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Do you think limiting resident work hours is a bad thing?

Discussion in 'General Residency Issues' started by Fanconi, Aug 19, 2002.

  1. Fanconi

    Fanconi Senior Member
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    So, I was operating with this one surgeon at 4 am Sunday morning, just chatting, shooting the breeze...

    All of a sudden he starts in on this rampage (yeah, this is the same guy who pimped me on chemistry, lol) about how residents these days are sloth-like, lazy, no-good SOBs. Back in *his* day, when he was a resident, he worked his 36 hours on and 8 hours off with a smile on his face. He was a real doctor, dammit. Residents, especially surgical residents, are all wimpy and poorly trained with an 80 hour work week according to this dude. Why, we ought to extend our surgical residency an extra two years at least to make up for the lack of training and exposure these future residents are gonna have!

    What's your reaction?

    Mine was "Screw you, buddy. I kinda want to have a life, and I think I'll be an even better doctor rested. And if I had any idea that my surgeon was as overworked as you were, there is no way in f-ing hell I would let you operate on me!"

    Of course, I didn't say that. I just nodded my head and smiled.
     
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  3. Silvertip

    Silvertip Member
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    :eek:
    I'm in agreement with Fanconi. I don't see how operating sans sleep for 36 or more hours is a good learning experience. Especially after reading quotes from current surgery residents on a link from this site, many of whom fell asleep at the wheel while driving home (very safe) and one who almost face-planted into a leg operation after falling asleep (he was holding the wound open). Medicine is no different- writing orders with no sleep is incredibly dangerous and counter-productive.

    My wife works for a family practice/peds group of 12 physicians, many of whom voiced negative reactions to the new hour regulations for residents. They felt residents just wouldn't get enough hours immersed in learning cases.

    My thoughts: I would rather spend an extra year or two learning surgery or medicine under conditions that are conducive to retention of the material/operation/procedure. I wonder if surgeons like the one Fanconi described aren't just pissed off that they had to make the "right of passage" and that the surgeons/physicians of the future may not.
     
  4. Vader

    Vader Dark Lord of the Sith
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    Let's break the chain of abuse...
     
  5. Jessa

    Jessa New Member

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    I'm afraid my reply to his "Back in MY day..." rant would have been a somewhat-sardonic, "In the snow? Uphill? Both ways?"

    This bodes ill for my future success. I'm too old to be cowed by an irate surgeon.

    At no time in history has "I did it, so you have to do it" been a valid reason for anything. Revenge is not an appropriate teaching technique.

    Frankly, we don't KNOW if making residents work fewer hours is a good or a bad thing. We can surmise; fewer work hours will hopefully mean more sleep, better eating habits, more exercise. We KNOW those things mean better health, better concentration.

    What will the effect be of the lost learning hours? We can guess. Wasn't there a study done last year that said something to the effect that memory retention wasn't affected by how tired you are, but memory recall was? I remember clinging to that study as a sign of hope while studying for finals. ;> So maybe being tired doesn't really affect how much you learn. It does negatively affect what you recall, it negatively affects coordination, and ability to concentrate on a task.

    That should at least make the medical community at large willing to try it. Unfortunately, jealousy is not an uncommon reaction. "How come you get to slack off at 80 hours and I had to work 120?! No fair!"
     
  6. Winged Scapula

    Winged Scapula Cougariffic!
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    As someone "in the trenches", so to speak, I am frankly tired of hearing comments like the one noted by the OP. WE (the residents) didn't ask to work less hours; surgery (and other residency) programs will have it FORCED upon them because they steadfastly, FOR YEARS, refused to make the changes themselves. Call it stubborness, egoism, whatever...fact is, programs have lost the control to make those changes themselves because of refusal to do it on their own.

    I know of no surgery program in the US which is currently strictly adhering to the 80 hour per week rule, so comments about residents "only working 80 hours per week" are generally an exaggeration (RRC doesn't require it until next July). Most are trying but I will not be suprised to find that many programs have difficulties in instituting it or even go as far as "ask" their residents to lie about the number of hours they work.

    IMHO, most of us would be willing to spend more time in residency if you could show us evidence that we come out less well-trained due to the decrease in work hours.

