ACGME work hours

[KeyzerSoze]

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My school sensibly decided to apply the new ACGME intern duty hour limits to M3 clerkships and M4 sub-I's, most importantly a maximum of 16 hours on site duty. I think it's great; I function terribly when I'm sleep-deprived and I'm glad that I won't have to do 24 hour call for at least the next 3 years, if ever. We can still do overnight call, but our shift would have to start in the afternoon.

Have most schools done this? What do you guys think about it?

 

[Dwindlin]

Thankfully mine has not.

 

[Perrotfish]

My school sensibly decided to apply the new ACGME intern duty hour limits to M3 clerkships and M4 sub-I's, most importantly a maximum of 16 hours on site duty. I think it's great; I function terribly when I'm sleep-deprived and I'm glad that I won't have to do 24 hour call for at least the next 3 years, if ever. We can still do overnight call, but our shift would have to start in the afternoon.

Have most schools done this? What do you guys think about it?

I came in before the new work hour rules, but we still only had one third year rotation with traditional call for students.

I feel like the biggest advantage here is for the Sub-Is. For several years my school has been on a system where Sub-I don't take call and Interns do, which basically means that the Sub-I is not an I in any meaningful sense. I think this system will, by giving them more parity with the real interns, give them proportionately more repsponsibility for patients.

 

[badasshairday]

I think it is stupid. As a third year on IM and Surg services, I saw the fourth years acting as interns and doing overnight calls and admits and dealing with the post admit work, which is when everything happens. I am paying to learn how to be a doctor, not a baby.

My school hasn't released anything official yet.

 

[Perrotfish]

I think it is stupid. As a third year on IM and Surg services, I saw the fourth years acting as interns and doing overnight calls and admits and dealing with the post admit work, which is when everything happens. I am paying to learn how to be a doctor, not a baby.

My school hasn't released anything official yet.

The reason that's when everything happens is because your hospital is designed around a call schedule: everyone admits all day and night on their call day until they cap. The new rules mean everyone is going to a night float system, so everything won't happen during a small fraction of the time you spend in the hospital but instead gets spread throughout the week.

I personally like the night float system more, at least at the hospital where I've seen it implemented. With this sytem patients are admitted to every team, every day. If they come in during the day the team admits, if they come in at night the night float team admits and then the day team basically re-evaluates them the next morning. So rather than the ridiculous binge and purge system where census lists swell to 20+ every call day and then might be at 3 people pre-call each service instead maintains a steady number of patients throughout the week.

You still do admits and you still do H&Ps. You just do them steadily throughout the week.

 

[KnuxNole]

Am i the only one who is HAPPY about that?

I greatly dislike 24 hour crappy calls. 16 hrs maximum is realistic for medical students. Most of the 24 hours is pointless anyway, since the sole reason med students are on the rotation is to learn...and I spend the majority of nights playing on my Iphone or sleeping, or interns tell me to go home early >_<

Personally, I dont see a point to night call at all after experiencing it. I haven't gained anything from it at all. People say cool cases come in at night, but I've experienced the opposite, all the cool and exciting stuff happens in the day, and people just sleep at night.

 

[MossPoh]

I think my school is supposed to follow it, but we train with attendings. No 4th years, interns, residents, fellows, etc. I have no idea how that will play into the equation with us, but I can easily see it as being a self-reported thing. I really don't care about working hard, but I would like a little time where I'm not exhausted to study on my own too. My biggest problem is that I've never been a clockpuncher type. I've also adopted the viewpoint that I wouldn't be doing anything more beneficial if I were home anyway. (I function on very little sleep on a normal day) I suppose I will find out in 2-ish weeks for sure though...

 

[Law2Doc]

The reason that's when everything happens is because your hospital is designed around a call schedule: everyone admits all day and night on their call day until they cap. The new rules mean everyone is going to a night float system, so everything won't happen during a small fraction of the time you spend in the hospital but instead gets spread throughout the week.
...

