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AMA debates residency hours... Opinions??

Discussion in 'Clinical Rotations' started by LibraTN, Jul 4, 2001.

  1. LibraTN

    LibraTN Junior Member

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    I read an article today at TIME magazine's site talking about the AMA's upcomming annual meeting, and the fact that residency hours will be a topic of discussion there. It basically states the two sides of the arguement as
    1) Current physicians (and perhaps some others) who think that 100 hours weeks and the 36-hour day are the key to fantastic infalliable doctors.
    2) Groups of residents and their supporters who have submitted petitions to reduce the working hours. These requests have been supposedly backed up with proof that residents are at higher risks for car accidents, depression, and making incorrect decisions on the job.

    I am just interested to see what everyone thinks about this topic. If you have a strong opinion either way, it might be more interesting if you include you current relation to the medical field.

    If anyone wants to check out the whole article (it's short), here's the link:
    http://www.time.com/time/health/article/0,8599,131146,00.html
     
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  3. Stephen Ewen

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    Thank you for posting this. I will be watching with great interest. Obviously, I concur with the more sane view on this subject.

    I really think the biggest barrier is simply personal vendetta, as the article stated--"I went through hell to get here, and I'll be damned if you're going to get through this without experiencing exactly the same hell."

    It is truly incredible how progress forward, whatever the realm, can be so impeded by this "underneath" thing, which is often the real undegirding thing under all the supposedly higher arguments for maintaining "things as usual."
     
  4. LibraTN

    LibraTN Junior Member

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    I agree with your thoughts Stephen. Although it is surely human nature, it is sad that sometimes those who have jumped 100 hurdles to win want their teammates to jump 100 as well, even if 80 would win the race. I am reminded of a tribe in Africa that practices a certain unpleasant tradition involving removal of external aspects of the female pleasure center during adolescence. Who are the biggest proponents??? None other than the adult women of the tribe.
    Whether or not the shortening of residency hours will compromise the quality of physicians the American system produces is open to debate, but aren't there other relevant issues here? What about doctor's well-being? It will be interesting to see what happens here. I personally think that any changes will be minimal, having little or no overall effect on residency lifestyle. At least patients in the US know that their doctors are hard workers and are willing to do whatever it takes to learn to best care for them. ;)
     
  5. pre-hawkdoc

    pre-hawkdoc Senior Member

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    I completely agree with everything that has been said, except for the fact that the ONLY reason the practice of 100 hour weeks still exists is because it is a rite of passage. The fact remains that there is work to be done and only so many people that are qualified to do it. So, until med schools start cranking out more doctors and someone comes up with a way to pay them, residents will continue, partly out of necessity, to work incredibly long hours. The argument would be to have the attendings pick up the slack, right? On the surface, this seems logical, but they don't exactly work 9-5, either. Besides, how many people would reconsider medicine if they knew that they would be pulling resident-like hours until they retire?
    Again, I don't disagree with the fact that there are definite downsides to the current system. However, it is naive to think that you can just limit residents' hours and the problem will be solved. Keep in mind that they're at the hospital doing things that need to be done, not just hanging out to get their hours in.
     
  6. Winged Scapula

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    Ahhhh....a topic near and dear to my heart.
    Its day 4 of residency (I haven't counted today yet) and I've worked 67 hours, 1 night on call on which I would have gotten a couple of hours of sleep except that my roommate was on adult trauma and his pager went off all night long and the call room was freezing. :eek:

    Its actually not too bad, I'm not too tired. Fortunately for me, yesterday was a holiday and we got to go home early - no clinic, no scheduled surgeries and me post-call. Had it been a regular day I would have had to stay all day. Apparently "post call home early" isn't the norm here! :(

    I'll move this topic to Rotations and Residency forum for ya!
     
  7. mcwmark

    mcwmark Senior Member

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    Kim-

    Good to hear you're surviving...I remember the days from Chrononet (that was you, right?) with Greg and Kent, helping a bunch of pre-meds like me back in the (Internet) stone ages...

