Anyone notice a real change in intern/junior residents

[Skialta]

I was talking to a few of the chief residents today about how there seems to be a considerable change in resident dynamics from when we were interns. It seems like the interns and more junior residents seem very shift work in mentality and don't take as much ownership of the patients. It also seems like the surgery residents don't seem to have the team mentality like there was when I started. It used to be like we all suffered together but we were a team and now it is like I have to go home because of hours so here is the work that needs to be done (dump). The work has just shifted up to the chief. I wonder what is going to happen in 5 years when no resident has every worked post-call. Seems like there is going to be a rude awakening when they take a job and realize they are expected to operate or see clinic patients post-call. Anyone else notice these changes? I can't say these new hours rules are helping anyone. just my thoughts.


Skialta

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[OtoHNS]

Perhaps. But one thing that will always stay the same is chiefs and senior residents complaining about junior residents and interns.

 

[Skialta]

No doubt that is true.

 

[SLUser11]

I was talking to a few of the chief residents today about how there seems to be a considerable change in resident dynamics from when we were interns. It seems like the interns and more junior residents seem very shift work in mentality and don't take as much ownership of the patients. It also seems like the surgery residents don't seem to have the team mentality like there was when I started. It used to be like we all suffered together but we were a team and now it is like I have to go home because of hours so here is the work that needs to be done (dump). The work has just shifted up to the chief. I wonder what is going to happen in 5 years when no resident has every worked post-call. Seems like there is going to be a rude awakening when they take a job and realize they are expected to operate or see clinic patients post-call. Anyone else notice these changes? I can't say these new hours rules are helping anyone. just my thoughts.


Skialta

2003 called. They want their opinion of junior residents back.....

 

[SouthernSurgeon]

Things I've noticed so far this year (from the PGY-2 perspective):

First off I'd just say - night float sucks, as a lifestyle. I hate working night float, and feel like a zombie all the time. I feel like my schedule is tougher and more tiring this year. We are forced to use the post-call day as a "day off" this year bc the new rules have taken away so much of our flexibility. Last year I would have 4-5 "real" days off per month, my post call days, and often a golden weekend. This year it's more like 2 real days and 2 post-call days.

Now as for how it's working out:

Pros:
-The interns don't sleep at night or expect to sleep. I think because of this they are checking up on the patient's more often and may have a little better handle on what's going on.
-Collaboration at night. Since we now have teams with multiple junior residents working at night, the interns aren't quite as on their own as they were last year. Obviously they still call the chiefs with problems, but at least they have someone else there to talk it through with first.

Cons:
-Sign-out. The interns aren't very good at giving or getting sign out yet, and we have to sign out more often.
-Offloading work on the night team. Last year, if someone was signing out to me on call they wouldn't dare hand me a big To Do list; they'd take care of it before leaving the hospital. Now the interns are being watched closely to make sure they aren't violating their hour rules, so it's becoming acceptable to pass things along to the night team. Encourages a shift work mentality.
-Lack of confidence. Maybe it's just that I have a hard time remembering where I was a year ago, but the interns still seem to have low confidence given that we are nearly 4 months into residency.
-Lack of OR time. I don't have the data (i.e. case logs) to support this, but from what I am hearing I think the interns are getting robbed of operative experience because of the new rules. Last year I got a lot of my cases by staying post-call until noon to operate. They can't do that anymore.

 

[45408]

I feel like my schedule is tougher and more tiring this year. We are forced to use the post-call day as a "day off" this year bc the new rules have taken away so much of our flexibility. Last year I would have 4-5 "real" days off per month, my post call days, and often a golden weekend. This year it's more like 2 real days and 2 post-call days.

Feel like I could have written this...

-Lack of OR time. I don't have the data (i.e. case logs) to support this, but from what I am hearing I think the interns are getting robbed of operative experience because of the new rules. Last year I got a lot of my cases by staying post-call until noon to operate. They can't do that anymore.

On the other hand, we have more upper-level people leaving post-call, and sometimes our interns are the ones who end up covering cases that they wouldn't have gotten otherwise.

