Hawaii Rumor - 56 hours/week?

[BogglestheMind]

I heard a rumor that there maybe a new maximum number of hours worked, 56 hours, so residents don't fall asleep on the job I guess, . . . but with pediatric residencies being increased to 5 years! Has anybody heard this rumor, if OBP could comment that would be great, specifically:

1. Is this rumor true?
2. Does this mean less/more residency spots? Less residents in the hospital I would think would mean more residents would be needed, but again if the residency is stretched to five years then more residents in the program?

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[oldbearprofessor]

I heard a rumor that there maybe a new maximum number of hours worked, 56 hours, so residents don't fall asleep on the job I guess, . . . but with pediatric residencies being increased to 5 years! Has anybody heard this rumor, if OBP could comment that would be great, specifically:

1. Is this rumor true?
2. Does this mean less/more residency spots? Less residents in the hospital I would think would mean more residents would be needed, but again if the residency is stretched to five years then more residents in the program?

There is currently an Institute of Medicine (IOM) committee evaluating work hours

http://www.ahrq.gov/news/sp120307.htm

Their report is due early next year.

This issue is widely debated on many of SDN's forums so you can catch some of the debate with a search. I personally doubt we'll see any major change in work hours in the near future and have real doubts about the benefits of any changes to the current system. However, we will see what happens.

 

[BogglestheMind]

There is currently an Institute of Medicine (IOM) committee evaluating work hours

http://www.ahrq.gov/news/sp120307.htm

Their report is due early next year.

This issue is widely debated on many of SDN's forums so you can catch some of the debate with a search. I personally doubt we'll see any major change in work hours in the near future and have real doubts about the benefits of any changes to the current system. However, we will see what happens.

Thanks for the reply OBP, I would prefer the 80 hours as a student we are working pretty much 12 hours a day in many clerkships with only a day off, and we take unlimited call. It would be pretty weird if residents basically worked maybe four 12 hours shifts a week, but at least they would be relaxed, I don't know how a hospital would function though, I guess attendings would have to be hired as hospitalists more . . . however, the math sure works out:

80/week x 50 weeks x 3 years (rough) - 12,000 hours

56/week x 50 weeks x 5 years (rough) - 14,000 hours during residency and they would be quality hours too,

however, if the resident's yearly income stays the same then there would a noticeable increase in the dollars paid for cheap labor by us government, so a roughtly 15% increase in hours worked for approximately 40% increase in salary per hour work, hmmm, not that everything should be determined by money though, . . . so if a 3 year peds resident becomes an attending after residency and they pass this rule then they would be supervising third, fourth, and then fifth year residents who enter/transfer into their program assuming no grandfathering!

 

[MedGoatTX]

That link is actually terrifying. They've clearly already made up their minds. 56 hours would absolutely destroy residency education in this country even more than 80 have. That's five 11-hour shifts a week and done. Think about that. You wouldn't see any continuity or process of care. And in a field with the turnover of pediatrics, how many patients would you admit, start a work-up on, and then never see again? Enacting this kind of insanity may decrease the amount of these mythical "errors due to sleep deprivation" as long as those bright-eyed residents are backed up by attendings who trained in an era where they got to see and do more. But in 20 years, when today's residents are in charge, we're all screwed. Our health will be in the hands of a crop of well-rested dolts who crap their pants at the sight of something they only read about in a book once. That will be me included. You can get book smart by going to endless conferences and lectures. You can get book smart by reading your journals and texts. But you learn how to run the show and how to be comfortable dealing with whatever goes down by being at the hospital when it does. There's no other way to do that and it's the irreplaceable cornerstone of being a competent and independent physician.

In short, work-hour restrictions will eventually kill us all.

 

[TexasRose]

I have to ask. In countries where medical training work hours are shorter, is the medical care that bad? (yes, the training is longer, but is it truly poorer?)

 

[oldbearprofessor]

Okay, forgetting some of the pros and cons, I've wondered how this would work in practical terms. Lets focus on what I know...the NICU.

To oversimplify, in the current system lets say there are 40 babies and 4 residents. Each resident covers 10 babies Mon-Friday, Various systems of cross-coverage usually have 2 or 3 residents rounding on Sat-Sunday. On call is q4 and the post-call resident leaves at noon or thereabouts the next day. I entirely realize this is an idealized scheme and isn't exactly what happens, but it isn't that far off and if properly handled, is consistent with residents basically following their own patients and working every 4th night and keeping in the 80 hours (if programs are good about not having early pre-rounds or keeping too late post-call, etc).