    As a future resident (current med student) I realize how difficult it is (trying) to stay awake the next morning after call, and how dangerous that can be for yourself and your patients. But then again, after residency, I do want to have been exposed to as much as possible, so that one day when someone needs a rare procedure done, it will not be the second time I've done it.

    But who knows? This debate will continue long past my residency years...
     
  8. lilycat

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    As pre-hawkdoc mentions, the work has to be done somehow, by someone, if residents aren't available to pull 100-hour weeks. So, my question is how do other countries manage this (ie, Australia, England, etc.). I know Kimberli has mentioned that in Australia, residency is longer, but how is the actual slack picked up? Can anyone shed some light on this?
     
  9. Hopkins2010

    Hopkins2010 Banned
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    I am actually very surprised that their have not been more lawsuits alleging that the resident was too sleepy to perform well and somehow caused the injury/death of a patient. Of course I've heard about the NY case and the ensuing legislation, but thats the only case I've ever heard of.

    That brings to mind two possibilities:

    1) The AMSA is greatly overexaggerating the possible risk that patients experience from long resident hours; or

    2) Hospitals/attendings are very good at covering up what happened at the hospital so that the patient and his/her family were never aware in the first place what mistakes might have been made due to resident exhaustion.
     
  10. Winged Scapula

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    Yes. That was me. Kent just finished his residency in FP and is now working in southern Virginia. Greg has a couple more years left of Rad Onc at the MD Anderson Center in Houston.

    Staying awake has not been a problem for me - I don't require much sleep. However, functioning at full capacity IS a problem when you are dead tired. I had trouble following orders and even started to write an order incorrectly. And that was just after being up "only" 36 hours! :eek:

    I'm sure once my system gets back into work mode after being off on vacation for so long, it will get easier. And "they" say your intern year is the hardest - it takes you twice as long to do everything because you're learning and it isn't second nature.
     
  11. Winged Scapula

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    Remember its socialized medicine in Australia. Residents are scheduled like shift workers - if I'm scheduled for days, I go home after rounds around 5 pm, someone else covers from 5-11 or so and then there is night cover until 8 am.

    The obvious disadvantage is that the person covering at night is cross-covering (ie, covering multiple services, some of which he may have little knowledge of the patients).

    Residents are paid a salary and overtime, although departments vary in how willing they are to pay for it.

    Citizens in these countries pay more money in taxes and the governments spend more in health care than the US government does. I'm sure some of it goes to physician salaries but everyone has a baseline coverage, with options to buy private insurance should they wish more.

    At any rate, the "slack" as it where is picked up by residents. Medical students do very little scut as compared to the US, but the residents can and do work long hours. Some services, like Surgical services, have someone who takes call and actually comes in - thus, these persons are often on all day and then work the nights, just like in the US. But they do get to go home when their done with their shift...unlike the US.
     
  12. Winged Scapula

    Winged Scapula Cougariffic!
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    I'm sure a fair bit of the latter goes on.
     
  13. lilycat

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    Kim,

    Glad to hear you're surviving (and managing to log on every so often). Have you managed to find a nice little med student to bring you food?

    Thanks for the info. on the Australian system. Is there any reason why shift work couldn't be adapted into the American system? I'm not sure if see how a socialized health care system facilitates it one way or the other.
     
  14. Annette

    Annette gainfully employed
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    In the UK, like the land down under, the system seems more humane than the US system. In medicine, teams (4) are on call once a week, and they take turns covering Fridays and the weekends. There is always a reg on duty, with two available for backup. There are two SHO's, one covering the wards and one the A+E. Same with the house officers. The people covering the wards are supposed to be off at 3am. The people covering the A+E leave early the next day. Everyone else goes home when the work is done. House officers average about 70 hours a week.

    The surgeons are a little differnt. For some reason they are always "there" but no one ever sees them! The house officers usually put in less time than the sho's and reg's.
     