Nah, the reason you miss stuff has very little to do with admissions and call schedules. You learn in intern year that the crazy stuff all happens at night. Why? A couple of reasons. First, there is a phenomena called sundowning, that late at night is when a disproportionate number of patients crash. Second, people often bide their time in coming to the hospital, maybe suffering through their ailment while at work, and decide to come to the hospital after. Moreso in peds. Third, the drunks, drug abusers and the gun and knife club come out at night, so that's the time people are going to do stupid things to themselves and others. Finally, there is not a lot of attending or senior supervision, so a med student will get more of a window into how interns have to function independently. And since there are fewer free hands at night, a med student my get to do more.

I honestly have to say that some of my sub-I experiences and working q3 helped a lot in terms of the adjustment to intern. I am not really sure how the experience changes now that the 24 hour shifts don't start until PGY 2, but think that med students do benefit from the long hour shifts, even though they will hate them at the time. There's a lot you can learn on the wards at night if you are there enough. My two cents from someone who had NO hour restrictions as a med student and who did components of both 30 hour call and night float during intern year.

 

[deleted263296]

Medical students need hour restrictions because they aren't employees and they have to study. Still, though, as a medical student, you shouldn't realistically be at the hospital more than 12-14 hours a day unless you are on call.

 

[KnuxNole]

Medical students need hour restrictions because they aren't employees and they have to study. Still, though, as a medical student, you shouldn't realistically be at the hospital more than 12-14 hours a day unless you are on call.

QFT

I basically try to read after rounds until the day is over(unless residents need excessive help) to make up for it though, just to have at least a little bit of productivity.

 

[Perrotfish]

Nah, the reason you miss stuff has very little to do with admissions and call schedules. You learn in intern year that the crazy stuff all happens at night. Why? A couple of reasons. First, there is a phenomena called sundowning, that late at night is when a disproportionate number of patients crash. Second, people often bide their time in coming to the hospital, maybe suffering through their ailment while at work, and decide to come to the hospital after. Moreso in peds. Third, the drunks, drug abusers and the gun and knife club come out at night, so that's the time people are going to do stupid things to themselves and others. Finally, there is not a lot of attending or senior supervision, so a med student will get more of a window into how interns have to function independently. And since there are fewer free hands at night, a med student my get to do more..

1) Sundowning is not when patients 'crash'. The medical term sundowning refers to a phenomenn where demented patients seems to get less coherent around sundown. However it doesn't mean that there is a sudden rash of code Blues, fevers, and projectile vomiting that occurs in the middle of the night, which would be actual medically treatable phenomena that would need your attention. If that's happening at your hospital it's a sign your nurses are doing something horribly wrong at shift change. Actually sundowning is yet another great reason why all the real changes in patient management happen on morning rounds: many of your patients will be too incoherent to give a meaningful history if you try to significantly change your plan in the afternoon.

2) At least on my ER shifts there was not a sudden rash of patients in the afternoon or at night. Night was when the ER got empty. It turns out that most people, even drunks and drug abusers, sleep at night and do their shady antics during the day. At night patients with heart pateients don't move around and strokes quiets miss the tPA window without anyone ever waking up. Gangbangers get their beauty sleep and diabetics utterly fail to send themselves into hypoglycemic shock by miscalculating their insulin dose. As for the idea that there is an evening rush because people are 'suffering through work' rather than miss a day of precious labor, all I can say is that I LOL'd pretty hard.

The reason you see more patients at night on call is that that's when your team starts accepting patients. That's it. They stack up in the ER during the morning while you round on your existing service and then, when you start accepting at noon, you slowly work through what has built up throughout the day. You could have accepted and managed them in the morning if you were doing H&Ps then, but you were getting in (relatively) late and then rounding on your existing patients because that's how hospitals work when they have a traditional call schedule. If you did admits throughout the day, every day, you would probably notice that then you, like the ER, would have most of your business in the morning.