In a system maxing at 56 or 60 hours with let's say 12-16 hour maximums on a shift length, there are two possibilities I can readily see.

In one mode, you would basically go to pure shift work like in an ER. It wouldn't be easy to schedule this and crossover time would be needed, but basically 4 folks could cover 168 hours in a week and meet the rules with a 1-2 hour cross-over time at shift changes. Of course, in this scheme someone else is actually doing much of the daily care of the babies (rounds, physical exams, etc) - the resident can only be doing admissions and handling specific problems. Presumably the hospital has to either, 1) hire NNPs/PAs or hospitalists to see most patients, 2) Get attendings and fellows to do that (problematic as hour limitations may/will apply to them as well) or 3) Hire more residents who cover day-time which means, given RRC rules, a longer residency. This would not be easy, even with longer training you aren't all of a sudden going to have 4 more residents in that NICU as no one is going to double residency length for this. On the whole, I'd guess that academic children's hospitals would use a mixture of all 3 or these, mostly #1.

The second approach would be to use the residents to cover daytime only 7 days/week with some complex system by which the 4 residents would cover the daytimes and someone else would cover nights (same folks as in the first schema). This would give residents the longitudinal experience but not night-times. You could shift residents into some of the nights, but the 12-16 hour consecutive rule would make this very hard to schedule.

One could come up with a mix of these two such that on-service residents covered one night/week and some weekdays. You'd still need more residents or NNPs/PAs, but it would be feasible.

Bottom line would be increased costs, increased time of training, decreased role of residents in that NICU environment and the resident education being reduced (I think). Unlike an ER environment, shift work wouldn't allow for much teaching time as rounds would mostly go on without the resident as they'd be too busy handling problems or figuring out the patients.

I'd be interested in other ways people think this could be done in an ICU environment. I'm wondering if there are schemes that would be more effective for training. Has anyone plotted this out or the options and done a cost analysis for a pediatric setting?

 

[Stitch]

I have to ask. In countries where medical training work hours are shorter, is the medical care that bad? (yes, the training is longer, but is it truly poorer?)

No, it's not, but there are other factors as well. I had a couple of friends over seas who had opinions, but I don't know what others would say.

Take England or France. They pay little (if anything) for medical school itself so that they don't have the debt to pay off. And the number of 'attending' (called consultant) positions is limited, so you can stay a house officer for a longer period of time. Their sign outs tend to be better than ours and when change of shift rolls around, they switch over fairly efficiently.

I do think we have better fellowship training here as it tends to be more formal with a curriculum and with a program. But ultimately we end up in the same place.

Old Bear, that's a fantastic analysis and a good question. I'm trying to go over the same format you mentioned for our PICU and I think it would tough to work out even with fellows. As is I haven't seen a lot of PAs or NPs to cover like you use in the NICU, but that may be institutional.

I tend to think that the 80s is okay as long as it's enforced. I definitely believe that people aren't making good decisions beyond that, and we need to get better at sign outs, or realizing that we can sign things out.

 

[oldbearprofessor]

I'm trying to go over the same format you mentioned for our PICU and I think it would tough to work out even with fellows.

One unfortunate consequence for fellows is that they would, by necessity, lose a lot of protected time during their research years. That is, currently, in many programs, as you go farther along you take less call and have more months/weeks/whatever without call while doing research. It is difficult for fellows to take cross-cover night call AND spend the day in the lab and of course, this violates the spirit, if not the literal aspect of any work-hour limitations.

So, in a situation in which FELLOWS were not allowed to take night-call (e.g. NICU/PICU/Cards) while on service due to in-house limits, inevitably, the only alternative allowing for any continuity of care would be to assign a weekday fellow(s) and then cross-cover fellows for night-call/attendings (who might also be limited). This all would be very institutional dependent but NP/PA won't help with this. Although certainly cross-covering already exists, work hour limits would make it much more common throughout fellowship to balance hours out and make accomplishing research much, much more difficult in my view.

Lots of unintended consequences that would occur here I think and I suspect the needs of pedi specialty training won't be on the radar for two many policy makers in setting new rules.

I would note however, that I am far from convinced that any major changes will occur soon if at all.

