Hourly limit for residents?

[thomallama]

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Forgive me if this has been discussed recently - it didn't show up in my search.

As a (lazy) freshman, I was thrilled to hear about the 80 hour work week limit for residents.

But since I've started shadowing, my viewpoint has done a complete 180. Doctor A explained how residents being used to only 80 hours a week during residency will become completely overworked once in the real doctoring world, and will be prone to making more mistakes when tired or sleep deprived. Doctor B told me that 80 hours a week wouldn't be nearly enough time to complete his training, less extending the residency by a few years. He told me he worked 120 easily, going up to over 140 a week.

What do you guys think: do you agree with the hour limit?

 

[NickNaylor]

You can read all of the rules here, straight from the ACGME (page 16): http://www.acgme.org/acWebsite/home/Common_Program_Requirements_07012011.pdf

Another thing to keep in mind the limit for interns to a 16 hour shift, with no new patients being given to the intern on the last four hours of that shift.

I'm not sure how I feel. It's hard to judge the impact when you're not actually a resident.

 

[Charles_Carmichael]

It's not an 80 hrs/week limit. That seems to be a common misconception here. It's 80 hrs/week averaged over 4 weeks. So you can still work more than 80 hrs/week as long as the 4-week average is below 80 hrs/week.

Also, I think some residencies allow for 88 hrs/week averaged over 4-weeks. Neurosurgery comes to mind.

I don't know how the new rules are going to affect residency. I just wish there was solid evidence behind work-hour regulations before they're enacted. So far, it seems like they're choosing numbers pretty arbitrarily and the literature doesn't really seem to support the idea that the work-hour restrictions have improved patient care (which was the initial reason for the changes).

 

[NickNaylor]

It's not an 80 hrs/week limit. That seems to be a common misconception here. It's 80 hrs/week averaged over 4 weeks. So you can still work more than 80 hrs/week as long as the 4-week average is below 80 hrs/week.

Also, I think some residencies allow for 88 hrs/week averaged over 4-weeks. Neurosurgery comes to mind.

I don't know how the new rules are going to affect residency. I just wish there was solid evidence behind work-hour regulations before they're enacted. So far, it seems like they're choosing numbers pretty arbitrarily and the literature doesn't really seem to support the idea that the work-hour restrictions have improved patient care (which was the initial reason for the changes).

The guidelines I linked to said that a 10% increase (i.e., 88 hours) would be permitted if it was educationally necessary/helpful.

 

[Charles_Carmichael]

The guidelines I linked to said that a 10% increase (i.e., 88 hours) would be permitted if it was educationally necessary/helpful.

Thanks for the link. I was typing when you posted, so I didn't see your post.

 

[aSagacious]

Here is an old editorial on the matter that I found interesting:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1514479/

 

[alwaysaangel]

As a (lazy) freshman, I was thrilled to hear about the 80 hour work week limit for residents.

But since I've started shadowing, my viewpoint has done a complete 180. Doctor A explained how residents being used to only 80 hours a week during residency will become completely overworked once in the real doctoring world, and will be prone to making more mistakes when tired or sleep deprived. Doctor B told me that 80 hours a week wouldn't be nearly enough time to complete his training, less extending the residency by a few years. He told me he worked 120 easily, going up to over 140 a week.

What do you guys think: do you agree with the hour limit?

Well the 80 hr work week has been in effect since 2007. So at least one class of IM, EM, Peds, etc residents have survived their first year of being fellows/attendings. There is no evidence that they are insufficently trained or significantly more overwhelmed than previous attendings.

So I don't think the 80 hr averaged work week is unreasonable. A lot of specialties don't meet the requirement anyway - they just don't report their true hours (surgery comes to mind).

I am concerned about the new 16 hr limits. While I think night float will be far less painful for me, I also know that handing off/signing out patients HURTS patients. Things get lost, things get dropped, and it can have serious repercussions. Some studies suggest it can hurt patients just as much as 'tired residents' do. They keep trying to adjust one thing to fix the problem, but they're creating issues on the other side.