3) As for the last qualification, that evening is the only time residents are unsupervised enough to grow as professionals, I will admit that's true but I will not admit that it needs to be true. The current system, where residents are only left unsupervised when they are also sleep deprived, is not a necesity but a bad tradition. The real challenge with the new work hour rules, I think, will be creating a system where attendings allow residents autonomy during the day, rather than just at night. A simple system, for example, would be for attendings not to round on patients until the first morning rounds after they've been admitted to the hospital, so the residents still manage the patients independently during the critical first 24 hours.

 

[Law2Doc]

1) Sundowning is not when patients 'crash'. The medical term sundowning refers to a phenomenn where demented patients seems to get less coherent around sundown...
2) ... It turns out that most people, even drunks and drug abusers, sleep at night and do their shady antics during the day... Gangbangers get their beauty sleep...

3) As for the last qualification, that evening is the only time residents are unsupervised enough to grow as professionals, I will admit that's true but I will not admit that it needs to be true.

I respectfully disagree with everything you just wrote. There are more than one definition of sundowning, and yes there are a disproportionate number of codes at night. And it is a national thing, not just one set of nurses.
As far as the knife and gun club and substance abusers coming out during the day and not night, this is simply not the experience of major EDs and trauma centers in big cities in the US. It just isn't. It might be true in small towns and community hospitals, but that can't be extrapolated. A big city ED is going to be dead during the day and hopping at night. During the day the place will be full of folks with stomach bugs and other non emergencies. As far as number three, I simply think there's more value with night work than you apparently do, which is your prerogative.

 

[Law2Doc]

I guess we'll agree to disagree. I will say that my only ER experience comes from rotating through the only level one Trauma center in New Orleans. Days were busy, early at night we cleared out the waiting room, and by about 1 a.m. we would start clearing the actual beds. When the day shift came in the ER was normally more than half empty.

I certainly have had the reverse experience at multiple hospitals -- nothing to do trauma-wise until about 8pm, and then a wild race until about 4am. I'm pretty sure this is more the norm. There's a reason most episodes of cops are filmed at night -- there's an element of society that only comes out at that time.

 

[Sol Rosenberg]

Nah, the reason you miss stuff has very little to do with admissions and call schedules. You learn in intern year that the crazy stuff all happens at night. Why? A couple of reasons. First, there is a phenomena called sundowning, that late at night is when a disproportionate number of patients crash. Second, people often bide their time in coming to the hospital, maybe suffering through their ailment while at work, and decide to come to the hospital after. Moreso in peds. Third, the drunks, drug abusers and the gun and knife club come out at night, so that's the time people are going to do stupid things to themselves and others. Finally, there is not a lot of attending or senior supervision, so a med student will get more of a window into how interns have to function independently. And since there are fewer free hands at night, a med student my get to do more.

I honestly have to say that some of my sub-I experiences and working q3 helped a lot in terms of the adjustment to intern. I am not really sure how the experience changes now that the 24 hour shifts don't start until PGY 2, but think that med students do benefit from the long hour shifts, even though they will hate them at the time. There's a lot you can learn on the wards at night if you are there enough. My two cents from someone who had NO hour restrictions as a med student and who did components of both 30 hour call and night float during intern year.

I've heard this argument before, and always thought that it was pretty dumb (no offense.) All you are arguing for is that working during the nighttime provides a better learning experience than does working during the daytime. So just assign interns to night float then. How is this an argument for 30-hour shifts (i.e. call?)

 

[OveractiveBrain]

I've heard this argument before, and always thought that it was pretty dumb (no offense.) All you are arguing for is that working during the nighttime provides a better learning experience than does working during the daytime. So just assign interns to night float then. How is this an argument for 30-hour shifts (i.e. call?)

The biggest argument is that once a patient is admitted, all the decision making therapeutics or additional diagnostics happen in the first 24 hours. If you admit a patient at 8pm, go home at 11, and cant come back in until 9 the next morning (10 hours out of hospital) you've missed half the admission.

It isn't working at night or working during the day. Its working with that patient, from the start to the finish. After day 1, its all social work and placement, or "fellow, help me, please!" The first 24 hours are crucial to find out where you did it right, where you did it wrong, and to force you to clean up your own mess (i,e, not leave one).

