Can someone explain to me what is residency and moonlighting?

[mimelim]

Is it really so hard to believe that 100 to 120 hour work weeks can be detrimental to patients.

Interesting. Playing devil's advocate, I have a couple questions:

1.) Do you believe this issue could be partially helped by better documentation or hand-off procedures? Or do you believe the issue can mostly be attributed to the increased frequency of handoffs?

2.) I suppose this varies between department, but how much would relaxation of work restrictions benefit continuity of care where patients tend to stay hospitalized longer (perhaps ICU)? Wouldn't hand-off still be necessary?

The effects of sleep deprivation are well documented. There is a reason for the rule. With too many hours, productivity goes down and mistakes go up. It is for both the resident and the patients.

Agreed that finding the best limit for the patient and resident will be difficult. The main point was still that at some point there is a trade off between not handing off and being sleep deprived.

More studies are probably needed. Specialty specific would be even more helpful.

I lost 2 patients on the table last weekend directly because of hand-off issues. Could you easily blame the residents doing the hand-offs as not spending additional time making sure that everything was better communicated? Sure. But, the reality is that those hand-offs are happening every day, several hundred times in each hospital and near misses are happening a lot. Better documentation helps you cover your ass going forward. It doesn't help protect patients. The biggest problem with pre-meds trying to tell people the evils of long hours is that they honestly have no idea what the system was like or what the system is like now. Be in the hospital for 50+ hours straight (with ~8 hours of sleep scattered in there), or sit in a sign out where two people (a July intern and a July 4th year 'chief') get sign-out from 6 services on 200+ patients before you knock either system.

There is a diffusion of responsibility when you hand patients off. The day team gets to say, "the night float team has all the information and is responsible." The night team gets to say, "I'm covering 200+ patients, I missed XYZ, it is somewhat expected." As big a problem as the hand-offs are, the culture change is even more significant. Within the last year I've heard any number of excuses for a piss poor sign out. Usually something big or time consuming happens right at sign out (5 or 6 pm) and people don't want to stick around to give a proper sign out. "I have a hair/massage/nail appointment." "I have a reservation for 6:30" "You are supposed to take my sign out at 6pm, it is 6:30, I'm leaving, you can call me for sign out, but only if its before 8" This is not a single institution problem. This is a global problem and it is not just residents, it is a mid-level problem as well.

Do not misunderstand me. I am not advocating an unrestricted system, increasing the work hour limit to 100 hours or removing them all together will not make anything better. Certainly getting rid of the intern rules and the hours off between shifts would avoid a lot of mistakes. But, the reason for the rule is because there was a bad outcome and someone got sued, not because there is actual science behind it. Many in surgery would make the argument that that rule change has hurt far more patients than it has helped and has hurt the training of thousands of surgery residents since.

So what is the best way to achieve optimal training in procedural fields without working 120 hour weeks? Would a 90-95 hour cap improve continuity of care? What about mandatory limits on resident scut work? <- Might sound ridiculous, but I imagine it would help.

I have no idea. In fields like surgery, scut work is typically pawned off to interns, which gives the more senior residents more time in the OR and less time on the floor managing patients pre- or post-op. However, this is probably something that @mimelim could provide more insight on.

I don't think any of our residents work less than 90-100 hours a week. Sure, the actual in hospital hours are 'capped' at 80 hours, which is violated all the time, all over the place, but then there is reading and prep work after you go home. Every week we have case conference and M&M, then we also have journal club and didactics. That means presentation preparation and textbook chapter reading. Then add to that case prep. I have to review the imaging on every single patient I operate on before I show up in the morning the next day. If you don't, your attending will know (because you will look like a idiot when you screw up because you didn't prepare) and the case will get taken from you. That is 3-4 CT scans and half a dozen angios before each operative day. Oh, and then there are the dictations for every single thing you do. Your intern H&P, consultations, discharge summaries etc. are replaced with operative reports as you go up the ladder. While they may get quicker, they still can take 10-15 minutes to do, each and that is only if you understood everything and have every device we used memorized.

It takes time to train a surgeon well. Can it be done in less than 80 hours/week over 5 years? Yes. No question. Are hospitals setup physically and financially to decrease the service required of residents to allow that to happen? No. Are residents capable of not falling into the hand-off, shift-work mentality culture? I don't think so.

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[bc65]

I agree with the above post. Just to clarify a couple of points:

the reason for the rule is because there was a bad outcome and someone got sued, not because there is actual science behind it.

True. The case that brought about this all about was due to bad outcome attributed to a drug interaction that almost no one knew existed, and was in no way related to physician fatigue.

