Do Drs. really need to work so hard?

[Brainsucker]

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Do you think there's any real advantage, in terms of patient care or producing certain characteristics in doctors, to having work hours be so crazy as a resident and later on? I feel like a residency schedule that still has long shifts, but fewer of them, would still give people the opportunity to follow patients for long periods.

I realize that some Drs. can regulate their hours fairly well. I also realize that cheap labor is a reason that residency is nutty. The artificial shortage of doctors is big, too. Even with all that, the real factor seems to me to be a profession full of people who are pushing to show how hardcore they are pushing this culture forward. Maybe the fact that a culture of hard work is established means that doctors push themselves to be better and that medicine attracts those that push themselves more than it would otherwise. Is there another way?

Ideally, I'd like to be able to work hard in medical school and then have a residency with 50 something hours a week (even if it mean a longer residency) and a career with 40 hours a week and a good amount of vacation. I'd have more time to think, relax, snowboard, have a functional relationship, see kids grow up if I have them...and I think I'd deliver better care in my working hours.

 

[Law2Doc]

Do you think there's any real advantage, in terms of patient care or producing certain characteristics in doctors, to having work hours be so crazy as a resident and later on? I feel like a residency schedule that still has long shifts, but fewer of them, would still give people the opportunity to follow patients for long periods.

I realize that some Drs. can regulate their hours fairly well. I also realize that cheap labor is a reason that residency is nutty. The artificial shortage of doctors is big, too. Even with all that, the real factor seems to me to be a profession full of people who are pushing to show how hardcore they are pushing this culture forward. Maybe the fact that a culture of hard work is established means that doctors push themselves to be better and that medicine attracts those that push themselves more than it would otherwise. Is there another way?

Ideally, I'd like to be able to work hard in medical school and then have a residency with 50 something hours a week (even if it mean a longer residency) and a career with 40 hours a week and a good amount of vacation. I'd have more time to think, relax, snowboard, have a functional relationship, see kids grow up if I have them...and I think I'd deliver better care in my working hours.

I don't think it's about a culture of showing how hardcore you are. It's quite simple -- the goal is to learn as much as you can in as short a time as possible. The only way to learn is by doing, and the only way to do is to be there. 50 hours a week of learning does not equate to 80 hours per week. There is a ton to know and lack of knowledge costs lives, so medicine necessarilly must be a career involving a continuous and substantial upgrade of your knowledge (both by long hours and outside reading). The fact that you would be willing to double the length of your residency to make up the time difference of shorter hours probably makes you in the minority. As for actual practice, you can probably line up some sort of lower hour practice schedule for a significantly lower salary, once you are done with residency, but shouldn't expect a 40 hour a week, never need to study again life, as you might in other fields. Because you will know less than the person who works 60 hours a week, and that can be a dangerous thing. Just my 2 cents.

 

[Brainsucker]

First, it's funny that you talk about doubling residency. Is that a comment on the lack of compliance of residencies to the 80 hour week? There are studies showing the common sense that people learn better when they're well rested. Doctors, of course, ignore these studies as well as common sense.

Second, I don't consider my professors and other doctors who work limited clinical schedules to be ignorant. I realize that they do lots of outside reading (the former more than the latter), but the fact remains that they remain good doctors with much less insane clinical schedules. I said nothing about a never study again life. I think if I study as much as the person who works 60 hours a week, but see fewer patients (and I'm likely to study more because I'll be less exhausted) I'll be just as well prepared, partially by view of being well rested. (I'd always rather be a surgeon's first case of the day than his second.) And I don't expect it--there's no hope any time soon.

 

[Lorrayne]

There probably aren't many options regarding residency hours. I'm one of those who would rather complete my residency in 3 years by working my butt off, rather than drag it out for 5-6 years.
However, when it comes to your practice, there are several specialties that allow a great deal of flexibility with hours. For example, at the ER where I work, most of the docs work 15-16 nine-hour shifts a month. Of course there is no call, so that works out to be about 40 hours a week. Some prefer to work more, some less. And the shifts can be scheduled in blocks to allow for vacation time each month.

 

[oldManDO2009]

I may be wrong - but is our medical training in the US the only system that requires 4 years of undergraduate, 4 years medical and 3+ years residency. I think 6 years of medical school straight out of high school and residencies would be a better approach. 11 plus years of school is a long time and I don't think a degree in poli-sci is absolutely necessary to become a god doc...