Let me ask you this. have you ever come in the morning after as a medical student to find that your patient has changed beds, maybe even upgraded to the unit? How about something less severe. Medications had been changed, new labs you didnt know were coming in came in (or worse, your attending asks for the results and you didn't even know they were ordered). You weren't part of the medical decision making and had no idea what had happened. Happened to me. Alot. Who were the people making those decisions? The interns. Those decisions were made sleep deprived, but with a resident and attending safety net.

Look at it from the float side. Ever get a patient where you were all like "crap, what is going on with this guy, and why is the patient with a PE stroking right now?" Fixing people's messes or beign horrendously confused on patients that aren't yours isn't good training. You just keep them alive until the next morning when the "real team" comes back in and says "oh yeah, I knew about that, we weren't going to touch it, we already ruled out that..."

Lets go a little farther than residency. When you're a private medicine attending at a local hospital, working 7 on 7 off, you've got to admit or consult whatever comes in (unlimited number) and round on your census of 27 patients. Sleep deprived. Remember when you got that training in residency? Oh yeah... thats right.

But you'll say you get it as a resident! PGY-2! When you're more experienced, when you've had more time in the hospital. More time as a 5th year medical student, you mean. So now, the less-experienced pgy-2 is left alone in the hospital, has never been on his own before, and is expected to know what to do with one less safety net. Only him and the attending now. Oh, and you're also supposed to manage medical students and the interns below you.

Maybe it will be awesome. Maybe it will be the best thing imaginable. I for one am against the change. As some one who has done a many no-sleepers, 2pm on day two does suck, but I learned a hell of a lot about my patients and the flow of the hospital while I was at it.

 

[Law2Doc]

...Fixing people's messes or beign horrendously confused on patients that aren't yours isn't good training. You just keep them alive until the next morning when the "real team" comes back in and says "oh yeah, I knew about that, we weren't going to touch it, we already ruled out that...
Maybe it will be awesome. Maybe it will be the best thing imaginable. I for one am against the change. As some one who has done a many no-sleepers, 2pm on day two does suck, but I learned a hell of a lot about my patients and the flow of the hospital while I was at it.

Agreed. This may be one of those topics that you can appreciate after you are on the other side of internship and start to realize that there are other aspects of your training that are more important than a few extra hours of sleep. Patient management is very different when you are on call overnight with patients you know from the day rather than being the caretaker of a bunch of cross covers on night float. The learning experience is different. And it doesn't hurt to get exposure to this as a med student, at a time when you don't have the level of responsibility that you can actually hurt someone. When you are a senior resident you will see a Huge difference between the former med students who were given the intern-type treatment and those who were babied. You just will. And since first impressions are huge in medicine, you can quickly become "that" intern. The learning curve is astonishingly steep, so anything you can do in med school to lessen this makes a real difference.

 

[KeyzerSoze]

Agreed. This may be one of those topics that you can appreciate after you are on the other side of internship and start to realize that there are other aspects of your training that are more important than a few extra hours of sleep. Patient management is very different when you are on call overnight with patients you know from the day rather than being the caretaker of a bunch of cross covers on night float. The learning experience is different. And it doesn't hurt to get exposure to this as a med student, at a time when you don't have the level of responsibility that you can actually hurt someone. When you are a senior resident you will see a Huge difference between the former med students who were given the intern-type treatment and those who were babied. You just will. And since first impressions are huge in medicine, you can quickly become "that" intern. The learning curve is astonishingly steep, so anything you can do in med school to lessen this makes a real difference.

I certainly expected you to show up with your usual curmudgeonliness in the guise of sage wisdom, although I'm disappointed that some of my fellow M3s have already drank the Koolaid. The part I bolded is where you missed the point. The "intern-type treatment" doesn't exist anymore, because interns don't have to work 24 hours. Possibly within 5 years, and probably within 10 years, as residencies rearrange their schedules, it won't exist for most residents.

The rest of your arguments are generally wrong. ER's are definitely not more busy at night. This was my experience when shadowing in a big city knife-and-gun club ER a few years ago. In case I was misremembering, I emailed one of the attendings; she agreed with my assessment. Certainly not in peds, which was much busier during the day.