I don't think any of our residents work less than 90-100 hours a week. Sure, the actual in hospital hours are 'capped' at 80 hours, which is violated all the time, all over the place, but then there is reading and prep work after you go home. Every week we have case conference and M&M, then we also have journal club and didactics. That means presentation preparation and textbook chapter reading. Then add to that case prep. I have to review the imaging on every single patient I operate on before I show up in the morning the next day.

Of course, in the days of unlimited resident hours, we still had to read and check all the studies, prepare for M&M, etc.

 

[7331poas]

Aren't the affects of sleep deprivation well documented?

I think you are misinterpreting my statement. I am not as much talking about patient safety, which isn't really the point of a residency program (although that is the claim). If a patient wanted to be safe they would ask to not have interns be involved in their care in the first place.

I am more wondering about the health of the resident which is a concern.

http://healthland.time.com/2009/10/...inked-with-more-mistakes/?xid=rss-topstories/

http://pss.sagepub.com/content/early/2014/07/15/0956797614534694

http://www.sciencedaily.com/releases/2008/03/080304075723.htm

I think you and I are arguing two different things. CLEARLY patient handoffs are worse for the patient.

My point is that there are other concerns for the program such as the suicide rates of residents and students, the depression levels of residents, and burnout rates.

Obviously you have more experience, but why do you think every other country in the world does it different than us and have similar outcomes (or maybe our doctors are 2x better due to more hours)?

 

[Cyberdyne 101]

Interesting video regarding call and surgical residents' skills. @mimelim, any thoughts?

 

[Mad Jack]

You won't retain as much if you're too tired to pay attention. It has been commented on. ACGME didn't make the rule for funzies. I personally would not want to be treated by a doctor who has been on active duty for 24+ hours, with certain exceptions regarding continuity of care. It's dangerous.

http://www.fiercehealthcare.com/sto...ictions-dont-help-patient-outcomes/2015-07-08
Every bit of research I've seen on the matter begs to differ. I've heard many graduating residents complain that they feel unprepared for practice, that they would have benefitted from more hours in residency. I also heard complaints during the transitional period that the way the hours and shift lengths are restricted actually made things worse, as they resulted in residents working more days overall. The work hour restrictions seem like a wonderful thing to a premed who just sees "Oh, less hours=better lifestyle!" But to someone that wants adequate training, they can be quite detrimental.

 

[rocklobstr]

http://www.fiercehealthcare.com/sto...ictions-dont-help-patient-outcomes/2015-07-08
Every bit of research I've seen on the matter begs to differ. I've heard many graduating residents complain that they feel unprepared for practice, that they would have benefitted from more hours in residency. I also heard complaints during the transitional period that the way the hours and shift lengths are restricted actually made things worse, as they resulted in residents working more days overall. The work hour restrictions seem like a wonderful thing to a premed who just sees "Oh, less hours=better lifestyle!" But to someone that wants adequate training, they can be quite detrimental.

The first part of my statement about cognitive performance and memory is still backed by a considerable amount of research. Sleep deprivation = decreased cognitive and motor abilities. I agree that the research has not shown the limit to be better for patients. However, the main criticism of those studies is that residents under report their hours (i.e. still work 80+), so it is difficult to adequately evaluate the 80-hour limit. A good study needs to be carried out on a carefully monitored program where the 80-hour limit is enforced as it was intended to be. Studies with self-reported hours and poor monitoring of hours will continue to have poor internal validity.

Also, that articles primarily points to the problem of increased hand-offs, which is of course a problem. So, it is certainly possible that the increased number of shorter shifts is detrimental. The flaws with and without the 80-hour limit need to be teased out.

 

[raindropx]

The first part of my statement about cognitive performance and memory is still backed by a considerable amount of research. Sleep deprivation = decreased cognitive and motor abilities. I agree that the research has not shown the limit to be better for patients. However, the main criticism of those studies is that residents under report their hours (i.e. still work 80+), so it is difficult to adequately evaluate the 80-hour limit. A good study needs to be carried out on a carefully monitored program where the 80-hour limit is enforced as it was intended to be.

I don't think anyone is denying the effects of sleep deprivation. Simply presenting flaws of the "grass is greener with 80 hr/wk" logic. Though I do not have experience of a resident, I would want to feel prepared and be absolutely sure I can handle the responsibility on my own when residency is over.