 

[ZagDoc]

Pros:
-The interns don't sleep at night or expect to sleep. I think because of this they are checking up on the patient's more often and may have a little better handle on what's going on.
-Collaboration at night. Since we now have teams with multiple junior residents working at night, the interns aren't quite as on their own as they were last year. Obviously they still call the chiefs with problems, but at least they have someone else there to talk it through with first.

Cons:
-Sign-out. The interns aren't very good at giving or getting sign out yet, and we have to sign out more often.
-Offloading work on the night team. Last year, if someone was signing out to me on call they wouldn't dare hand me a big To Do list; they'd take care of it before leaving the hospital. Now the interns are being watched closely to make sure they aren't violating their hour rules, so it's becoming acceptable to pass things along to the night team. Encourages a shift work mentality.
-Lack of confidence. Maybe it's just that I have a hard time remembering where I was a year ago, but the interns still seem to have low confidence given that we are nearly 4 months into residency.
-Lack of OR time. I don't have the data (i.e. case logs) to support this, but from what I am hearing I think the interns are getting robbed of operative experience because of the new rules. Last year I got a lot of my cases by staying post-call until noon to operate. They can't do that anymore.

I think this is a fair critique.

I would also add that at my program we are under a great deal of pressure from the GME and SurgEd offices to be in compliance and to not lie about hours. The issue is a very hot topic right now and I get the sense we're really under the microscope this year. So what may be perceived as a "shift work mentality" and "taking less ownership" may be less about how much we care about patient care and more a fear of non-compliance.

 

[SouthernSurgeon]

I think this is a fair critique.

I would also add that at my program we are under a great deal of pressure from the GME and SurgEd offices to be in compliance and to not lie about hours. The issue is a very hot topic right now and I get the sense we're really under the microscope this year. So what may be perceived as a "shift work mentality" and "taking less ownership" may be less about how much we care about patient care and more a fear of non-compliance.

Definitely...we are getting a LOT of pressure from above to strictly follow the new hours.

 

[drfamilymed]

 

[Buzz Me]

Well played!

 

[surgresident032]

I think a lot of upper level residents (I'm a surgical intern) feel the same way as those upper levels felt about the 80 hour work week. At my residency, we are caught between having to lie about our hours on our time sheets and to get the work done. We interns want to stay to take care of patients but we get in trouble for staying late, and we also get in trouble for not staying late. It's a no win situation for everyone involved in the residency and the patient's themselves. I've been told I don't care to be a surgeon because I inform my upper level that my time is up (which I was told to do in no certain terms by my seniors, and I'm already there an hour after I'm supposed to leave anyways). I hate having to leave because I want to contribute to the team and to the workload. I realize that as a surgeon you take ownership of your patients regardless of how much time it takes. It's very frustrating because no matter what you do, they think you don't care. As for night float, you simply have more work than you would have during the day. You have no time to stop (non-stop consults, fires on the floors, traumas), and then in the morning you do the same work as an intern (pre-rounding) except you don't get to do the OR cases in the morning. I feel it's much easier to have a night every 3rd or 5th night (the old style call) compared to having to do night every single night. I'd rather work more so I get the whole experience than being just someone to mop up the issues at night, and then never get to round on the patients with the team or to see the outcome of the plan.

 

[Dr JPH]

I think a lot of upper level residents (I'm a surgical intern) feel the same way as those upper levels felt about the 80 hour work week. At my residency, we are caught between having to lie about our hours on our time sheets and to get the work done. We interns want to stay to take care of patients but we get in trouble for staying late, and we also get in trouble for not staying late. It's a no win situation for everyone involved in the residency and the patient's themselves. I've been told I don't care to be a surgeon because I inform my upper level that my time is up (which I was told to do in no certain terms by my seniors, and I'm already there an hour after I'm supposed to leave anyways). I hate having to leave because I want to contribute to the team and to the workload. I realize that as a surgeon you take ownership of your patients regardless of how much time it takes. It's very frustrating because no matter what you do, they think you don't care. As for night float, you simply have more work than you would have during the day. You have no time to stop (non-stop consults, fires on the floors, traumas), and then in the morning you do the same work as an intern (pre-rounding) except you don't get to do the OR cases in the morning. I feel it's much easier to have a night every 3rd or 5th night (the old style call) compared to having to do night every single night. I'd rather work more so I get the whole experience than being just someone to mop up the issues at night, and then never get to round on the patients with the team or to see the outcome of the plan.