    Am I upset or jealous that the new crop of interns go home post-call, get 10 days off for vacation (per "week" instead of 7), etc. ? Absolutely *&^&*^% not. I want to be in a program which is seen as progressive and sensitive to its members needs. We still have a ways to go and we are struggling with covering services, cases, etc. but in no way would I see it fit to deride my fellow colleagues just because I worked 130+ hours on some services last year and never went home post-call and they do. Petty spiteful jealously is all that talk is. If I become a worse surgeon because of the hours, then I'm willing to work longer, but don't assume this to be the case. Programs still have to provide a certain number of cases to graduate their residents and be in compliance so programs will find a way to make sure their graduating Chiefs have the required numbers or risk losing accreditation that way.

    And on that note, I'll move this to General Residency Issues for further discussion...
     
  7. triathlete411

    triathlete411 Senior Member
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    A potential argument against limiting resident work hours is that in the "real world" one cannot limit work hours. I know several private practice general surgeons who work well over 100 hours/week. I know there are job options out there that do not mandate working that many hours, but with the decreasing number of general surgery applicants, will large practices be feasible while still providing surgical services to rural areas? I would argue no.
    Furthermore, I worry about continuity of care. If I am taking care of a patient, I don't want to be told that I am over my work hour requirements and must go home or the residency be sanctioned. And, again in the real world, sometimes you are the only surgeon so you certainly can't leave, no matter how tired you are.
    Just my two cents.
     
  8. gherelin

    gherelin Member
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    it's probably different for surgery residents but for we FPs, neither argument applies. Choosing to work long hours in private practice is just that-a choice. You can limit the number of patients you see, manage well from home often, share calls etc. It has to do with being willing to trade off money for a life. In terms of continuity of care-unless I am on my internal medicine rotation and on that particular team, I will never see again the patients I admit when I'm on-call. I feel more like an admitting clerk for the emergency department. Yes I could go visit them on the floors later etc. but who has time? So there is no continuity there. The continuity will be when I see my patients in clinic day after day and year after year, see them develop a disease, admit them to the hospital, follow them there, and then see them for follow-up when they come out. To me, that's continuity. But that's the difference between FP and more acute specialties. (So maybe you guys can take our call? :D Just kidding!)
     
  9. Renovar

    Renovar Senior Member
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    Well, in the real world, you get to choose what kind of life you get to live - if you want to do lots of hours and rake in cold cash, that's your perogative. At least you dont get bullied around by the system and am forced to do something that you wouldn't do otherwise.

    Your argument about rural areas lacks surgeons, and that those surgeons who do work in those areas do have to work long hours - is very true. But how many surgeons fresh out of residency is going to the rural areas to practice? Not many-most would prefer to stay in urban areas. Therefore long resident work-hours in general doesn't do jack in this regard. Besides, the rural-area/long hour is true not only for surgery, but for other fields as well, like FP, OB/GYN, etc.

    The truth is - you get to choose how you want to live your live after residency. Many physicians choose to relax and have better hours. Some intense individuals would choose to continue to work long hours and be very productive. In the real world, physicians and surgeons themselves have better control of their own state of health and physical need, and can better exercise their good judgement in that regard. Residents, under current policies, can't make this judgement for themselves, and therefore sometimes are forced to work in a compromising position that can sometimes jeopardize the patient's care.
     
  10. Voxel

    Moderator Emeritus 7+ Year Member

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    I've got 2 words for him, the first starts with an F and 2nd word is Off. Remind him/her when s/he is walking out of the OR saying thank you about who is doing the real grunt work. You are one closing the abdomen for the next 1/2 hr, cleaning off the pt, writing the BON, transfering the patient to the PACU/writing orders, while he is going out to dinner. So next time he whines about how lazy the residents are, tell him to FO.
     
  11. Fanconi

    Fanconi Senior Member
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    *taking notes*

    Thankfully, I'll never operate with this SOB again. I am having him write a letter for me, though! :laugh: Yeah, I'm charmed him real good. Why, I practically said an "Amen!" at the end of his lazy resident sermon. Little does he know I was mentally giving him the finger the whole time.

    BTW, I think acting classes should be a mandatory part of med school.

    You're not doing a surg prelim year, are ya, Vox?




    Edit - - Duh. I should just read your sig.
     
  12. Voxel

    Moderator Emeritus 7+ Year Member

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    In the real world you cannot tell him/her that. It is kinda fun doing it mentally and smiling at him/her as you do it. I walk around my transitional year with a smile on my face almost every day cause I know "there'll be better days."

    Even when you are an attending it is politically/professionally difficult unless you do primary care, where the surgeon will have to kiss your ass (unless s/he is the only surgeon in town).
     