 

[Mad Jack]

The first part of my statement about cognitive performance and memory is still backed by a considerable amount of research. Sleep deprivation = decreased cognitive and motor abilities. I agree that the research has not shown the limit to be better for patients. However, the main criticism of those studies is that residents under report their hours (i.e. still work 80+), so it is difficult to adequately evaluate the 80-hour limit. A good study needs to be carried out on a carefully monitored program where the 80-hour limit is enforced as it was intended to be. Studies with self-reported hours and poor monitoring of hours will continue to have poor internal validity.

Most residents do not underreport their hours. Some programs do, particularly in surgery, but that is the exception, not the rule. There's actually been studies on that as well.

http://www.ncbi.nlm.nih.gov/pubmed/21156294

Regardless, who cares about cognitive and motor abilities if patient outcomes are the same? You retain more information the longer you're in. Sure there are diminishing returns, but there are still returns, and from a hospital's perspective, it makes sense to have you work as many hours as possible to lower costs. From a CMS perspective (and they're paying us, after all) it also makes sense to have us work as many hours as possible if outcomes are not worse. Who's really winning with lower work hours, particularly when those hours are structured in such a way that you end up with virtually zero time off on the days you're working? Your education suffers, you're pressed for time to cram reports into and take handoffs when you come in, less patients get seen, and costs are higher.

 

[7331poas]

I've heard many graduating residents complain that they feel unprepared for practice, that they would have benefitted from more hours in residency.

Then perhaps they could extend the length of residency.

 

[rocklobstr]

Maybe a study showing which residents don't under report their hours would have been more appropriate to link. That study had a 13% response rate, and states that 52% of surgical residents do under report their hours. "The majority admitted underreporting work hours."

Other than that, I mostly agree with what you've said. I guess the main issue to to find the point of diminishing returns for the patients and residents in each specialty before more regulations are made.

 

[raindropx]

Then perhaps they could extend the length of residency.

The last thing anyone (or at least the majority) wants is an even longer education ESPECIALLY when it could be prevented by reverting to the system in the good old days.
I'm all for wanting to be better prepared but when it can be efficiently done (and has been done for many years) then I see absolutely no reason to extend.

Also that is not the only problem. Extending would still include the problem of patient shuffling and poor education (I doubt simply extending the length will fulfill the lack of longitudinal patient interaction)

Bottom line as mimelim shared is patients were lost due to the shuffling system and if that can be prevented with a better system then no other reason is necessary.

 

[Mad Jack]

Then perhaps they could extend the length of residency.

Studies have been conducted in the past that showed residents would much rather have longer work hours with a shorter residency than a longer residency with shorter hours. To further elaborate- a physician working 100 hours a week does in a year what a physician working 40 hours a week does in 2.5 years. So a three year IM residency of old would be equivalent to a 7.5 year European-style residency. Even cutting those hours down to 80 cost us the equivalent of 1.5 years (or more for longer residencies or the brutal programs that would push people even deeper into the 120 hour range) of experience. I mean, look at surgery- those 20 hours/week add up to 4,800 less hours of experience over the course of a 5 year GS residency. That's a TON of lost learning experience, and it's no wonder people are lying about their duty hours in many programs.

 

[raindropx]

Studies have been conducted in the past that showed residents would much rather have longer work hours with a shorter residency than a longer residency with shorter hours. To further elaborate- a physician working 100 hours a week does in a year what a physician working 40 hours a week does in 2.5 years. So a three year IM residency of old would be equivalent to a 7.5 year European-style residency. Even cutting those hours down to 80 cost us the equivalent of 1.5 years (or more for longer residencies or the brutal programs that would push people even deeper into the 120 hour range) of experience. I mean, look at surgery- those 20 hours/week add up to 4,800 less hours of experience over the course of a 5 year GS residency. That's a TON of lost learning experience, and it's no wonder people are lying about their duty hours in many programs.

Those numbers really put things in perspective!

 

[7331poas]

So a three year IM residency of old would be equivalent to a 7.5 year European-style residency.

Would you say that US doctors are 3 times better than German doctors or otherwise?

Thats the crux of my question. The US does residency totally different than any other country on the planet. My question is that US residents do double the hours a week. Are they double the doctors? Are US doctors substantially better than doctors in other countries? How are US outcomes compared to Europe?

 

[Cyberdyne 101]

FWIW, Vanderbilt thinks an 80 hour week is sufficient to train neurosurgeons, while other programs ask for 88 hrs. Obviously, I'm in no position to say that one format is better than the other. However, I am intrigued that they are advertising this fact about their program.

 

[Mad Jack]

Would you say that US doctors are 3 times better than German doctors or otherwise?