I have seen this as well with my own interns/juniors (I'm a senior resident). Some people...mostly attendings...scoff at the work hour regulations, but as the chief in any program will tell you, it comes down hard when someone violates the hours. Many places are becoming more aware of the people who try to push the boundaries and doing a lot to stop it.

I have said this before, I don't see a change in attitude of the junior level people...they want to be in the hospital and want to be involved...they are just pushed out by administration and the chief (like me) who doesn't want to risk an infraction.

 

[igap]

I think that if residents "really want" to be in the hospital and do cases, then they will.

Most programs use a self-reporting hours system so there should be no threat of an "infraction".

Residents who truly want to be in the hospital maximizing their residency experience will simply self-report that they are working within the 80 hour limit. Some people will claim that this is dishonest, etc... I stipulate that if work hours limitations interfere with your learning then it is perfectly fine to consider circumventing them.

As a resident I may have ignored the work hours restrictions so that I could maximize my education. I almost never missed doing a case I wanted to do, and I never put my program in jeopardy as my work hour logs were always compliant.

As an attending I can easily tell the residents who want to max out their learning opportunities and the ones who do not. THe ones who do, quietly go about doing their work and getting cases. The ones who do not, are constantly reminding people that they are "post-call", and that they are "way over hours", and need days off, etc. Mostly these residents are off-service residents like GS, anesthesia, and ED residents who have no vested interest in my specialty.

Somehow saying that residents should go home and miss out on opportunities because they are "protecting" the program is disingenuous. Residents go home because they want to.

I am sure that many will disagree, and claim that their program has a big brotheresque way of determining when the 81st hour starts, and if you are truly in a system like that then you are in the minority. Having knowledge of many institutions' abilities to monitor work hours, I guarantee that large bureaucracies like hospital systems have no idea what is going on most of the time. If you are a resident and want to work hard, there is really no one there to stop you but you.

 

[cpants]

I think that if residents "really want" to be in the hospital and do cases, then they will.

Most programs use a self-reporting hours system so there should be no threat of an "infraction".

Residents who truly want to be in the hospital maximizing their residency experience will simply self-report that they are working within the 80 hour limit. Some people will claim that this is dishonest, etc... I stipulate that if work hours limitations interfere with your learning then it is perfectly fine to consider circumventing them.

As a resident I may have ignored the work hours restrictions so that I could maximize my education. I almost never missed doing a case I wanted to do, and I never put my program in jeopardy as my work hour logs were always compliant.

As an attending I can easily tell the residents who want to max out their learning opportunities and the ones who do not. THe ones who do, quietly go about doing their work and getting cases. The ones who do not, are constantly reminding people that they are "post-call", and that they are "way over hours", and need days off, etc. Mostly these residents are off-service residents like GS, anesthesia, and ED residents who have no vested interest in my specialty.

Somehow saying that residents should go home and miss out on opportunities because they are "protecting" the program is disingenuous. Residents go home because they want to.

I am sure that many will disagree, and claim that their program has a big brotheresque way of determining when the 81st hour starts, and if you are truly in a system like that then you are in the minority. Having knowledge of many institutions' abilities to monitor work hours, I guarantee that large bureaucracies like hospital systems have no idea what is going on most of the time. If you are a resident and want to work hard, there is really no one there to stop you but you.

Sorry, but I'm not willing to violate my hours. I want to learn my trade and I even think that the duty hours are impinging on that. But it just isn't worth the risk to me. The administration has made it clear that if we are caught consequences will be swift and severe. You are right that 9 times out of 10 you won't get caught lying on your duty hours, but that is not the problem. You are asking residents to risk their careers here. And you might be asking them to risk yours. When a patient has a bad outcome, even if it was an expected complication, how do you think it will look to a jury that the resident scrubbed with you was in violation and scrubbed post call?

