Breaking ACGME rules on ICU rotation

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DrJere

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I'm an ER resident and have my ICU rotation next month. 'Calls' are scheduled from 6am to 12pm the next day. I know the 'more experienced' physicians on here will wax on about the good ol' days, but this is pretty clearly a violation of ACGME rules which limit us to no more than 16 consecutive hours. We are being told our university is part of a 'study' to see how well we can deal with these hours.

Has anyone heard of this or had experience with it? I don't want to be the one person who complains, but this is pretty bogus, no?
 
DrJere said:
I'm an ER resident and have my ICU rotation next month. 'Calls' are scheduled from 6am to 12pm the next day. I know the 'more experienced' physicians on here will wax on about the good ol' days, but this is pretty clearly a violation of ACGME rules which limit us to no more than 16 consecutive hours. We are being told our university is part of a 'study' to see how well we can deal with these hours.

Has anyone heard of this or had experience with it? I don't want to be the one person who complains, but this is pretty bogus, no?
Click to expand...
If you're an intern, could be a violation... that said, there are studies in progress to look at this question. The "naptime" rules - which were never really based on good data a priori - have increased error from handoffs.

So, some studies are indeed being done to ascertain the "ideal" balance betwixt rest & patient care. Ask your PD for a copy of the ACGME waiver showing participation.

If you're not an intern, 16h doesn't apply.
 
DrJere said:
I'm an ER resident and have my ICU rotation next month. 'Calls' are scheduled from 6am to 12pm the next day. I know the 'more experienced' physicians on here will wax on about the good ol' days, but this is pretty clearly a violation of ACGME rules which limit us to no more than 16 consecutive hours. We are being told our university is part of a 'study' to see how well we can deal with these hours.

Has anyone heard of this or had experience with it? I don't want to be the one person who complains, but this is pretty bogus, no?
Click to expand...

There are studies that look at this...http://www.thefirsttrial.org/Overview/Overview Interesting though when it comes to residents your participation is neither voluntary or really even informed.

I find it hilarious...you read the website and it says "study as they did not consider this trial to be human subjects research." Finally it is in writing, resident are not human.
 
I'm technically a PGY-2 so in reading the fine print for PGY-1 max is 16 hours consecutive, for PGY-2 it's 24 hours - either way we're still going above.

@Druggernaut - as part of the study we don't have to consent?

@Daiphon - I don't want to ruffle feathers and ask for the ACGME waiver - if they have one we pretty much have to comply?
 
DrJere said:
I'm technically a PGY-2 so in reading the fine print for PGY-1 max is 16 hours consecutive, for PGY-2 it's 24 hours - either way we're still going above.

@Druggernaut - as part of the study we don't have to consent?

@Daiphon - I don't want to ruffle feathers and ask for the ACGME waiver - if they have one we pretty much have to comply?
Click to expand...

Nope. As link2swim said, you're a resident, not a human subject. No consent needed.

But working all but 4 days out of the month isn't a great time either. You probably at least get more days out of the hospital, at least.

I'd just gut it out for the month, unpleasant as it may be. Keep your head down and get out alive.
 
DrJere said:
I'm technically a PGY-2 so in reading the fine print for PGY-1 max is 16 hours consecutive, for PGY-2 it's 24 hours - either way we're still going above.

@Druggernaut - as part of the study we don't have to consent?

@Daiphon - I don't want to ruffle feathers and ask for the ACGME waiver - if they have one we pretty much have to comply?
Click to expand...
Yeah. You're stuck. Only reason I suggested the waiver (not from IRB, mind you, as it's not "human research" but rather from ACGME allowing duty hour "violations") was if you didn't believe your PD.

If you trust them, then don't ruffle feathers; you're likely stuck in the long-hour group.
 
Sounds like you have no recourse. Look at this as a learning experience. I work in "the community", where after residency, surgeons work 36 hours straight several times a month. No joke - the guys and gals work a clinic day, operate all night on call, then work another clinic day with no time for catch up sleep. This is a busy hospital; on these call days, surgeons do not sleep. Sure, it sucks to be a surgeon, but for ED leadership, guess what? On call 24/7. Leadership is woken up at ungodly hours to help sort out ED/(name your consultant) disputes, along with a host of other ED issues. Doesn't matter that they just finished a 10 hour shift that was actually 13 hours, and that they are on again in another few hours. Get up, get it done, sleep when you can.
Take home point: at some point in your career, you may have to make life altering decisions on little to no sleep. Learn how that feels when you are in the protective cocoon of residency. Learn how to ask for help when you need it. Medicine is far from perfect, and it becomes less perfect after residency for many docs.
 
pianoman511 said:
Technically its 27 hours as there are three hours for "transition of care" after intern year.
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It's actually 4 hours, for a total of 28. Either way it looks like being in the study arm has taken you from the default 28 hour call to 30 hour call. This is definitely not worth ruffling any feathers over, mainly because, 1. It will do no good, 2. It will waste your time, 3. Nothing will change, 4. It will draw negative attention to yourself. Power through and remember, they can't stop the clock.
 