Given that the EU work hour restrictions for physicians only very recently took effect, it will be difficult to say whether German patients suffer from substantially reduced resident training hours. Regardless, it takes two extra years of residency to enter most fields in Germany (five or six years before fellowship), even before the work hour changes, something I've already noted that the vast majority of physicians in the USA do not want.

 

[raindropx]

Would you say that US doctors are 3 times better than German doctors or otherwise?

Thats the crux of my question. The US does residency totally different than any other country on the planet. My question is that US residents do double the hours a week. Are they double the doctors? Are US doctors substantially better than doctors in other countries? How are US outcomes compared to Europe?

Well you failed to mention that their medical training does not include 4 years of undergrad.

 

[mehc012]

Two things:
1. Keep in mind that all of the requirements are phrased as 'averages'. So you can still spend a huge chunk of time in the hospital, you just can't do it every week.

2. I have actually heard that the duty hour restrictions lead to less favorable schedule setups than you'd think. You can't work for x hours after your overnight call, so you get those off and then are scheduled immediately after the mandatory period, meaning that you switch from mornings to nights, for example, and generally get jerked around more on timing, rather than simply working loong days everyday with sporadic nights also spent trying to steal a few hours' nap in the on-call room.

I'm not sure how true #2 is, though...thoughts from the more experienced members here?

 

[mimelim]

Obviously you have more experience, but why do you think every other country in the world does it different than us and have similar outcomes (or maybe our doctors are 2x better due to more hours)?

Their laws and regulations are different, so they have different restrictions. Their training is also considerably longer.

Interesting video regarding call and surgical residents' skills. @mimelim, any thoughts?

Then perhaps they could extend the length of residency.

I will be 33 when I graduate from my residency. I went from high school to now without a single gap year. Every additional year is one less year of max salary from my career. A two year extension is about a million dollars in salary lost. Granted, it won't be that high for many, but the point still remains. Virtually nobody in training or finished with training advocates for extending the length of residency.

Would you say that US doctors are 3 times better than German doctors or otherwise?

Thats the crux of my question. The US does residency totally different than any other country on the planet. My question is that US residents do double the hours a week. Are they double the doctors? Are US doctors substantially better than doctors in other countries? How are US outcomes compared to Europe?

We have different education systems. We train as good or better physicians than anywhere else and there is no way to directly compare them in a meaningful way. We choose to make our physicians go through undergrad, we choose to have them work harder for a shorter period of time in residency. We have different labor laws than other places. You have to put in the hours to train people. And European physicians do, just at different points and for different amounts of time.

 

[Law2Doc]

Would you say that US doctors are 3 times better than German doctors or otherwise?

Thats the crux of my question. The US does residency totally different than any other country on the planet. My question is that US residents do double the hours a week. Are they double the doctors? Are US doctors substantially better than doctors in other countries? How are US outcomes compared to Europe?

Not "better" just more experienced by virtue of having logged more hours. In the more technical/procedural fields, where they guy who has done 10 procedures is more polished than the guy who has done 2, it matters. It's like in aviation -- it doesn't matter how many trips you've flown, its all about hours in the cockpit. I've met tons of European doctors who have come to the US and were forced to concede that the shorter hours of their residencies put them years behind some of their more junior US counterparts. By late in the career it kind of washes out. But if you have to be cared for by someone right out of residency, heck yes you are better off in the US and most of the European trained docs I've worked with would concede that.

 

[Goro]

Colleague, you obviously have had some very thorough training. For those of us unfamiliar with your professional pathway, can you break it down by length of positions? I'm assuming, for example it's something like:
med school 22-26
residency 26-30
fellowship [?] 30-33?

I will be 33 when I graduate from my residency. I went from high school to now without a single gap year. Every additional year is one less year of max salary from my career.

 

[Law2Doc]

There's a fair amount of misinformation in this thread. First, the 80 duty hour work week is a bit controversial because (1) its not at all evidence based, (2) makes it harder for residents to see and do everything they'd like during their training, and (3) is a bit of a misnomer because its an average -- you are allowed to go over that figure. In terms of residents making more mistakes or not usefully learning back in the days before the 80 hour week -- that was never really demonstrated, and in fact now that we've switched to the new system, we've seen error rates stay the same or even actually GO UP depending on whose data you believe. As Nick Naylor points out the most likely culprit is handoffs -- anyone who has participated in a handoff involving tons of patients from a tired guy in a rush to go home who is cross covering and carrying multiple pagers knows things fall through the cracks, sometimes important things. And that is what kills patients far more than the guy who's tired. No improved documentation is going to help this because frankly as a busy resident you don't have the luxury of sitting down and reading a voluminous document, you WANT the abbreviated version -- the highlights, from the guy handing off to you. We aren't talking about a dozen patients, we are talking about 50, and each would be a couple of page document.