 

[SLUser11]

I have seen this as well with my own interns/juniors (I'm a senior resident). Some people...mostly attendings...scoff at the work hour regulations, but as the chief in any program will tell you, it comes down hard when someone violates the hours. Many places are becoming more aware of the people who try to push the boundaries and doing a lot to stop it.

I have said this before, I don't see a change in attitude of the junior level people...they want to be in the hospital and want to be involved...they are just pushed out by administration and the chief (like me) who doesn't want to risk an infraction.

Welcome back.

 

[Smurfette]

Sorry, but I'm not willing to violate my hours. I want to learn my trade and I even think that the duty hours are impinging on that. But it just isn't worth the risk to me. The administration has made it clear that if we are caught consequences will be swift and severe. You are right that 9 times out of 10 you won't get caught lying on your duty hours, but that is not the problem. You are asking residents to risk their careers here. And you might be asking them to risk yours. When a patient has a bad outcome, even if it was an expected complication, how do you think it will look to a jury that the resident scrubbed with you was in violation and scrubbed post call?

Jurors won't know or care. Let's not even mention the fact that the overwhelming majority (90%+) of all malpractice cases never make it to trial. It's irrelevant to the malpractice suit, given that the ATTENDING is generally the one who is sued. Unless the attending is trying to throw the resident under the bus, no one cares about the resident since the attending is the main one responsible. The malpractice attorneys targeting the attending surgeon generally don't try to find out if your scrub tech was hung over or your anesthesiologist was up all night taking care of his sick children any more than they care about whether the resident scrubbed in worked 2 hours later than the rules state.

Obviously, programs caught violating work hours have serious potential consequences from the ACGME. Just disagree with the comment on malpractice implications.

 

[cpants]

Jurors won't know or care. Let's not even mention the fact that the overwhelming majority (90%+) of all malpractice cases never make it to trial. It's irrelevant to the malpractice suit, given that the ATTENDING is generally the one who is sued. Unless the attending is trying to throw the resident under the bus, no one cares about the resident since the attending is the main one responsible. The malpractice attorneys targeting the attending surgeon generally don't try to find out if your scrub tech was hung over or your anesthesiologist was up all night taking care of his sick children any more than they care about whether the resident scrubbed in worked 2 hours later than the rules state.

Obviously, programs caught violating work hours have serious potential consequences from the ACGME. Just disagree with the comment on malpractice implications.

Yes, they go after the attending, but you don't think they would use that against you in court or to extract a bigger settlement? Ultimately the attending is responsible for what goes on in the OR. If the resident scrubbed is on hour 32 and starting a case postcall in clear violation of ACGME standards, YOU are responsible, and it will be pretty hard to argue that standard of care was followed. Internal records like schedules and duty logs are discoverable. Again, I'm not saying this is right, but it is a risk for all concerned now that the ACS/ACGME standards say that it is unacceptable for this to go on.

 

[Smurfette]

Yes, they go after the attending, but you don't think they would use that against you in court or to extract a bigger settlement? Ultimately the attending is responsible for what goes on in the OR. If the resident scrubbed is on hour 32 and starting a case postcall in clear violation of ACGME standards, YOU are responsible, and it will be pretty hard to argue that standard of care was followed. Internal records like schedules and duty logs are discoverable. Again, I'm not saying this is right, but it is a risk for all concerned now that the ACS/ACGME standards say that it is unacceptable for this to go on.

I still disagree that this would likely be of real consequence. Duty hours have been in effect since 2003, while they revamped the rules this year, it's not a brand new concept now compared to when it first started. Malpractice risk should be very low on the list of reasons to comply with duty hours. The big reasons to comply is to keep your program accredited and to remain board eligible.