In any case, as others have pointed out, cutting down maximum work hours to 16 doesn't decrease number of hours worked at night. You just have to start working later in the day. Nor have the total number of hours decreased. The only change is that you are required to have a reasonable amount of time to rest in between shifts.

Amusingly, people were making the exact same arguments as you about continuity of care in the bad old days when Q2 call was the norm.

 

[Law2Doc]

...Certainly not in peds, which was much busier during the day. ...

Amusingly, people were making the exact same arguments as you about continuity of care in the bad old days when Q2 call was the norm.

first, the peds mention was a separate concept than the knife and gun club/trauma issue. Peds gets busy during the hour when the parents get off work, and then quiets down significantly. I don't think I was trying to suggest that peds was busier at night, but if it read that way, that's not how I meant it. The shootings/stabbings/substance abusers/drunk drivers come out at night. To suggest otherwise is simply inaccurate. I don't know what else to tell you, except that your experience is not the norm if you are suggesting that violent traumas happen at comparable rates during the day.

As for the continuity of care argument, I don't get your point. Yes people made those arguments when times moved from q2. Probably was true. That doesn't mean q2 was the ideal for other aspects of training, but for that aspect of patient care it was. It's pretty safe to say that the guys who did q2 learned more than my generation, who in turn will probably learn more than the folks who only do 16 hour shifts. And it's likely the patients will be similarly disadvantaged as we move to more sign offs. And that's fine as a policy decision. My only issue is, and always has been, that if you do it in the name of patient safety, it's bogus. You have to call a spade a spade-- you are doing it as window dressing to make the public happy that their doctor isn't tired in the wake of the Libby Zion fiasco. There is no data to support that patients are better off or that doctors are going to receive the equivalent training in ferew hours.

Also, I think we decided on another thread that the phrase "drinking the kool aid" has become the cliche of choice for folks who don't have a real argument. You may want to avoid that in the future.

 

[DrBowtie]

Anyone else hate how you get new patients in the AM night float checkout? We get an H&P but it is never enough info to really be able to present the patient so we are scrambling to round on our old patients and then go basically retake the H&P on the new admit.

 

[Jolie South]

Anyone else hate how you get new patients in the AM night float checkout? We get an H&P but it is never enough info to really be able to present the patient so we are scrambling to round on our old patients and then go basically retake the H&P on the new admit.

I thought that was the point. Where I am, the night admitting resident just tried to keep them alive till the actual day team took over. We always did a new H&P on them and ordered extra labs/imaging.

We would never round though until noon or so if we were short call or on day call that accepted all previous night time admits.

 

[45408]

The reason that's when everything happens is because your hospital is designed around a call schedule: everyone admits all day and night on their call day until they cap. The new rules mean everyone is going to a night float system, so everything won't happen during a small fraction of the time you spend in the hospital but instead gets spread throughout the week.

You still do admits and you still do H&Ps. You just do them steadily throughout the week.

So that way, your day is steadily interrupted with new admissions while you're trying to take care of your existing patients?

Personally, I dont see a point to night call at all after experiencing it. I haven't gained anything from it at all. People say cool cases come in at night, but I've experienced the opposite, all the cool and exciting stuff happens in the day, and people just sleep at night.

I've only seen one ruptured AAA, and it came in at 12:20am. I've only had one full-on v-fib arrest in one of my patients, and that was around 3am.

The med students sleep at night because we forget to call them 😉

2) At least on my ER shifts there was not a sudden rash of patients in the afternoon or at night. Night was when the ER got empty. It turns out that most people, even drunks and drug abusers, sleep at night and do their shady antics during the day....Gangbangers get their beauty sleep

Then your experience must be jaded by the Louisiana heat where everyone comes to the hospital in the heat of the day to get some nice A/C, because in the dozen+ hospitals I've worked at, and especially the ambulance company I worked for, the bad sh-t happens at night, without fail. People do suffer through abdominal pain all day, and when they realize they're not going to be able to sleep at night, they come in for their appy/perfed ulcer/fecal peritonitis to get taken care of. In my entire intern year, I can't think of a single patient who came to the ER at 8am with an intra-abdominal catastrophe, compared to the dozens who show up between 10p-3a. As an EMT, all the violence happened after people woke up from their drunken stupors in the late afternoon.