I agree, you just need to deal with it.

-Those "good ol days" were less than 5 years ago when 30hrs were considered "cush" call. You have it much, much better than people a few years before you and than the peers you'll be in the ICU with. Be grateful for what you have. This is just one month. Any complaining will not come off well. Besides, you might find you like the 30 hr call (and coinciding golden weekend) better than multiple 16s in a row.

- Don't get me wrong. I support the duty hour changes and think they're headed in the right direction. I'm not some blowhard trying to tell you to suck it up and we all walked uphill both ways etc. But, at your stage in your training your best move for almost any inequity or hardship is to smile, remember that you only have 2-3 years left, and ask for another.
 
That was my ICU schedule in residency. Ask your PD if you have concerns.
 
two guys said:
Don't get me wrong. I support the duty hour changes and think they're headed in the right direction. I'm not some blowhard trying to tell you to suck it up and we all walked uphill both ways etc. But, at your stage in your training your best move for almost any inequity or hardship is to smile, remember that you only have 2-3 years left, and ask for another.
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I'm not as sure. As an educator I can see the stress this adds to making the schedule, and all of the literature shows no difference in patient outcomes. It makes logical sense, as truck drivers, airplane pilots, and pretty much everyone else has limited working hours, but there isn't any data on safety for medicine.
However, if we start wittling down the hours much more we will end up with a Euro/Australian system, and residency will take 5-7 years. Not sure anybody wants that (unless they pay us like Aussie residents).
 
As has been mentioned before, this IM program is likely part of the iCompare study. You're correct that the current literature shows no difference in patient outcomes, but this is all retrospective data. The iCompare study is a prospective, randomized study (admittedly between, not within, programs) to try to definitively answer the question. At least in IM.
 
And the companion trial in General Surgery is the FIRST trial. Both perfectly legitimate, cleared by IRBs, and with waivers from the ACGME allowing them to bypass some (but not all) duty hour restrictions. You're still limited to 80 hr weeks as averaged over 4 weeks.
 
gutonc said:
iCompare study
Click to expand...

Oh god. Please tell me that the "i[name]" is not going to be a thing when it comes to study titles.

Anyone else remember when studies didn't need catchy acronym names?
 
DrJere said:
I'm technically a PGY-2 so in reading the fine print for PGY-1 max is 16 hours consecutive, for PGY-2 it's 24 hours - either way we're still going above.

@Druggernaut - as part of the study we don't have to consent?

@Daiphon - I don't want to ruffle feathers and ask for the ACGME waiver - if they have one we pretty much have to comply?
Click to expand...

It's not limited to 24 hours. It's 28 hours. You get 24 hrs of continuous duty, followed by 4 hours of transition of care hours (e.g. rounding, signout, etc). You still appear to be going over by 2 hours per shift though.
 
I loved the 28 hour calls when they happened on Thursday into Friday mornings. Golden weekend!! One time it even happened to me when Monday was a holiday!!
 
We do pgy-2/3 24+ hour ICU stuff. Our pgy-1's brain's get mushy after 12+ hours. Most of the stuff I encounter overnight I'm doing on motor memory and pattern recognition. It takes a little longer to process new situations 22 hours in. Having a pgy-1 around overnight would turn my 1-2 hours of interrupted sleep into none hours. I enjoy teaching them and "supervising" procedures during the day but happy to go it alone overnight.
 
RuralEDDoc said:
Sounds like you have no recourse. Look at this as a learning experience. I work in "the community" .... Take home point: at some point in your career, you may have to make life altering decisions on little to no sleep.Learn how that feels when you are in the protective cocoon of residency. Learn how to ask for help when you need it.
Click to expand...

Awesome insight, I hope this helps some people.
 
jonb12997 said:
I loved the 28 hour calls when they happened on Thursday into Friday mornings. Golden weekend!! One time it even happened to me when Monday was a holiday!!
Click to expand...

sure sucks when you get Saturday call. Still worth the Golden weekends though
 
Back in my day, residents worked 164 hour weeks, and if they were lucky they'd get to eat lunch every day or two.


Kids these days.....grumble...grumble...
 
Ok, so I did all my ICU rotations in residency with the q4 30hr calls.

Hands down, these were some of the most valuable hours in my entire residency. There is something to being the one body in the ICU in the middle of the night when you're fighting to keep the open-book-pelvic-fx-in-DIC-from-massive-transfusion from dying. In the still of the night, you call the shots, and you learn exactly how far you can be pushed, and you toe that line.

Real world medicine does not care about hour limits. I trained under the 80h week, which was averaged over 4 weeks. (Meaning they could kill for you 3 if you had the last off.) Some of the real world does q2 call. Forever. I rotated with a couple of rural general surgeons who LIVED q2 call. Their careers were Q2. It was brutal, but that's how you do it.