 

[mimelim]

Colleague, you obviously have had some very thorough training. For those of us unfamiliar with your professional pathway, can you break it down by length of positions? I'm assuming, for example it's something like:
med school 22-26
residency 26-30
fellowship [?] 30-33?

Completely traditional:

18 - Graduate high school
22 - Graduate Undergrad
26 - Graduate Medical School
29-33 - Graduate Residency (range based on specialty)
30-35 - Graduate Fellowship (range based on specialty and fellowship)

Some people do multiple fellowships, or things called, "Super fellowships", ie one year fellowships outside of ACGME in a super sub-specialized field. An example would be after finishing Vascular fellowship going to Cleveland Clinic to do one year of endovascular aortic fellowship. You are somewhat treated like junior faculty, but it is a single year contract and you focus on a single area.

Things get a little muddy pretty quick with regard to residency vs. fellowship. For starters, integrated programs have taken the place of many fellowships. And then there are simply variable length of training for different things. For example, I am a Vascular resident at our hospital, we had brand new cardiology fellows start in July. Now, they may be fellows, but we graduated the same year from medical school and by number of hours in the hospital, I've probably spent 1.5x the time they have taking care of patients. Even further, some of my classmates from medical school just started as attendings in July as hospitalists or pediatricians. Again, likely having spent less time taking care of patients than I have at this point (and I'm not even half way through my residency). It leads to some interesting phone calls for sure when you are the resident calling an attending from another service.

 

[Law2Doc]

... ACGME didn't make the rule for funnies. ...

It was not based on evidence. The change all stemmed from the Libby Zion case in NY, where a young woman failed to reveal the multiple party drugs she was on and the resident treating her mis-medicated her as a result, not because she was tired. The young woman's father, Sidney Zion, a media bigwig, started a national campaign and the NY hospitals and ACGME caved and changed the rules. So no, they didn't change the rules because tired doctors were killing their patients. They did it because of a fear of Sidney Zion and bad press.

 

[raindropx]

It was not based on evidence. The change all stemmed from the Libby Zion case in NY, where a young woman failed to reveal the multiple party drugs she was on and the resident treating her mis-medicated her as a result, not because she was tired. The young woman's father, Sidney Zion, a media bigwig, started a national campaign and the NY hospitals and ACGME caved changed the rules. So no, they didn't change the rules because tired doctors were killing their patients. They did it because of a fear of Sidney Zion and bad press.

Why is it still in place? Are there movements working to get rid of it?

 

[Law2Doc]

There's a perspective issue here. I think a lot of premeds on here hear numbers like 80-100 hours and think -- that's crazy, it would really be brutal and is exploitative, if I didn't get 6 hours of sleep a night I'd die.

Fast forward to later residency and you are started to get nervous about going into practice and doing things on your own. You want to get as much experience under your belt as possible while working with the safety net of residency. A case comes in toward the end of a shift that would be great experience, or a doc asks if you want to scrub in on a procedure you haven't done nearly enough of. And you WANT to do it, but $%&& -- if you do you'll be over duty hours. So you are cursing the stupid 80 hour rule that's standing in the way of getting the experiences you need.

 

[raindropx]

There's a perspective issue here. I think a lot of premeds on here hear numbers like 80-100 hours and think -- that's crazy, it would really be brutal and is exploitative, if I didn't get 6 hours of sleep a night I'd die.

Fast forward to later residency and you are started to get nervous about going into practice and doing things on your own. You want to get as much experience under your belt as possible while working with the safety net of residency. A case comes in toward the end of a shift that would be great experience, or a doc asks if you want to scrub in on a procedure you haven't done nearly enough of. And you WANT to do it, but $%&& -- if you do you'll be over duty hours. So you are cursing the stupid 80 hour rule that's standing in the way of getting the experiences you need.

Who cares about premeds opinions on this? Shouldn't the medical community have more of an influence in these policies

 

[Law2Doc]

Why is it still in place? Are there movements working to get rid of it?

A number of surgery groups have lobbied for longer hours for surgery specifically, but I doubt much will change because it just sounds intuitive to non-doctors (who don't understand things like handoffs) that if you are tired you are dangerous.

 

[Law2Doc]

Who cares about premeds opinions on this? Shouldn't the medical community have more of an influence in these policies

Residency programs compete for med students. Saying you'll get an extra 20 hours a week of free education working for us is a hard sell, even if it's probably true.