The reason you see more patients at night on call is that that's when your team starts accepting patients. That's it. They stack up in the ER during the morning while you round on your existing service and then, when you start accepting at noon, you slowly work through what has built up throughout the day. You could have accepted and managed them in the morning if you were doing H&Ps then, but you were getting in (relatively) late and then rounding on your existing patients because that's how hospitals work when they have a traditional call schedule. If you did admits throughout the day, every day, you would probably notice that then you, like the ER, would have most of your business in the morning.

As a surgery service that accepts patients 24/7/365 with no caps, no other teams, and no buffer, I can say this is patently false. I also know that the ER is by far the most swamped around 8pm on a Friday/Saturday night.

I've heard this argument before, and always thought that it was pretty dumb (no offense.) All you are arguing for is that working during the nighttime provides a better learning experience than does working during the daytime. So just assign interns to night float then. How is this an argument for 30-hour shifts (i.e. call?)

For surgery anyway, night float involves no elective cases, so you lose all of that experience every time you're on night float.

I certainly expected you to show up with your usual curmudgeonliness in the guise of sage wisdom, although I'm disappointed that some of my fellow M3s have already drank the Koolaid. The part I bolded is where you missed the point. The "intern-type treatment" doesn't exist anymore, because interns don't have to work 24 hours. Possibly within 5 years, and probably within 10 years, as residencies rearrange their schedules, it won't exist for most residents.

It won't, but it does as of today (which is why I'm on overnight call right now).

The rest of your arguments are generally wrong. ER's are definitely not more busy at night. This was my experience when shadowing in a big city knife-and-gun club ER a few years ago.

So why do they always film Cops at night? And, in your experience, what time do drunken bar fights happen?

 

[KnuxNole]

That happened to me in my family med rotation, the resident told me to go to sleep and I'll get woken up when there is a cool admission or if there is a backup in admissions. I ended up sleeping for 10 hours straight because he forgot I was still there =O

 

[ZagDoc]

All the central lines I put in as a student, I did at night. 90% of the lacs I sewed were at night. 90% of the trauma evals I was part of were at night. All of the emergent surgeries. I definitely got more resident teaching at night. Most of my experience learning to function independently as a sub-i was at night when I would help the on-call resident triage. You don't have someone say "I need to see these 3 new trauma admits, can you go eyeball the x that just got out of the OR and tell me if they're stable, trying to die, or actively dying?" to you and send you to go make clinical decisions during the day.

Plus I'd be very hesitant about choosing to go into a call-heavy specialty without ever experiencing call. I had quite a few classmates who were all set on surgery until they saw what surgery call was like.

Call (and hours in general) shouldn't be a masochistic thing for students, I agree. Students need time to study for shelf exams and read up on their patients. But not everything you need to learn as a med student is on the shelves or in the books. And call is also an important part of what your residency will be like. Choosing a field without experiencing would be a disservice to the student IMHO. Do a q6 or q7 thing, one call a week. Thats enough to get your feet wet and hopefully have some memorable experiences.

 

[KeyzerSoze]

So why do they always film Cops at night? And, in your experience, what time do drunken bar fights happen?

What's with the fascination with Cops in this thread?

 

[45408]

What's with the fascination with Cops in this thread?

The Five Oh go hand in hand with the Knife and Gun Club.

 

[45408]

Plus I'd be very hesitant about choosing to go into a call-heavy specialty without ever experiencing call. I had quite a few classmates who were all set on surgery until they saw what surgery call was like.

Absolutely. I needed to know if Q4 in-house call would be murder or if it was something I could handle.

 

[cpants]

For surgery anyway, night float involves no elective cases, so you lose all of that experience every time you're on night float.