 

[AntiHouseMD]

Well the 80 hr work week has been in effect since 2007. So at least one class of IM, EM, Peds, etc residents have survived their first year of being fellows/attendings. There is no evidence that they are insufficently trained or significantly more overwhelmed than previous attendings.

So I don't think the 80 hr averaged work week is unreasonable. A lot of specialties don't meet the requirement anyway - they just don't report their true hours (surgery comes to mind).

I am concerned about the new 16 hr limits. While I think night float will be far less painful for me, I also know that handing off/signing out patients HURTS patients. Things get lost, things get dropped, and it can have serious repercussions. Some studies suggest it can hurt patients just as much as 'tired residents' do. They keep trying to adjust one thing to fix the problem, but they're creating issues on the other side.

Isn't there a ban on taking in new patients near the end of shifts? What may fix the problem would have the resident stay on until all of the cases are at a a point where they could be safely handed off. If a resident needs to stay on significantly longer for a patient, their hours over the next few days could be adjusted. Not a perfect solution by any means, but could help.

 

[Charles_Carmichael]

Isn't there a ban on taking in new patients near the end of shifts? What may fix the problem would have the resident stay on until all of the cases are at a a point where they could be safely handed off. If a resident needs to stay on significantly longer for a patient, their hours over the next few days could be adjusted. Not a perfect solution by any means, but could help.

That most likely isn't a practical solution.

 

[deleted393595]

That most likely isn't a practical solution.

Why so?

 

[alwaysaangel]

Isn't there a ban on taking in new patients near the end of shifts? What may fix the problem would have the resident stay on until all of the cases are at a a point where they could be safely handed off. If a resident needs to stay on significantly longer for a patient, their hours over the next few days could be adjusted. Not a perfect solution by any means, but could help.

Actually thats written into the new rules. If the resident needs to stay on to finish up the acute care of a SINGLE patient they can work as much as 20 hrs (probably most applicable to surgeons in the middle of a case).

But its not really that residents are walking out in the middle of a critical resuscitation or surgery. General, everyday hand-offs hurt patients. Even stable patients that have been in the hospital for days. Things just get lost and then they can slide downhill. There really isn't a good solution that I'm aware of.

 

[AntiHouseMD]

Actually thats written into the new rules. If the resident needs to stay on to finish up the acute care of a SINGLE patient they can work as much as 20 hrs (probably most applicable to surgeons in the middle of a case).

But its not really that residents are walking out in the middle of a critical resuscitation or surgery. General, everyday hand-offs hurt patients. Even stable patients that have been in the hospital for days. Things just get lost and then they can slide downhill. There really isn't a good solution that I'm aware of.

Could technology help prevent lost information? Not foolproof, but still a large improvement. If a hospital began to use tablets for information, you could possibly just send the patient's file to another doctor without anything being lost in the shuffle. Of course, that doesn't include software glitches, computer issues, etc. In time, though, that could be a major advantage.

 

[Charles_Carmichael]

Why so?

The "adjusting hours over the next few days" is what I'm saying is impractical. The other residents will have to take on more work if a resident's hours are adjusted for staying later to take care of one patient. Like alwaysaangel mentioned, handoffs are dangerous. And by cutting hours, you're (theoretically) risking more harm to patients due to the compensatory increase in handoffs.

 

[alwaysaangel]

Could technology help prevent lost information? Not foolproof, but still a large improvement. If a hospital began to use tablets for information, you could possibly just send the patient's file to another doctor without anything being lost in the shuffle. Of course, that doesn't include software glitches, computer issues, etc. In time, though, that could be a major advantage.

They're working on it. Especially with the new requirements for EMR (electronic medical records). Many EMRs build the 'sign out' into the system. It helps but isn't perfect.

It will significantly improve hand offs and transfers. Med reconciliation should be more accurate, hospital course will be more complete. But that is all dependent on the new resident having time to read and remember it all and on the old resident putting it all down.

Human brains will always be better than a computer. The original doc easily remembers minor details and events that may not be so minor. The hand off doc doesn't have that advantage.