 

[Freibi]

One unfortunate consequence for fellows is that they would, by necessity, lose a lot of protected time during their research years. That is, currently, in many programs, as you go farther along you take less call and have more months/weeks/whatever without call while doing research. It is difficult for fellows to take cross-cover night call AND spend the day in the lab and of course, this violates the spirit, if not the literal aspect of any work-hour limitations.

This is actually how it works in Germany and France. In-house work hours are officially restricted to numbers <80 h/week (e.g. in the 50's or 60's) for residents and fellows, but remain more or less the same throughout all years (and months) of training, and research and/or education has to happen "in your free time". In Germany, for example, pretty much all residencies are either 5 or 6 years.
This does not diminish the time spent in patient care, obviously, but research and education (including reading to become "book smart" as mentioned by a previous poster) has to take place in a self-directed manner, and there are no training "programs" in the US sense of the word.
Since stuff happens with patients at all times of the day and night, it doesn't matter in my opinion whether one is there every day, or every night, or a mixture of days and nights. Whether "continuity of care" should be the highest good and how it should be defined at all, remains debatable.
By the way, even the distinction between resident, fellow, and attending is not much of a monetary one, at least in Germany (salary doesn't change all that much just because you pass the boards).

 

[oldbearprofessor]

Since stuff happens with patients at all times of the day and night, it doesn't matter in my opinion whether one is there every day, or every night, or a mixture of days and nights. Whether "continuity of care" should be the highest good and how it should be defined at all, remains debatable.

Although stuff does happen 24/7, in an ICU type setting, care plans and rounds will virtually always be daytime, especially morning, activities. This is different than in an ER where teaching occurs on a patient-patient basis making shift work more compatible with teaching. Failing to have some consistency in the team that sees the baby/child each day for rounds cannot be good for continuity of care or consistency of care approaches. There are data indicating that consistency of care approaches matters in outcome.

As it is, we have lots of cross-covering that currently occurs on weekends.holidays due to the current limits. Cross-cover residents, fellows and attendings do their best, but there is an inevitable "wait until the regular team is here tomorrow" attitude that exists about making changes. Families also need consistency of daytime decision-makers. Going to pure shift work while trying to cover 24/7 would remove the residents and fellows from much of this and frustrate teaching efforts as well as families.

There are some private attending groups of neonatologists (and I'm sure others) that work on a 24 hour or similar shift basis. This however, mitigates things a bit as they usually are small groups and are attendings that are synchronizing care approaches reasonably well. This won't work so well for trainees for their education and patient experiences. Not to mention the fact that any new work hour changes would probably ban anyone at any level from more than 16 consecutive hours....

IF it happens.....

 

[Freibi]

Although stuff does happen 24/7, in an ICU type setting, care plans and rounds will virtually always be daytime, especially morning, activities. This is different than in an ER where teaching occurs on a patient-patient basis making shift work more compatible with teaching. Failing to have some consistency in the team that sees the baby/child each day for rounds cannot be good for continuity of care or consistency of care approaches. There are data indicating that consistency of care approaches matters in outcome.

There could be morning AND evening rounds - the whole team participates, because that would be the time of signout and overlap of shifts. Each patient would then not have one primary resident and many different cross-cover people they don't know, but two primary residents, with one or the other of the two being there at all times.
You might not want to call that "continuity" as in "maximum humanly possible hours worked CONTINUously", but it does sound "consistent".

 

[windycitygirl]

call me crazy, but i agree with the people who think this is disastrous. i am graduating peds residency in 3 weeks (!) and as it is, it can be difficult to finish your work/see your patients in the allotted amount of time. at my hospital the work hours are VERY strictly enforced. if we go down to 56 hours/week, that might be nicer...but are people going to want to go into peds, given the extra investment of time and the (relatively) low pay compared with our peers in other specialties? i think we might see a leveling off of applicants if attending pay decreases and length of training and medical school costs (and loan burdens) increase. (i am doing peds critical care fellowship, but let me tell you, when my derm friends tell me about their starting $400K salaries, i do cry a little inside for my loans and overall indebtedness.)

plus--i left out the most important thing--the best learning (in my opinion) OCCURS on call. trust the weird kid you can figure out to show up at 1 am, or someone to start crashing when everyone else has left. these things never occur at 1 pm when all attendings and support staff are there for you.