 

[raindropx]

There's a perspective issue here. I think a lot of premeds on here hear numbers like 80-100 hours and think -- that's crazy, it would really be brutal and is exploitative, if I didn't get 6 hours of sleep a night I'd die.

Fast forward to later residency and you are started to get nervous about going into practice and doing things on your own. You want to get as much experience under your belt as possible while working with the safety net of residency. A case comes in toward the end of a shift that would be great experience, or a doc asks if you want to scrub in on a procedure you haven't done nearly enough of. And you WANT to do it, but $%&& -- if you do you'll be over duty hours. So you are cursing the stupid 80 hour rule that's standing in the way of getting the experiences you need.

also, what happens if someone does scrub in that procedure

 

[jl lin]

So what is the worse thing that will happen to an intern/resident if s/he decides to stay in order to insure a sound hand-off????

I mean in the units, crappy sign-out can mean trouble for 2 or maybe 4 ICU patients. I'm a PITA. I don't want to hear from someone that I didn't share the details or big picture or missed labs, etc. I mean this is only as an ICU RN.

I just cannot fathom this: "... sit in a sign out where two people (a July intern and a July 4th year 'chief') get sign-out from 6 services on 200+ patients before you knock either system...."
That's just unreal to me.

 

[Law2Doc]

...
I just cannot fathom this: "... sit in a sign out where two people (a July intern and a July 4th year 'chief') get sign-out from 6 services on 200+ patients before you knock either system...."
That's just unreal to me.

200 is a lot but >50 is not uncommon.

 

[Law2Doc]

also, what happens if someone does scrub in that procedure

Worst case scenario is they can get the program in hot water. Most of the time if the attending gets wind of it, they say, never mind I'll let Bob scrub in instead. Then there's always the scrubbing in on the DL, and not mentioned in the duty report, which I see above in this thread never happens (wink wink).

 

[raindropx]

Worst case scenario is they can get the program in hot water. Most of the time if the attending gets wind of it, they say, never mind I'll let Bob scrub in instead. Then there's always the scrubbing in on the DL, and not mentioned in the duty report, which I see above in this thread never happens (wink wink).

if that's what it takes..

 

[Goro]

Many thanks, colleague!

Here's a comparison for the hard sciences:
18 - Graduate high school
22 - Graduate Undergrad
27 - Finish Graduate School with PhD
~30: Finish post-doctoral fellowship -> academia or industry
sadly, it's getting more common for people to do a 2nd post doc (like I did). getting a faculty job is being in the right place at the right time.

The ages above are not what I did...I worked after college and went to grad school much later.

Completely traditional:

18 - Graduate high school
22 - Graduate Undergrad
26 - Graduate Medical School
29-33 - Graduate Residency (range based on specialty)
30-35 - Graduate Fellowship (range based on specialty and fellowship)

Some people do multiple fellowships, or things called, "Super fellowships", ie one year fellowships outside of ACGME in a super sub-specialized field. An example would be after finishing Vascular fellowship going to Cleveland Clinic to do one year of endovascular aortic fellowship. You are somewhat treated like junior faculty, but it is a single year contract and you focus on a single area.

Things get a little muddy pretty quick with regard to residency vs. fellowship. For starters, integrated programs have taken the place of many fellowships. And then there are simply variable length of training for different things. For example, I am a Vascular resident at our hospital, we had brand new cardiology fellows start in July. Now, they may be fellows, but we graduated the same year from medical school and by number of hours in the hospital, I've probably spent 1.5x the time they have taking care of patients. Even further, some of my classmates from medical school just started as attendings in July as hospitalists or pediatricians. Again, likely having spent less time taking care of patients than I have at this point (and I'm not even half way through my residency). It leads to some interesting phone calls for sure when you are the resident calling an attending from another service.

 

[7331poas]

Many thanks, colleague!

Here's a comparison for the hard sciences:
18 - Graduate high school
22 - Graduate Undergrad
27 - Finish Graduate School with PhD
~30: Finish post-doctoral fellowship -> academia or industry

Could you do one for European or Japanese medical education. I am curious actually. I may have a misconception on their education.

 

[raindropx]

Could you do one for European or Japanese medical education. I am curious actually. I may have a misconception on their education.

Google

 

[7331poas]

Google

You have 240 posts in 1.5 days. Figured you had the time to walk me through it.

 

[mehc012]

You have 240 posts in 1.5 days. Figured you had the time to walk me through it.