 

[AntiHouseMD]

The "adjusting hours over the next few days" is what I'm saying is impractical. The other residents will have to take on more work if a resident's hours are adjusted for staying later to take care of one patient. Like alwaysaangel mentioned, handoffs are dangerous. And by cutting hours, you're (theoretically) risking more harm to patients due to the compensatory increase in handoffs.

True. I could see the potential danger in messing up the schedule over the next few days. I'm somewhat conflicted, to be perfectly honest. I believe that the hours required for residency are too long (going over 100 hours seems excessive, from a possibly naive mind) and that somewhat of a work-life balance should be allowed. That being said, I don't know how to achieve that without putting patients in somewhat more risk. It seems to be choosing among two evils. Having doctors who are overworked vs. potentially risky handoffs. Very difficult question, I have to admit.

 

[smq123]

Could technology help prevent lost information? Not foolproof, but still a large improvement. If a hospital began to use tablets for information, you could possibly just send the patient's file to another doctor without anything being lost in the shuffle. Of course, that doesn't include software glitches, computer issues, etc. In time, though, that could be a major advantage.

No, because it takes a LOT of time to read through a patient's file. In most cases, the information is AVAILABLE, but the person covering that patient at that particular moment just doesn't have time to sift through an entire chart and find out everything.

 

[alwaysaangel]

And here's todays article on it: http://www.latimes.com/news/opinion/commentary/la-oe-0701-leape-medicine-20110701,0,4340188.story

They talk about studies linking sleep deprivation to mistakes. And they talk about mistakes that patients suffer.

What they fail to mention is whether a given mistake actually causes adverse outcomes (MANY MANY don't) and whether or not the mistakes made late in a residents shift cause mistakes that cause adverse outcomes. Where as studies have shown that mistakes caused by handoffs can cause adverse outcomes.

Its hard to study stuff like this - its very complex and difficult to really prove causation.

 

[Charles_Carmichael]

True. I could see the potential danger in messing up the schedule over the next few days. I'm somewhat conflicted, to be perfectly honest. I believe that the hours required for residency are too long (going over 100 hours seems excessive, from a possibly naive mind) and that somewhat of a work-life balance should be allowed. That being said, I don't know how to achieve that without putting patients in somewhat more risk. It seems to be choosing among two evils. Having doctors who are overworked vs. potentially risky handoffs. Very difficult question, I have to admit.

Agreed.

Though I have to say, it's not uncommon to work long hours. I conduct research full-time and it's not uncommon for me to be in the lab for 60-70+ hours a week. All the grad students and postdocs in my lab work far more hours than I do. My dad, as a software engineer, works a ridiculous number of hours per week. I know, I know, anecdotes are useless. But sometimes I get the sense that some people seem to think that only physicians work long hours. And that's not true. IMO, in order to be successful in most fields, you have to put in a significant amount of time. But that's just me as a premed, so I don't have a resident's perspective.

 

[thedrjojo]

Well the 80 hr work week has been in effect since 2007. So at least one class of IM, EM, Peds, etc residents have survived their first year of being fellows/attendings. There is no evidence that they are insufficently trained or significantly more overwhelmed than previous attendings.

So I don't think the 80 hr averaged work week is unreasonable. A lot of specialties don't meet the requirement anyway - they just don't report their true hours (surgery comes to mind).

I am concerned about the new 16 hr limits. While I think night float will be far less painful for me, I also know that handing off/signing out patients HURTS patients. Things get lost, things get dropped, and it can have serious repercussions. Some studies suggest it can hurt patients just as much as 'tired residents' do. They keep trying to adjust one thing to fix the problem, but they're creating issues on the other side.

The 80 hour work week has been in effect since 2003, and studies have shown it has not helped outcomes, it has also shown not to hurt outcomes (a wash, so you get less resident abuse for same outcomes in my perspective). The new 16 hour rule rolled out today, and it has yet to be seen what sort of affect it is going to have.

 

[AntiHouseMD]

One of the commenters on that article made a good point, however. The idea behind residency is for new doctors to learn how to practice medicine. Is it learning how to practice medicine, or more how to handle the long hours? He also made a good point as to changing medical school curriculum to cut out the unnecessary science components and prolong residency, with less of a workload. It seems that residency trains the physician more in how to practice medicine rather than medical school right now.