The 4 year curriculum could stay the same and 2 years of pre-med training could focus on science and language. You would be accepted during pre-med and could avoid all of the other stuff we do to become more "competitive" applicants.

My 2 cents...

edit - I think residency is fine as it stands - just long enough not to kill people

 

[LanceArmstrong]

I may be wrong - but is our medical training in the US the only system that requires 4 years of undergraduate, 4 years medical and 3+ years residency. I think 6 years of medical school straight out of high school and residencies would be a better approach. 11 plus years of school is a long time and I don't think a degree in poli-sci is absolutely necessary to become a god doc...

The 4 year curriculum could stay the same and 2 years of pre-med training could focus on science and language. You would be accepted during pre-med and could avoid all of the other stuff we do to become more "competitive" applicants.

My 2 cents...

edit - I think residency is fine as it stands - just long enough not to kill people

I think you are right. 6 years from high school is quite long enough to learn all the basic science and basic clinical stuff that for some reason we stretch out to 8+ years. There are some propgrams like that in the US now ("accelerated" 6 and 7 year programs) but the business of education for most part is not about efficiency.

I also think 4th year of med school should be like intern year is now - not spend months applying to programs and the rest of the time goofing off at easy rotations.

 

[Taus]

Without a college experience we would likely have a society full of doctors who know nothing except science and couldn't relate to their patients socially.....oh wait....we already have too many of those....

I'm sure that there are many exceptions to this, but the kids (and I mean kids) that I met in undergrad who were in joint 2+4 med programs had the social skills of a middle schooler and most had never had a beer in their lives....

and btw...a college experience does not just mean taking 18 credits of hard core science and studying all day/night.....

This is just my opinion....no one get their panties in a bunch....

 

[bulma]

Without a college experience we would likely have a society full of doctors who know nothing except science and couldn't relate to their patients socially.....oh wait....we already have too many of those....

I'm sure that there are many exceptions to this, but the kids (and I mean kids) that I met in undergrad who were in joint 2+4 med programs had the social skills of a middle schooler and most had never had a beer in their lives....

and btw...a college experience does not just mean taking 18 credits of hard core science and studying all day/night.....

This is just my opinion....no one get their panties in a bunch....

I had the option of going to med school in France out of high school but instead I chose to get a 3yr bachelor (transeferring from a french high school gave me 30 AP credits), and then an MPH for personal reasons. I do understand your point about going straight from high school to med school. It works for some countries and then they don't really have residency programs as much as they have specialty programs. They actually graduate doctors, primary care doctors.

Now I chose to get a bachelor's first because like some people have mentionned it gave me the time to mature and make sure i wanted to commit my life to this profession, which is hardcore for all the reasons mentionned by others (the culture, the responsability to our patients, the infinite amount of knowledge and limited amount of time...). I think very few people are mature enough at 18 to embark on this life long journey. And imagine having a class full of 18 yo and than you have the not-so-rare 34 yo who decided he/she wanted to become a doctor after a career in something else... I don't think 18 yo and 30 yo mix very well...

I do think there is some sort of narcissim in the profession that makes us want to appear hardcore to others. it's like being hardcore correlates to being a good practitionner. I don't know why...

I do think however that no book can replace the patient. So if you are working 60 hours and studying 20 a week, somehow the guy who's working 80 hours will probably know more than you.

That's my 2 cents.

 

[Law2Doc]

First, it's funny that you talk about doubling residency. Is that a comment on the lack of compliance of residencies to the 80 hour week?

No - YOU suggested that you would rather work more normal hours "even if it would mean a longer residency". I just extrapolated that if you wanted a regular schedule to match the hours you would need to double the residency. I didn't comment on the 80 hour week. While people may learn better when they are well rested (I don't question this, although certain medical programs do), I would suggest one actually cannot learn certain clinical things at all if they aren't there. Unlike med school, residency experience is not something you can replicate learning from home using books and lecture tapes. Thus a well rested experience of a 50 hour week will never equate to an 80 hour a week experience in terms of learning, no matter how much sleep you get, UNLESS you proportionally increase the weeks (I said twice, but okay, 8/5th)... That's all I was saying. And I certainly have no interest in doubling up my residency years, so 80 hour work week here I come.

(And I don't think I suggested that your professors who spent less time in their schedule doing clinical work were ignorant. But I do think you are probably underestimating their hours, and note that they probably did their residency training in an era where residencies were MORE than 80 hours per week, and probably otherwise paid their dues pretty significantly and so were fairly high up the learning curve before they cut down their hours..)