Gee, I wonder if there is a difference between having conversations with people of your own volition, and researching something unrelated to your own future that you aren't interested in just because someone you don't know isn't willing to do it themselves.

 

[raindropx]

You have 240 posts in 1.5 days. Figured you had the time to walk me through it.

Are you intellectually incapable of walking yourself through it?

 

[WedgeDawg]

Guys, come on, it was such an innocuous question/response, why get so worked up over it?

 

[raindropx]

Guys, come on, it was such an innocuous question/response, why get so worked up over it?

Because he's asking--no expecting--others to do his work for him about a career path that he will never consider and one that most here are not interested in. Aka lazy on top of all his obnoxious ignorant posts in this thread.

 

[mehc012]

Because he's asking--no expecting--others to do his work for him about a career path that he will never consider and one that most here are not interested in. Aka lazy on top of all his obnoxious ignorant posts in this thread.

Exactly. It's rude, and more than a little self-centered.

Guys, come on, it was such an innocuous question/response, why get so worked up over it?

The first post was an innocuous question, sure...maybe they didn't think about it, or realize that it was something others would have to research.

The response to 'Google it' is reasonable...it's saying "I don't know, I'd have to research it, so you may as well just look it up."

It was the followup, where the poster acknowledged that they were expecting a favor and basically said "well, you have no life so do it for me" that was inappropriate. THAT'S what they're getting flak for.

 

[mimelim]

also, what happens if someone does scrub in that procedure

So what is the worse thing that will happen to an intern/resident if s/he decides to stay in order to insure a sound hand-off????

I mean in the units, crappy sign-out can mean trouble for 2 or maybe 4 ICU patients. I'm a PITA. I don't want to hear from someone that I didn't share the details or big picture or missed labs, etc. I mean this is only as an ICU RN.

I just cannot fathom this: "... sit in a sign out where two people (a July intern and a July 4th year 'chief') get sign-out from 6 services on 200+ patients before you knock either system...."
That's just unreal to me.

Our vascular service has 54 patients on it right now, we are one of 6 services covered by the general surgery night float system. Of those 54, 8 are ICU patients. Granted, there is a CV intensivist + PA in house all night, but these are sick people. If they have to go back, it is on our night people to recognize it if called by the ICU. It is a Friday night, I am on call Saturday/Sunday. The night team knows that if the **** hits the fan, I want them to call me at 2am and that I will be in the hospital by 2:15am. A lot of my colleagues think that I'm crazy because I actually want to be called, but I don't think that there is any other way to do it. I'm not coming in at 5am and be 3 hours behind in managing a patient properly because the night float was overwhelmed or miss things on the morning sign out of the service. Frankly, that is how people end up crashing and burning.

Worst case scenario is they can get the program in hot water. Most of the time if the attending gets wind of it, they say, never mind I'll let Bob scrub in instead. Then there's always the scrubbing in on the DL, and not mentioned in the duty report, which I see above in this thread never happens (wink wink).

There are very specific ACGME rules about this. A resident can break the hours rules for two reasons. Both require you to fill out paperwork, but relatively benign.

#1 Continuity of care/patient safety - If there is an emergency or situation that requires a) that particular resident or b) a level of resident that is not coming on to replace them, they can stay and ensure that it is dealt with appropriately. A couple of examples: SICU patient is near death and family is in end of life discussions with the critical care team. It is appropriate for the resident that has been working with the family all day and the prior days to stay and continue working with them. A ruptured AAA comes in at 4pm, complicated type B dissection comes in at 5pm and while seeing the type B in the ER, you find the ER was sitting on two cold legs. Knowing that likely you will be running 3 ORs well into the evening, it is appropriate for the day residents/fellows to stay to do those cases.

#2 Education - I actually didn't know about this until I bothered to read the ACGME rules governing our program earlier this year. If there is something relatively rare going on or you are already scrubbed/managing a large case, you can stay to finish it, even though you will go over hours.

In general, people simply don't log the hours so they don't have to do the paperwork, but the reality is that from an education standpoint, the rules really aren't actually that bad. What is bad is the mindset. Some institutions don't tell their residents the details (like ours that I had to figure out on my own). Others have their own rules on top of the ACGME ones that further restrict residents so that they stay well within the ACGME rules. But, by setting up a system that pushes shift mentality, people don't generally stay for those later cases. They would rather make hair appointments or see a movie or whatever. It is hard for most people, especially the general public (or pre-meds) to fault those residents, after all, they have already worked 12-14 hours that day. But, as others have said, what most of us have realized in surgical training, most people feel like at the end of their training they wish they had more and they end up trolling for those extra cases to get in the practice before their ass is on the line. I had the chance to talk to one of our former fellows yesterday (3 years now in practice) and he echoed that by far the scariest thing is to realize that you are the most senior person in the room and possibly in the hospital at that moment and you don't have a resident with you or a fellow or a PA, just a scrub tech who may or may not have any Vascular experience.