It would be easy to argue the program/PD is responsible for the resident's hours, and that you as the attending didn't know the resident was over hours. Legally, the rules do not put the burden on the attending to confirm the resident's hours, but the program itself, which is governed by the ACGME and not the states (except NY which has it's own laws for this). Our attendings in residency had no clue who was post call (and often didn't care, but that's a different issue). Standard of care has to do with the procedure and care of the patient, and less so the rules for the resident. Plus, given that there are exceptions for the work hour rules (which are vague but give allowances for chiefs and for continuing patient care until someone adequately trained is available, among other things), it would be hard to successfully try this approach. Like I said, then they should be subpoenaing the work hour logs of EVERYONE in the room....circulator, scrub tech, etc.

Besides, it is weak sauce to try and use the resident "trainee" in the case to argue that the only reason the case went bad is because the "trainee" was over hours. Maybe if the attending was not present, but otherwise that is VERY hard to establish as the reason something went bad. Keep in mind that non-ACGME programs (not that there are many) don't even have such rules to follow in the first place. If you want to use this tactic, sue the resident only if that's what the case hinges on. Of course, that's not how it works since the resident doesn't have the $$. Malpractice attorneys would have to subpoena the work hour records for the resident in question, and given the wide range of how programs keep track of this, that may not be very easy. Especially if the lawsuit is brought up well after the resident is gone. Very few malpractice suits are successful. It's more likely that you get tortured with the suit for a while and then it gets dropped. The resident hours argument doesn't hold up well. It's far more relevant to sue an attending who has been working more than 30 hours....that is technically allowed legally, but of far more relevance to the issue of malpractice. We can agree to disagree, I guess.

Since I brought it up, is there a rule saying how long a program has to keep duty hour logs for their residents? I'm curious.

 

[Winged Scapula]

Besides, it is weak sauce to try and use the resident "trainee" in the case to argue that the only reason the case went bad is because the "trainee" was over hours. Maybe if the attending was not present, but otherwise that is VERY hard to establish as the reason something went bad.

Weak sauce indeed and hard to establish yes, but there has been precedent and as society has become more litigious, there are reports that more and more attendings *are* throwing residents under the bus. Having been in a lawsuit, I can tell you that it can often be "every man for himself" with a lot of finger pointing.

Of course, that's not how it works since the resident doesn't have the $$.

No, they may not currently have the $$ the attending does, but they carry the same malpractice insurance which is what the plaintiff's lawyers are going after. In fact, many wise attendings have no real assets in their name whereas the resident may. Its unusual, of course, to be found to be liable for an amount over and above your defense liability but it can happen.

In addition, residents may be working under malpractice insurance contract which does not allow them the ability to refuse to settle if named in a suit. In that case, even more damaging than the financial, would be the listing in the NPDB and other public records.

Very few malpractice suits are successful. It's more likely that you get tortured with the suit for a while and then it gets dropped.

Now THAT I agree with you on.

 

[Fah-Q]

We are slowly seeing the erosion of the quantity and quality of resident education. The nurses are increasing their education requirements while we are decreasing ours. Soon there will not be much difference between a trained physician and a trained nurse practitioner.

The duty hour restrictions are bad for doctors and bad for patients. We can't bury our head in the sand any longer.

 

[Tired Pigeon]

I have heard that if your program is audited by the RRC, they can compare your reported work hours against hospital computer logs and OR case records to determine whether your reported work hours were falsified. Is this possible? I find this concerning.

 

[cpants]

I have heard that if your program is audited by the RRC, they can compare your reported work hours against hospital computer logs and OR case records to determine whether your reported work hours were falsified. Is this possible? I find this concerning.

Of course it's possible. Why is it concerning? What's the point of duty hours if they can be falsified at will with no chance of audit?

 

[45408]

Welcome back.

It was a brief visit, I guess.

In fact, many wise attendings have no real assets in their name whereas the resident may.

Well, no worries here...

I have heard that if your program is audited by the RRC, they can compare your reported work hours against hospital computer logs and OR case records to determine whether your reported work hours were falsified. Is this possible? I find this concerning.

Possible, sure. I've never heard of a specific example of it happening. It would be pretty tedious to do that.