There really is something to learning exactly how far you can stretch. And doing that in residency, when you have backup and oversight, is the safest place to learn this.

It also gives a new meaning to the words "exhaustion." I was in a relationship once where I heard "I'm so exhausted" too many times. I just thought, "yeah, right buddy. Exhausted is 30 straight hours in the Trauma Bay, wearing lead, and sending your co-intern to the cafeteria for gatorade because the team is now dehydrated and on the brink of syncope. I know what that word means, and you have no right to use it."
 
Funny how you need double blind placebo-controlled studies to back-up work hour restrictions but no studies to validate the "benefits" of sleep deprivation to prepare you for sleep deprivation...
 
DeadCactus said:
Funny how you need double blind placebo-controlled studies to back-up work hour restrictions but no studies to validate the "benefits" of sleep deprivation to prepare you for sleep deprivation...
Click to expand...
So I think everyone can agree that misery just for the sake of misery isn't widely beneficial. Rural's point about sleep deprivation is true. Even if you're just a pit doc with an average schedule that punches the clock and goes home there are some points to consider.

1) You're going to have to work night shifts.
2) You're going to try and do as few night shifts as possible.
3) The corollary of #2 is that because you're trying to limit night shifts, very few of your overnights will be entrained with your circadian rhythm. It's been months since I've worked an overnight with an adequate amount of sleep prior.
4) Your decision making changes when you're tired. You're less likely to pick up on subtle clues and more likely to anchor on a diagnosis prematurely. You tend to put more trust in the correctness of your decision making because your brain will shy away from the work of re-examining your plan.
5) Learning the specific ways in which fatigue compromises your decision making in a protected environment lets you put strategies in place to safeguard against those failings. I order more tests and err on the side of admission more frequently at the end of late overnights and I force myself to be explicit with my differential.
 
Again, we want double blind studies to confirm that an 80 hour limit and minimal protections against sleep deprivation is beneficial in an educational environment. But we'll accept as fact the long line of assumption that:

1) People can learn to be fatigued
2) People need to learn to be fatigued
3) People need weeks or months of fatigue to adequately learn to be fatigued
4) Being fatigued either doesn't affect or outweighs learning actual medicine

Sorry, I call bull****. It's one generation trying to justify why they suffered through what they did and another generation trying to justify why their life shouldn't be made harder. The answers not as clear cut as people make it seem.

The best part is that it's an asinine argument. The industry killing 100,000 people a year wants to figure out a way to train people to be fatigued while the guy hauling a truck full of pillows is told to take a nap...
 
Are you on a SICU rotation? I'm at an institution that was in the "no restrictions" arm of the surgery RCT, and we were told when we were off-service we play by their rules. There are still plenty of duty hour restrictions even within that study though, I haven't heard of anything too brutal. Generally agree that, given appropriate supervision, there's a lot to be said for sticking around and seeing the course that sick patients take v. signing out to a night float system.
 
DeadCactus said:
Again, we want double blind studies to confirm that an 80 hour limit and minimal protections against sleep deprivation is beneficial in an educational environment. But we'll accept as fact the long line of assumption that:

1) People can learn to be fatigued
2) People need to learn to be fatigued
3) People need weeks or months of fatigue to adequately learn to be fatigued
4) Being fatigued either doesn't affect or outweighs learning actual medicine

Sorry, I call bull****. It's one generation trying to justify why they suffered through what they did and another generation trying to justify why their life shouldn't be made harder. The answers not as clear cut as people make it seem.

The best part is that it's an asinine argument. The industry killing 100,000 people a year wants to figure out a way to train people to be fatigued while the guy hauling a truck full of pillows is told to take a nap...
Click to expand...
The pillow truck doesn't have to have someone driving it all day every day no matter what. Hospitals can't just close for naptime.

Its obviously not a simple solution and both sides make valid points. That's why studies like this are being done.
 
I finished EM residency in 2003, which of course was the last year before these work hours went into effect. The hours were horrendous at times and it was very depressing at times but I never would want to extend residency in exchange for shorter hours. That being said, I went back and did a fellowship a few years ago and the hours rules were broken routinely. It wasn't a big deal to me since I had done way worse in residency. I preferred just to work longer and get my stuff done, otherwise we just dumped the work on one of the other fellows, defeating the purpose. Also, having been a doc in the community for years pushed me much more than some of the duty hours violations, so some of the regulations seemed laughable.

I think one rule was that you had to have at least 10 hours between shifts (or was it 12?) so you could sleep at least 8 hours between shifts. Hell, I had done shifts as an EM attending were I was expected to work on zero, or just a couple hours sleep, lol (for a night shift or 24hr turn around from nights to days).

For that reason, I see both sides. It was horrible going through it (residency pre-2003), but I'm glad I did, because it made me stronger and makes you realize you have reserve far beyond what you think. That being said, patients deserve better than a weak error-prone trainee with zero sleep. Yet attendings need tough training so they're not weak, error prone attendings. And on it goes.

It's a catch 22.
 
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