  15. Dreamer

    Dreamer Senior Member

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    In the Eastern Europe where I started, we worked as long as it was necessary but by 6pm we usually were done. There was a schedule of docs on call including residents. In my hospital it was 1 IM, 1 OBGYN, 2Anesthesiologists and 1 Surgeon. When we were on Surgical city call 2-3Surgeons + resident and it could be a hell broken loose. After 24h shift you had to do your job and go home to sleep. If you had a hard night you could be covered with an expectation you'll return the favor.
     
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  17. Winged Scapula

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    I don't see how socialized medicine faciliates the hours either except that because of the higher rate of taxes perhaps there is more money to go around, thus having more money to pay salaries for more residents, etc. The per capita expenditure on health care is much higher than in the US (we are pitifully low on the list internationally).

    Dunno...my brain's too tired to firgure it out. Good thing I'm taking care of patients today eh? :eek:
     
  18. Annette

    Annette gainfully employed
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    I don't know, but it doesn't seem as though there are more residents in the UK. In fact, they are crying for docs.

    One thing I forgot to mention earlier, people don't start the day until 8:30-9 am. If not on-call, they usually go home around 6pm.

    All this brings me to wonder if there isn't alot of extraneous, time wasting work in the US system. For instance, how many rounds are done on patients? The consultants round about everyother day with the entire team. All the work is assigned at this time. On the days the consultant isn't rounding, the rest of the team rounds once, and decides what needs to be done. The house officers are in charge of checking labs before the rounds. The longest consultant round I've had to endure is 6 hours, but they usually average 3 for medicine. Surgery rounds usually last less than 30 minutes (1 hour if there are a lot of patients).

    How do US residents spend their days?
     
  19. hey dreamer...would love to hear more about your experience in eastern europe...i am in prague now, looking forward to clinicals. send me an email if you have the time

    [email protected]

    thnaks
     
  20. Winged Scapula

    Winged Scapula Cougariffic!
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    </STRONG>

    I loved that. In Surgery clinics we always broke at 10:30 am for tea and cakes. Very civilised! :D I once got chastised for pre-rounding on patients - the surgeon was dismayed that I would wake up his patients in the "middle of the night".




    Don't get me started! We round 4 times a day. I preround with the other junior residents and medical student(s). Then we round with the Chief resident. Then, EVERY DAY, we round with the attending - whenever he is free. It could be 9 am, it could be 4:30 pm. Finally, after the OR or clinic os over for the day, we round once more with the Chief Resident. If we're lucky it can be card rounds but more often than not, its bedside again.

    So my day is spent doing the above, making sure ordered tests have been done and checking results, reading xrays and other films with the radiologists, MAYBE going to the OR, and generally sorting out floor stuff (ie, ordering TPN, rewriting med orders, getting surgical consent) and going to traumas down in the ER.

    Grand total for this week: 105 hours :D
     
  21. Hopkins2010

    Hopkins2010 Banned
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    I cant really fathom working a 105 hour work week, but let me ask you about it Kim.

    I'm assuming that this week you did absolutely nothing else but work, eat, sleep, and of course check this forum? :eek:
     
  22. Winged Scapula

    Winged Scapula Cougariffic!
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    That's about it. I haven't read a newspaper since last Saturday, done any laundry, watched tv, written any long emails or gone to see a movie. I haven't even been able to study either - I'm trying to read 1/2 hour each night but its hard. I even cut my own hair this week because I didn't have time to go out and get it done - unfortunately, I didn't exactly cut straight in the back and had to have someone tidy it up for me!

    Of those 105 hours, add an additional hour and 1/4 each day for showering and driving to and from the hospital. So even if I get home "early" - ie, 7:00 pm, I still have only a couple of hours before bedtime to get stuff done. Stuff like more unpacking, grocery shopping, paying bills, etc.
    I do have some time during the day, on some days, hence I can check the forums here. I have the weekend of the 20th off so will do some playing then. :D

    Interestingly enough, I haven't been really tired. I worked 38 hours Friday-Saturday but didn't get really tired until I got home around 6:30 pm on Saturday and laid down. A friend called and I was fighting it not to drift off to sleep during our conversation. I could actually lay down now but am not too tired. Once you stop going, then it gets hard.
     