When you talk to surgical graduates about how to pick a program as an MS4, what it always comes back to is case volume and autonomy. You need to do lots of cases and you need to actually do them (you can't be logging cases watching faculty operate).

 

[7331poas]

Ha,

Sorry peeps, was thinking it would be pertinent to the conversation. I had seen that European medical education was in fact shorter than the US but responses in this thread indicated otherwise.

Thats why I asked how long it was because I was probably working on a misconception.

The response to 'Google it' is reasonable...it's saying "I don't know, I'd have to research it, so you may as well just look it up."

Not sure about this. If he didn't know it then why not just not comment on it and let someone who did know it answer? Working on this thought process there would be 30 "google its" in every thread from people who are browsing and dont know the answer to a specific problem.

My assumption is that there is a mysterious alternate reason for the snarkiness.

It was the followup, where the poster acknowledged that they were expecting a favor and basically said "well, you have no life so do it for me" that was inappropriate. THAT'S what they're getting flak for.

Yea, well I do admit, when I saw the guys number of posts and the day he joined I did have to take the shot. Thought it was pretty funny since he is likely on an alt.

 

[7331poas]

But, as others have said, what most of us have realized in surgical training, most people feel like at the end of their training they wish they had more and they end up trolling for those extra cases to get in the practice before their ass is on the line.

I guess my question is here, do residents want more cases in the same period of time, or are they strictly against lengthening residency to get more cases in. What is the solution to that?

There must be a number that can be agreed on. Maybe even the current length at 100-120 hours a week isnt enough?

 

[Law2Doc]

...
There must be a number that can be agreed on. Maybe even the current length at 100-120 hours a week isnt enough?

if you are talking experience, more is better. I think people want to do a ton of cases before they get out of residency but for obvious reasons don't want residency to be 8-10 years long. So you can shorten the years and up the hours and a lot of people would actually be happy about that. There's a breaking point but I think most will say 80 hours isn't close to it. 120 for 1-2 fewer years might be something a lot of people would sign on for though.

 

[mehc012]

Not sure about this. If he didn't know it then why not just not comment on it and let someone who did know it answer? Working on this thought process there would be 30 "google its" in every thread from people who are browsing and dont know the answer to a specific problem.

My assumption is that there is a mysterious alternate reason for the snarkiness.

Because that is not an area which many people on this forum are familiar with. Trust me, you hang out here a short while and you start to get a sense of which users are knowledgeable about which areas...that is not one of the ones where you are likely to find an authoritative answer. Foreign medical education systems come up occasionally, but those discussions don't garner many answers. Regardless, it was a valid response to a presumptuous request...people often volunteer information, but when you demand it, you're lucky to get a 'google it' response.

Besides, the forum IS full of 'google it' responses (or 'use the search function')...the only reason it's not 30 posts/thread is because a lot of SDN users, myself included, like to THINK they know a lot about the US MD system. Even when people DO know the answers, they often recommend googling or searching things, because a) repeating yourself gets tiring, and b) you learn more when you do the footwork.

 

[Stagg737]

For all you kids arguing about medicine in Europe, here's a pretty extensive link. I'm too busy/lazy to read details, but it should be a decent starting point.

http://www.medicalstudyguide.com/medical-specialisation-in-europe.html

 

[7331poas]

Trust me, you hang out here a short while and you start to get a sense of which users are knowledgeable about which areas...that is not one of the ones where you are likely to find an authoritative answer. Foreign medical education systems come up occasionally, but those discussions don't garner many answers.

Gottcha, I mistakenly presumed that raindropx was simply being rude since he couldn't of known that not many people are familiar with other education systems since he has only been here since Wednesday.

if you are talking experience, more is better. I think people want to do a ton of cases before they get out of residency but for obvious reasons don't want residency to be 8-10 years long. So you can shorten the years and up the hours and a lot of people would actually be happy about that. There's a breaking point but I think most will say 80 hours isn't close to it. 120 for 1-2 fewer years might be something a lot of people would sign on for though.

I think what I was going for was, if most residents feel like they aren't prepared enough when they exit residency, why not just lengthen it another 6 months to a year?

Although there is an obvious conflict though with a large debt looming over many of their heads.