EDIT: Just saw your new post, Kaushik. I completely agree that most professions require many hours to be successful. But, you have that in those admit with those fields, you are not making life-or-death decisions in a shift that extends over 24 hours. Once again, it is very complicated. However, as a previous poster said, there haven't been any adverse outcomes with the change. So, if patients are getting the same quality of care and there is less abuse of residents (still exists, I admit), why are the longer hours needed?

 

[Charles_Carmichael]

The 80 hour work week has been in effect since 2003, and studies have shown it has not helped outcomes, it has also shown not to hurt outcomes (a wash, so you get less resident abuse for same outcomes in my perspective). The new 16 hour rule rolled out today, and it has yet to be seen what sort of affect it is going to have.

That's what scares me. That these regulations are arbitrary without actual evidence supporting them. And curbing hours even more might tip the balance toward hurting patient outcomes.

One of the commenters on that article made a good point, however. The idea behind residency is for new doctors to learn how to practice medicine. Is it learning how to practice medicine, or more how to handle the long hours? He also made a good point as to changing medical school curriculum to cut out the unnecessary science components and prolong residency, with less of a workload. It seems that residency trains the physician more in how to practice medicine rather than medical school right now.

Yea, I want even longer training with those huge loans piling up interest...🙄

What's unnecessary in a medical curriculum though? What part do you decide to cut out? What's not needed to build a clinical foundation on? Genuinely curious here. I interact mostly with oncologists, but I see them referencing to the minutiae of biochem/molecular biology/immunology all the time. Physiology is obviously important for practically every field. So, what can we remove?

 

[alwaysaangel]

The 80 hour work week has been in effect since 2003, and studies have shown it has not helped outcomes, it has also shown not to hurt outcomes (a wash, so you get less resident abuse for same outcomes in my perspective). The new 16 hour rule rolled out today, and it has yet to be seen what sort of affect it is going to have.

My bad. I believe it was rehashed in 2007. Forgot the original rule was 2003.

And I seriously doubt the 16 hour rule will have any positive effect. It doesn't even affect all residents. Most hospitals have been working with night float systems for months (at least where I am) - they switched early so they could adjust to the system by today. From what I've seen - Interns like it more, other residents (at some programs) are getting a brunt of extra work since the intern has to go home, and there are more hand offs which I think is going to result in bad outcomes.

 

[ywlke]

Doctor A explained how residents being used to only 80 hours a week during residency will become completely overworked once in the real doctoring world, and will be prone to making more mistakes when tired or sleep deprived.

I'm not sure that's a valid argument...even if it is true. If you make mistakes from being overworked, and you're overworked as a resident then you'll start making more mistakes early on (as a resident), and of course by the time you transition to the "real doctoring world", you stay overworked and make just as many mistakes if not more. But because your baseline is the "more", then "making just as many" is just as bad. Are there studies that you can adapt to persistent sleep deprivation? The last time I checked, there were only studies showing the cumulative negative effects of it.

To the poster that mentioned how the new regulation didn't seem to improve patient outcomes, there's the confounding factor of reported vs actually worked hours. Residents/hospitals/etc don't seem to want to take the risk and give the 80 hours rule a chance to prove itself either good or bad. I'm not saying I know better and they should take that risk, but you can't draw a conclusion otherwise. As far as studies showing hand-offs as being bad for patients...that's considering sleep-deprived residents right? I'd be interested to see how that changes, if at all, with actual 80 hour compliance.

 

[Charles_Carmichael]

I'm not sure that's a valid argument...even if it is true. If you make mistakes from being overworked, and you're overworked as a resident then you'll start making more mistakes early on (as a resident), and of course by the time you transition to the "real doctoring world", you stay overworked and make just as many mistakes if not more. But because your baseline is the "more", then "making just as many" is just as bad. Are there studies that you can adapt to persistent sleep deprivation? The last time I checked, there were only studies showing the cumulative negative effects of it.