 

[tupac_don]

Without a college experience we would likely have a society full of doctors who know nothing except science and couldn't relate to their patients socially.....oh wait....we already have too many of those....

I'm sure that there are many exceptions to this, but the kids (and I mean kids) that I met in undergrad who were in joint 2+4 med programs had the social skills of a middle schooler and most had never had a beer in their lives....

and btw...a college experience does not just mean taking 18 credits of hard core science and studying all day/night.....

This is just my opinion....no one get their panties in a bunch....

I just think that too much emphasis is placed on volunteering and doing all this other stuff for med school admission, that lot of kids don't have a rounded life. I think it's better that you study hard and party hard, so go date, lift weights and party in your free time, rather than volunteer in the nursing home or whatever else. I think it would be much better use of time. If med schools required say mandatory volunteering in a medical field as mandatory for admission, rather than general volunteering stuff. I think if you had people who worked hard but also played hard you would have more well rounded doctors. But so much emphasis is placed on having to have volunteering or EC activities, that basically no time is left to just have good old fashioned fun. Plus if you had people going into med school straight from high school, I think it would be much better. Every year you could increase intensity so once in med school, people would have more time to socialize over a 6 year period than briefly over a 4 year period or more accurately 2 years of classes. That I think would make med school less stressful and it would give more of an adjustment to people. Also you could actually give time for all that knowledge to be soaked in, rather than feel like you are on a wonderland ride. Just my 2 Cents.

 

[Law2Doc]

I think it's better that you study hard and party hard, so go date, lift weights and party in your free time, rather than volunteer in the nursing home or whatever else.

From what I've seen, a lot of the high GPA, high MCAT crowd in med school ended up with those numbers because dating and weight lifting are not realistically something they were going to be adept at anyhow. So making them volunteer at least got them out of the library and someplace where people are...

 

[tupac_don]

From what I've seen, a lot of the high GPA, high MCAT crowd in med school ended up with those numbers because dating and weight lifting are not realistically something they were going to be adept at anyhow. So making them volunteer at least got them out of the library and someplace where people are...

hahahahaha, You might have a point there.

 

[WatchingWaiting]

I do think however that no book can replace the patient. So if you are working 60 hours and studying 20 a week, somehow the guy who's working 80 hours will probably know more than you.

That's my 2 cents.

I think you're 100% wrong on this one. You'd be much better off doing the 60 hours of patient care and 20 hours of reading uptodate and primary literature on your patients' conditions than just doing 80 hours of patients. Maybe 80 hours of patients + 20 hours research would be better (although the problem is, after 80 hours of patients, you're generally too dead tired to be throwing on 20 more hours of reading). Every one knows how to do a good h&p by the end of third year, but the challenge of residency is learning how to manage your patients' conditions well, which requires a lot of reading on stuff that was not covered in the first two years of med school.

 

[Law2Doc]

I think you're 100% wrong on this one. You'd be much better off doing the 60 hours of patient care and 20 hours of reading uptodate and primary literature on your patients' conditions than just doing 80 hours of patients. Maybe 80 hours of patients + 20 hours research would be better (although the problem is, after 80 hours of patients, you're generally too dead tired to be throwing on 20 more hours of reading). Every one knows how to do a good h&p by the end of third year, but the challenge of residency is learning how to manage your patients' conditions well, which requires a lot of reading on stuff that was not covered in the first two years of med school.

You cannot learn new procedures or surgery as well from a book. And you cannot learn much in the way of managing a patient through the night if you are hardly ever there through the night (or at least there less than the person working 80 hours). In the ideal world you would do both the 80 hour work week and read "some" daily. Sounds herculean, but older docs worked even longer hours. The jury is still out as to whether they learned more or just made more mistakes by the longer hours. In a number of years enough good data will have been generated either applauding or damning the 80 hour limit.

 

[Brainsucker]

You cannot learn new procedures or surgery as well from a book. And you cannot learn much in the way of managing a patient through the night if you are hardly ever there through the night (or at least there less than the person working 80 hours). In the ideal world you would do both the 80 hour work week and read "some" daily. Sounds herculean, but older docs worked even longer hours. The jury is still out as to whether they learned more or just made more mistakes by the longer hours. In a number of years enough good data will have been generated either applauding or damning the 80 hour limit.