  13. Fanconi

    Fanconi Senior Member
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    Actually, this is sorta funny/sad, but the week before I got there, his PA yelled at him something to the effect of "You are such a m*therf*cking prick!" in the middle of clinic (in front of patients and everything) and stormed out of the building. :laugh:

    Damn, that had to feel good.

    The amazing thing is that she still works for him!
     
  14. Take it from someone who ended up in a fender-bender after a 30 hour call night, there is no reason why residents are forced to endure these crazy shifts, other than because of what docs did "in the old days".

    I always use the same argument. Would you want to be a passenger on a plane where the pilot-in-training had been awake for 36 hours because that's what they did "back in the day"?
     
  15. Foley

    Foley New Member

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    I am currently a 4th year at a NY medical school and would like to offer my perspective from my experience in a state that has the Bell Commission (law that mandates no more than 24 hrs. straight on call and no more than 80 hrs. per week total).

    I have rotated at several different hospitals and witnessed several different scenarios for dealing with the Bell (night float, post-call off, and ignoring the law). All of my rotations have been affected in one way or another by the Bell. Most cope with the situation by giving residents post-call day off (or at very least the afternoon).

    Time intensive fields (surgery and ob/gyn) generally have post-call off, although this varies (some leave after rounds in the morning while others leave sometime in the afternoon). Other fields get to leave right after rounds in the AM (peds, psych, im, etc.). Some, as I mentioned, like the night float - residents rotate a week on a service which basically covers from 10 pm to 7am. Smaller services, like GU, have hired PA's and NP's to cover the night. Everything considered, it seems to me that the residents get something to help them out.

    In talking to the residents there are mixed feelings. In general, the residents are pleased with the Bell, but there are those who dislike it. In surgical fields, in particular, the residents feel that part of the training is preparing them to deal with cases when they are totally exhausted. They argue that going to the OR completely wiped out on a regular basis trains you to be able to perform in situations which are not very pleasant (sleep deprivation, stress, etc.). The kind of surgeon who can hack this type of supervised training is the type of surgeon you want taking your appendix out at 3 AM on a Saturday morning.

    I personally feel that the Bell Commission works. The surgical fields, who are the biggest opponents, don't adhere to the Bell strictly so they still get their "intense training." But, the residents still get something - the post-call afternoon off (as opposed to staying till 6-7 PM).

    I have witnessed both residents in programs that strictly follow the Bell and those that loosely follow the Bell, and I see no big differences between the two. In general, all residents work hard and receive the basics tools of their field. I must say, however, that the programs offering more hours off tend to have brighter residents. I'm not sure if this is due to the attraction of the program or because the residents have more time to study.
     
  16. dr.evil

    dr.evil Senior Member
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    I can't believe I'm going to write this but here goes. I do think limiting resident work hours is a bad thing. Let me clarify my statement. "Limiting resident work hours CAN BE a bad thing."

    I'm a surgery resident in a program where we never "check-out" our patients when we leave to go home at night. We also take calls on our patients from home 24 hours/day, 7 days/week. At first, I thought this was going to be hell (and sometimes it can be). Just think about it. When you go home at night you're still "on call". Home call 24 hours/day, 7 days/week plus in house call 2-3x per week. As you can see, it can get a little hairy BUT this is the way it will be when I'm done in 5 years (except for the in-house call). It provides a continuity of care that I appreciate. When the nurses call me about a patient, I know everything about that patient and am usually able to manage most things by phone. When I arrive in the morning there are no surprises from overnight events. I can go on and on, but I like the way my program does things and that's the reason I chose this place.

    Now, if these hour restrictions do what I think they're going to do, my home call will be nixed. My program is talking about a night float (which I hate). I will lose continuity of care with my patients and have to cover other people's patients (and screw up their plan) when I'm on night float. I just hate cross-covering and left my home program to avoid it. I will also have a month or two at a time where I'm the night float. This really sucks on surgery because you pretty much only get emergent cases, which are becoming more rare in these days of non-operative management of trauma. I guess I'll get the appy's and likely some cases that were added on after the hour of 5, but I still worry about it.

    We'll see how it all works out. It will likely all balance out but right now, the change has me a little worried. Don't get me wrong, I do appreciate not having to work 40 hours straight and a little sleep is a good thing.

    I know inherently that the problem does not lie within the proposed 80 hour work week, but rather how we make adjustments in our schedules to continue to receive a consistent amount of education and more importantly, continuity of care with the people we are in this profession for, our patients.
     

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