True, but you always miss cases during your off time. You miss all the elective cases on post-call day every time you are on overnight call. On a Q3 schedule that is missing 7ish full days of elective cases every month, more than you would miss taking a week of night float every month. The new rules provide for the same 80 hour work week that interns currently experience. It just requires programs to restructure the scheduling so that people who have been awake and working for 30 hours aren't operating/prescribing dangerous medications/missing diagnoses/etc.

How many physicians get in car accidents driving home from a call night? What's scarier: that these docs were driving that tired or that that they were making life and death decisions ten minutes earlier? It is a pretty common sense move, one which they will be expanding to encompass all of residency in the future by the way.

 

[ZagDoc]

True, but you always miss cases during your off time. You miss all the elective cases on post-call day every time you are on overnight call. On a Q3 schedule that is missing 7ish full days of elective cases every month, more than you would miss taking a week of night float every month. The new rules provide for the same 80 hour work week that interns currently experience. It just requires programs to restructure the scheduling so that people who have been awake and working for 30 hours aren't operating/prescribing dangerous medications/missing diagnoses/etc.

How many physicians get in car accidents driving home from a call night? What's scarier: that these docs were driving that tired or that that they were making life and death decisions ten minutes earlier? It is a pretty common sense move, one which they will be expanding to encompass all of residency in the future by the way.

I know it's probably coming, but let me tell you, getting just the interns compliant with 16 hours has been freaking ridiculous - but gettings the seniors compliant would be literally impossible. It's a simple manpower issue and the math doesn't add up. Plus it undermines the very foundation of surgery (i.e. you cut the person, you're their doctor, hell or high water).

 

[Perrotfish]

I know it's probably coming, but let me tell you, getting just the interns compliant with 16 hours has been freaking ridiculous - but gettings the seniors compliant would be literally impossible. It's a simple manpower issue and the math doesn't add up. Plus it undermines the very foundation of surgery (i.e. you cut the person, you're their doctor, hell or high water).

If that's the foundation of surgery, why does this philosophy disapear the second someone's an attending? I know very few senior private practice surgeons working 80 hour weeks or 30 hour shifts, and we've all seen pleny of attendings finish their last surgery of the day and then walk straight out of the hospital for their week off. So why is OK for them to have a different physician round on their patients for them but not us?

 

[45408]

True, but you always miss cases during your off time. You miss all the elective cases on post-call day every time you are on overnight call.

Uh, no, you don't. Far more of our cases start and finish before noon than after. I did an elective inguinal herniorrhaphy on Monday while being post-call.

The new rules provide for the same 80 hour work week that interns currently experience. It just requires programs to restructure the scheduling so that people who have been awake and working for 30 hours aren't operating/prescribing dangerous medications/missing diagnoses/etc.

Psssst, the interns aren't doing much operating. It's the PGY 3-5s who are doing the bulk of it. Now they won't be doing a whole lot of operating or seeing all of the stuff that rolls in at night.

How many physicians get in car accidents driving home from a call night? What's scarier: that these docs were driving that tired or that that they were making life and death decisions ten minutes earlier? It is a pretty common sense move, one which they will be expanding to encompass all of residency in the future by the way.

So, error rates have gone down since they implemented these rules, and they're going to be researching the effectiveness of the new changes too, right?

The new rules are trying really hard to turn your intern year into your fifth year of med school, at least for surgery. Might as well keep the short coats.

 

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If that's the foundation of surgery, why does this philosophy disapear the second someone's an attending? I know very few senior private practice surgeons working 80 hour weeks or 30 hour shifts, and we've all seen pleny of attendings finish their last surgery of the day and then walk straight out of the hospital for their week off. So why is OK for them to have a different physician round on their patients for them but not us?

Last night, one of my attendings called in to check on his ICU patient at 11pm, when he wasn't on call. You're using anecdotes like gospel.

The reason you rarely see an attending surgeon working 30+ hours straight is that they're not covering nearly as much as a resident is. I'm covering a lot more than just one general surgeon and his/her patients at night.