I agree that the OR is the best place to learn how to operate, but there's a lot more to being a surgeon than cutting. I absolutely agree with watchingwaiting: Much of that knowledge is best learned from the literature.

I'm very sympathetic to your concerns about continuity of care. That's why I think some test strategies for improving work hours are flawed. See http://content.nejm.org/cgi/content/short/351/18/1838 and the responding letters for a good debate about work hours. One of the major points in responses to the paper was that interns weren't able to follow patients. I think a schedule with some long shifts would be reasonable.

Of course, another major point is that the economics are inappropriate. The main solution to this is more medicare money for resident training.

 

[Law2Doc]

I agree that the OR is the best place to learn how to operate, but there's a lot more to being a surgeon than cutting. I absolutely agree with watchingwaiting: Much of that knowledge is best learned from the literature.

As with any trade, you cannot learn everything from the literature. It's important BACKGROUND, but you can only become a good surgeon by doing a lot of surgery. Similarly you can only become good at any procedure, or in monitoring a patient's course, or in handling a series of emergency situations etc. etc. by doing a lot of them. When you need to have surgery done, you'd far rather prefer having the surgeon who had done that procedure a couple of hundred times than the one who has better read up on it. The smartest and most well read book learner can easily be the worst clinician/surgeon etc. In that respect this is a skilled trade, not a purely academic one.
I can tell you from my prior career that you learn a whole lot more about what happens in real life when it is happening and you are actually there in the thick of it. You can be well read in the law and still not be able to negotiate a deal, win a case, etc. etc. I suspect medicine (including but not limited to surgery) is doubly so. So I would posit that while SOME amount of your knowledge during residency must come from reading (a lot of which you hopefully did back in med school), the vast majority comes from actually practicing your trade and honing your skills in real life.

 

[deuist]

Without a college experience we would likely have a society full of doctors who know nothing except science and couldn't relate to their patients socially.....oh wait....we already have too many of those....

UMiami recently did away with its "baby doc" program, a six-year, straight from high school program for the reasons that you just mentioned. Many of the baby docs are extremely immature and can't relate to their classmates, much less their patients.

 

[Brainsucker]

Laws are man-made and arbitrary. Biology is science. Good to know some of the science if you plan to interfere with the biology.

Nah, I'd like to have a surgeon who's read up on the literature so that he'll know what the long-term outcomes are of different surgeries, what drugs to prescribe after the surgery and what other treatments might be available.

In med school you have time to do reading on general medicine, not so much on your specialty unless you're a freak (I give props to you if you are) and are honoring everything while doing years worth of reading on your specialty of choice. Your med school knowledge is going to be out of date soon enough, so it's still important to keep reading throughout your career.

I guess it also depends on what specialty you're interested in. Some change more than others and require more reading than others. I think you and I are suited to very different specialties.

 

[bulma]

(...)
Nah, I'd like to have a surgeon who's read up on the literature so that he'll know what the long-term outcomes are of different surgeries, what drugs to prescribe after the surgery and what other treatments might be available.

(...)
Your med school knowledge is going to be out of date soon enough, so it's still important to keep reading throughout your career.

I see your point.

I don't think anyone is saying that surgeons (or any doctor really) would be better off spending 0% of their time reading and 100% of their time in the OR. The idea, I believe, is that you can't replace the time spent at the bedside by an equal amount of time reviewing the literature and gain the same amount of knowledge. Sure you can read about things that you wouldn't learn from being only in clinic. No doubt about that. But if revewing the lit was the best way to learn, than we'd probably have 3 yrs + of academic training and a few months in clinic as med students, like in the old days. And really, we all know the first 2 yrs spent in med school are no where near equalling the last 2 in terms of learning medicine.

A lot of people learn better when they are placed in context. It's called "practicing medicine" (and law too by the way) for a reason, I believe. Each time you practice, you should be learning as well. Reviewing literature should help you strengthen what you learn/observe in the field. I think most research stems from clinical issues. You go from the bed side to the bench back to the bed side. But the goal is to be at the bed side.

Personally I'd like to believe that I'm heading into a world where physicians working 80+ hrs discover clinical aberrations that they then read about because of their relevance to their practice. Maybe that doesn't leave much time for 😴 though... oh well...

 

[Law2Doc]

You go from the bed side to the bench back to the bed side. But the goal is to be at the bed side...

Well put.

 

[Smurfette]

It'll be interesting to see how your perspectives change as you advance in your medical education.