 

[europeman]

where i'm in residency, you can't lie. if you log into the computer or if you scrub, you are logged into an automatic computer log which at the end of the month cross checks with what you submit as your hours.

the only way someties you can add an hour or two is if you avoid logging into the computer when you first come to the hospital but still see patients.

as a pgy4, i understand the juniors need to follow the work hours.

but the MENTALITY of shift work is what is bothersome to me.

i have defintately seen a change in most of the juniors. not all... but many.

it's sad.

 

[tussy]

Sorry, but I'm not willing to violate my hours. I want to learn my trade

Surgery is not a trade. Plumbers and electricians learn a trade. surgery is a vocation. It's a way of life. You give your life to surgery. You don't clock in and clock out. It sucks and it's rewarding all at once. If you treat it as a "trade" you will not be a good surgeon.

The work hour rules have their place. I did residency in the old days with 1 in 2 call, 36 hours on, 12 off and it was unsafe and brutal. the Pendulum has shifted too far in the other direction. It is not good for learning and it is not good for patient care and it is not good for the future of surgery.

 

[cpants]

Surgery is not a trade. Plumbers and electricians learn a trade. surgery is a vocation. It's a way of life. You give your life to surgery. You don't clock in and clock out. It sucks and it's rewarding all at once. If you treat it as a "trade" you will not be a good surgeon.

The work hour rules have their place. I did residency in the old days with 1 in 2 call, 36 hours on, 12 off and it was unsafe and brutal. the Pendulum has shifted too far in the other direction. It is not good for learning and it is not good for patient care and it is not good for the future of surgery.

You attack the word trade? I wasn't using it to belittle the field. It is an honor to train as a surgeon, and I treat it as such. That said, I am not willing to jeopardize my opportunity to train by violating my hours.

Honestly, I agree with you that the pendulum has swung too far. We didn't ask for these rules, and I think they are degrading not only training, but quality of life for the interns. Weeks or months of night float are brutal on your body and mind. Random nights scattered about is even worse. It's impossible to get on a sleep schedule. We also get much fewer days off now. With no post call days you get a strict four 24 hour periods off per month. No golden weekends and no 5-10 post call days during the month.

 

[absolutproof]

I get that the new hours fosters shiftwork. Hell; I pulled longer hours on a given day as a medical student than as an intern. Ive definitely pulled my fair share of staying past my hours to get patients dispo'ed because if I don't do it, it just won't get done. I've also found ways to make it into the OR as my leisure time by coming in on my days off. The problem is, if it wasnt the attending who calls me out for being past my hours; it was my upperlevels. Ive even been told I was irresponsible for sticking around. So its pretty frustrating to hear about interns being shiftwork mentality when its the people who are complaining about us, are also the ones under pressure from their higher ranks to make sure the interns leave. Its noones fault, the current system and its repercussions for its violations are enforced by an entirely too powerful ACGME task force that never had a surgeon on staff fight for the education of the next generation of surgeons. Its a wake up call to have seasoned surgeons get involved in policy instead of griping at the residents borne into a system that current surgeons did not participate in. Cause if it could happen to interns, what makes it foolproof that it couldnt be extended to other PGY levels or even to practicing surgeons? Alot of our futures rest in their hands, all I know is that until then, Im trying to do my best to get the training I deserve to be fully prepared as a pgy2, but in a restricted.envirinment. Anyhow, my boo hoo of the day

 

[absolutproof]

We are slowly seeing the erosion of the quantity and quality of resident education. The nurses are increasing their education requirements while we are decreasing ours. Soon there will not be much difference between a trained physician and a trained nurse practitioner.

The duty hour restrictions are bad for doctors and bad for patients. We can't bury our head in the sand any longer.

No disagreements here, but I would also counter that the future of Surgery lay in the hands of the surgeons who we aspire to become. Allowing it to erode, be it indifference, or being too busy to invest time (be it as little as emailing or voicing your opinion to Congress, or actively involving.yourself in politics) is equally damaging and.eroding as hour restrictions