonding with a single physician. It's really important. This team based care stuff is crap. When I'm sick, I don't want a team. I want a doctor to take care of me.
We could fix this with shorter shifts, just like the nurses do. Problem is, that doesn't work well
Honestly, this is the thing that drives me crazy about nursing. We see a patient. I spend 20 minutes talking to the nurse, getting them up to speed on the plan. 4 hours later I get paged. New nurse, same questions. They sign out BM's, IV's, and anything else that can be nicely put in a nursing flowsheet. They have no good way to actually signout knowledge -- because I'm not sure there is one.
The other problem with shifts is teaching. We have morning report every day. It's the best conference of the day. Problem is, if we create afternoon (swing) and night shifts, you can't go to morning report. And I can't simply create Evening reports -- there won't be enough attendance, etc.
The IOM is being generous (and reasonable in my opinion) by mandating a maximum of 16 hours on duty. 10 hours is a reasonable rest period, given what we know about sleep requirements of mammals.
I agree. I feel that 24 hour shifts are wrong. 16 hour shifts + 10 hours rest = 26 hours, so really the maximum shift is 14 hours.
The problem in my program is very simple. Most discharges happen in the early AM, but most admissions happen in the late PM. because the hospital is full almost all the time, we can't take outside transfers until the current patients are discharged and the rooms have been "turned over". So, teams need to be here in the early AM to round / discharge, but then also late to admit, and you can't really fit both in. I wonder if the way to address this is to have an "admitting" team who just does admissions, and then "rounding" teams that just take care of the daily needs of patients. This leads to many more handoffs, which is not necessarily a good thing.
The problem is that prior to the threat of legislation by Conyers/Wellstone in 2001/2002, the ACGME and institutions gave lip service to the hours limits, even those enacted by law in NY and RRC rules, which one PD brazenly told me that "RRC rules don't apply to this hospital. The needs of the hospital come above the RRC rules." This phrase and that attitude is etched into my memory forever. It is wrong. It is unjustified. It cannot be made right. And the worst: it teaches precisely the wrong lesson.
It is wrong.
I still wonder exactly what the right answer is. I worry that as we create more rules and shifts, we will simply move the responsibility for patient care from residents to others. And in the end, residents will become as disposable as medical students, not have any real responsibility for patient care, and not learn anything. There must be a happy medium somewhere, but I fear overshooting it.