Assuming a surgeon who is well-read has a better understanding of post-op complications or meds to prescribe compared to a surgeon with more "hands-on" experience is fairly naive. You need to be well-read (not necessarily an encyclopedia) but experience is key (in all fields, not just surgery). There are a lot of things in medicine and in residency that we do that is not well-described in literature. It is the little bumps in the road and subtle things that you see, deal with and learn from that allows you to better deal with things. MANY patients break the mold of typical presentations, and having seen patients who presented atypically allows you to better assess, anticipate complications and treat the underlying pathology. Books cannot teach you to recognize the look on a patient's face when they are about to crump, or the dexterity with which to quickly do a given procedure on a patient, or how to adapt the procedure to accommodate a particular body habitus or physical impediment to safely completing the procedure with minimal risk.

You do need to both read and gain experience, but the experience you gain will include a lot (not all, obviously) of what you can read, but reading does not equal experience.

 

[Brainsucker]

Ya'll act like I say you should be reading more than you see patients. That's not the case at all. I just think the balance could shift a little more to the well-read side of things. There's a reason we have the first two years of medical school.

Outcomes research is really important reading. It took a long time to convince doctors that bleeding wasn't a good strategy, which shows that one can't rely only on anecdotal evidence. Someone on here has the great sig: "The plural of anecdote is not fact." Yeah, I think it's vital to see that look on a patient's face, but it's also vital to know the lit. Tons of the protocols we'll all use are based on clinical trials.

(The big irony in this argument is that you'll normally hear me bemoaning the EBM movement because I think that understanding the pathophys of a patient's problem is better for unusual patients. Here I am supporting outcomes research...)

The crux of the issue is that something's got to give. You can say that you'll work some crazy schedule and read on top of that, but there's no way in hell I'll believe you. It's just like all the people who go into med school thinking that they're going to read every book, go through every detail, volunteer in this and that, etc etc. Maybe a few do, but most are human, so they do human things (see the slacker thread...). It's simply unrealistic to expect that doctors working crazy hours are going to stay up on the lit at all.

There are a few superhumans who spend their entire lives fully focused on medicine, but there are also plenty of humans in medicine. (I'm still wondering if I can be one of the superhumans. I think I have to, to do what I want to do.) Figuring out how to design medicine so that the humans deliver the best care possible is an important challenge. Assuming that the status quo is best isn't particularly realistic.

 

[Law2Doc]

Assuming that the status quo is best isn't particularly realistic.

What status quo? The hours JUST got cut down to 80 hours max (from the status quo of much higher hours). Your original post suggested 50. I'm not sure who's being unrealistic here.

 

[Brainsucker]

True that it was just cut down to 80 hours, but that doesn't make 80 hours right. And you hit on a good point about realism: Things aren't going to change because no one is going to want to put the money in to make them change, so we'll get to keep the crazy schedules you're defending. Whoo!

 

[werd]

i think there's a peak to the curve... tired and overworked doctors make mistakes and hurt patients, as do doctors that don't know a lot or don't see many patients. you have to find the point where the preparation is best for the patient... unfortunately i think that point sits in the "med students and practicing doctors shalt work hard" area.
with regard to health of us med students, there's a compromise between our mental health and getting us out as real doctors in a reasonable amount of time. honestly, i wouldn't mind having 6 more months if it would slow down the pace a little bit; i think the statistic is that 40% of med students get clinically depressed at some point during school. and that statistic makes me sad 😉

 

[Law2Doc]

i think the statistic is that 40% of med students get clinically depressed at some point during school. and that statistic makes me sad 😉

You shouldn't get depressed at the possibility of getting depressed. 🙄 I suspect that depression has less to do with residency hours given that it's med students, you say, who are getting it. Probably has more to do with coming to grips with things like death, disease, old age and your inability to halt the progression of these.

 

[Law2Doc]

True that it was just cut down to 80 hours, but that doesn't make 80 hours right. And you hit on a good point about realism: Things aren't going to change because no one is going to want to put the money in to make them change, so we'll get to keep the crazy schedules you're defending. Whoo!

As I said, I'm not exactly excited about the crazy hours, but I do hope to get the same amount of learning and value out of my residency and I have no interest in increasing the number of years of residency. Partly due to my having come to this path later in the game and partly because it's generally been my personality to try and do everything today rather than spread it out over today and tomorrow. Different strokes.