To the poster that mentioned how the new regulation didn't seem to improve patient outcomes, there's the confounding factor of reported vs actually worked hours. Residents/hospitals/etc don't seem to want to take the risk and give the 80 hours rule a chance to prove itself either good or bad. I'm not saying I know better and they should take that risk, but you can't draw a conclusion otherwise. As far as studies showing hand-offs as being bad for patients...that's considering sleep-deprived residents right? I'd be interested to see how that changes, if at all, with actual 80 hour compliance.

The studies are based off of programs that do comply with the work-hour regulations. So you're wrong about that part.

The question isn't "is sleep-deprivation bad?" We know the answer that. The question is, IMO: is a better-rested resident (assuming that residents use that extra time off for sleep) who has a patient handed off to them better than a sleep-deprived resident who (arguably) has a better idea of the patients physio/pathophys/etc and hasn't lost information during a hand-off? That's a complex question to answer.

Edit: By the way, there are no work-hour regulations once you're an attending. Do you want the first time you pull a 30 hr shift to be as an independent attending where the buck stops with you? Or do you want to build up that endurance as a resident where you're not the final decision-maker? That's another important question to ask, IMHO.

 

[AntiHouseMD]

That's what scares me. That these regulations are arbitrary without actual evidence supporting them. And curbing hours even more might tip the balance toward hurting patient outcomes.


Yea, I want even longer training with those huge loans piling up interest...🙄

What's unnecessary in a medical curriculum though? What part do you decide to cut out? What's not needed to build a clinical foundation on? Genuinely curious here. I interact mostly with oncologists, but I see them referencing to the minutiae of biochem/molecular biology/immunology all the time. Physiology is obviously important for practically every field. So, what can we remove?

Very good points. Personally, I just feel that residency doesn't need to be as grueling as it exists. Maybe that's just from someone who wants to have a somewhat decent life during residency, and I have to realize that medicine really doesn't allow for that. Honestly, like I've said before, this is an extremely complicated issue that can't be answered quickly.

 

[thomallama]

I'm not sure that's a valid argument...even if it is true. If you make mistakes from being overworked, and you're overworked as a resident then you'll start making more mistakes early on (as a resident), and of course by the time you transition to the "real doctoring world", you stay overworked and make just as many mistakes if not more. But because your baseline is the "more", then "making just as many" is just as bad. Are there studies that you can adapt to persistent sleep deprivation? The last time I checked, there were only studies showing the cumulative negative effects of it.

My point comes solely from the doctor I shadow. His point: As a resident, you learn to be a doctor. You learn to work under pressure, under stress, under sleep deprivation. Thousands of doctors work through sleep deprivation because they know how to. The doctor I shadowed today had an emergency heart surgery last night and had no sleep, but still went to work today and did his job.

 

[NickNaylor]

Very good points. Personally, I just feel that residency doesn't need to be as grueling as it exists. Maybe that's just from someone who wants to have a somewhat decent life during residency, and I have to realize that medicine really doesn't allow for that. Honestly, like I've said before, this is an extremely complicated issue that can't be answered quickly.

It's very easy to say that it shouldn't be "as grueling as it is" when we haven't even run the gauntlet yet. I'd be much more likely to trust the physicians that HAVE been through the process and, for the most part, say that it is a crappy but necessary part of the training process.

 

[Charles_Carmichael]

My point comes solely from the doctor I shadow. His point: As a resident, you learn to be a doctor. You learn to work under pressure, under stress, under sleep deprivation. Thousands of doctors work through sleep deprivation because they know how to. The doctor I shadowed today had an emergency heart surgery last night and had no sleep, but still went to work today and did his job.

Exactly! There are no work-hour rules when you're an attending. I personally would want to build my endurance up during training (residency) rather than when I'm out practicing independently. At least as a resident, there's a safety net. That won't exist as an attending.

It's very easy to say that it shouldn't be "as grueling as it is" when we haven't even run the gauntlet yet. I'd be much more likely to trust the physicians that HAVE been through the process and, for the most part, say that it is a crappy but necessary part of the training process.