  23. COMP Bound

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    I think the best way to tackle this sort of problem is to first get a view from the mountaintop. Remember the old movies where a group of people would send one person to the highest place they could find so they could scout out the trail ahead? This gave them a better perpective of the entire thing, didn't it?

    Well, here's my mountaintop view for ya and it comes down to this:

    It is true that the "old guard" doctors worked the same or maybe more hours in their residencies. It is true that working these hours only made them better doctors than they would have had they worked less hours. I believe that.

    BUT there was only one major difference and of which I believe is central issue to this entire argument: the time in which they did their residencies is not the time we now live in.

    You see back then, the pace of life was slower. The hours they had off were a retreat back to the gentle, and less intrusive family life that existed then. So it was truly a rest for them.

    But the society we live in now has a strange compulsive quality to it, that even when we physically remove ourselves to solitude, say out to the country to fish or something, inside we're still racing. You see when we are conditioned to this day-in-and-day-out, it will take the same amount of time or more to reverse the effects of such stimuli before one CAN rest.

    So, handling the present pace of life AND present residency hours goes beyond the "100 hours" that the old guard did.

    Because of the very statistics that are being sited-- "car accidents; depression; and making incorrect decisions on the job;" and I might add, the bizarre behavior of doctors we have heard about who have of recent been charged with murder; drug addiction; molestation of patients while sedated; incompetant treatment; tells you there is a problem.

    So, the question is: what does or doesn't exist in the present that did or didn't exist back then?

    What I see from the "mountaintop" and what I would pass on to the:

    Old Guard of Physicians: It's true, you did work hard. It was a proper rite of passage worthy of tradition, but times are different now. Even you would be the first to admit that you have less control of your lives and that they are fragmented, driven, constantly intruded upon as a result of this culture we now live in. It is not a valid argument, and depending on the person, may teeter on immorality, for one to say, "well we did, so can you!" or "If we had to do it, then so do you!"

    Attendings: Don't merely accept the, "well we did, so can you!" Actually, you then become a proliferate of the practice, making it more difficult for positive change.

    Hospital Administrators: The financial burden you carry is understandable and acknowledged i.e. cutbacks. It is also understood that to decrease the hours of residents, if you will, is like removing a main support truss of a building. That truss has been there for many years now and so many things have been built onto it that it may seem impossible to remove it.

    But it's not. Balanced against the increase in liability, malpractice suits, steady increase of more liberal malpractice laws (by the way, this is a direct result by the noticeable increase of incompetant treatment by doctors), all says the time for change is now.

    It will have to be a gradual process just as it wasn't an overnight occurence that you became so dependant upon the residents.

    Collectively address the issue, come up with a plan, START that plan, and you will see the issue resolved, and it will be done with. Keep on putting it off and it will continue biting you in the heels forcing you to notice it; all the while gaining strength until you are relagated in doing something about it. At that point there will be so many factions i.e. media, government involved that you will have less control on the solution and may not like the outcome.

    Last but not least, there is a real danger that within your very own hospital/system--the policies that you have authority to change in order to render some relief to residents, are being neglected to protect greed that exists to maintain what may be inflated salaries.When determining a budget, contextional proportionality and balance is the judge, not precedence with regard to salary.

    If a resident falls a sleep at the wheel and dies or kills someone else, or a resident prescribes the wrong drug or dosage because of lack of sleep and the patient dies or is other wise maimed because of working too many hours, knowing you could have effected a change but didn't, is in fact immoral.
     
  24. Dreamer

    Dreamer Senior Member

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    Neil,

    mind to send me e-mail first through private messge. Just do not bore you to death, what do you wanna know about rotations in Chech Republic, beware I am from Baltic States.
     

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