+1

 

[thomallama]

+1

+2

 

[ywlke]

The studies are based off of programs that do comply with the work-hour regulations. So you're wrong about that part.

But that was part of my point. "In compliance" would mean that residents reported hours are in compliance. There isn't really a way to figure out the actual number of hours worked if the general attitude is that the regulation is wrong and therefore we'll just get around it by underreporting hours.

You couldn't really study a non-compliant program anyways. Because if it was known that the program was in violation, they would lose accreditation.

 

[pfaction]

I've been told to avoid July 1st since all the interns start.

A lot of people get f'd up due to interns prescribing incorrectly, medication errors, and general chaoticness.

I'm all for limiting everything.👍

 

[45408]

Doctor A explained how residents being used to only 80 hours a week during residency will become completely overworked once in the real doctoring world, and will be prone to making more mistakes when tired or sleep deprived.

What a load. There are a minority of physicians in a minority of specialties that come anywhere near 80 hours a week in "the real world." A few of them still go way over, like the cardiac surgeons where I work. It's no big deal to see a few of them chit chatting in the surgical ICU at 1am after someone's patient just coded and the other one just finished a 9 hour case. Those guys work insane hours every single week. Transplant surgeons can work pretty wild hours too.

The outpatient specialties though? Give me a break. I had a psychiatrist tell me that they "really only come in for emergencies when we're on call," at 3pm on a mid-week day.

BUT, for all the trash that many attendings talk about how they don't get to go home post-call like residents, it's often a lie. All of our anesthesiologists go home at 7am when they're "post call." If they were "short call" (until 7-9pm), then they go home at noon. Our radiologists, ER docs, hospitalists, and a few other specialties don't take call. We have off-site radiologists for at night. The neurosurgeons have no clinic and no elective cases on the weeks that they're on call. The orthopedic surgeons schedule days off when they're post-call. Even our general surgery staff get 1/2 a day per week completely free of responsibilities, and that could easily be your post-call afternoon (it's up to them). Not to mention that in a large academic group, you might only be on call three nights in a month (like two of my staff this month).

Doctor B told me that 80 hours a week wouldn't be nearly enough time to complete his training, less extending the residency by a few years. He told me he worked 120 easily, going up to over 140 a week.

Unless he's in a surgical specialty, I don't believe a word of it. Even if he is, it's still only part of the truth. There's work, and then there's "work." One of the subspecialty surgeons I worked with gave me frequent grief about how easy we have it now (he did a general surgery residency). Then he talked about how they would have Halo tournaments on Xbox with up to 12 residents in the hospital on weekends, since there were so many of them working that there wasn't much to do!

It was worse before 2003, and they did work longer hours, especially in surgical specialties. I find it hard to believe that some specialties ever came near 80 hours a week back then either. Times have changed though for all of medicine. Things are much faster paced than back in the good ol' days (more like the 60s-70s) when a patient was admitted for a week after an inguinal hernia repair! Their patients were not anywhere near as sick as they are now, period. Therefore, we're learning with much sicker patients than they were, so are we better off now?

I am concerned that a surgeon trained in the late 90s had a better learning experience than I do now, but the only thing I can do is try to make the best of my opportunities now.

 

[Charles_Carmichael]

But that was part of my point. "In compliance" would mean that residents reported hours are in compliance. There isn't really a way to figure out the actual number of hours worked if the general attitude is that the regulation is wrong and therefore we'll just get around it by underreporting hours.

You couldn't really study a non-compliant program anyways. Because if it was known that the program was in violation, they would lose accreditation.

Take the time to actually read the studies before commenting please and you'll realize that your statements don't make much sense (in the context of the studies). Many (most?) programs stay under the 80hr regulations and I would bet that quite a few did so even before the regulations came about. Like I said though, read the actual studies instead of guessing on the methodology/design.

 

[NeuroTyler]

It would appear to me that not restricting the hours has worked in the past, and that the initiative to limit experience will, if anything, hurt the future physicians of 'Murica.

 

[pfaction]

It would appear to me that not restricting the hours has worked in the past, and that the initiative to limit experience will, if anything, hurt the future physicians of 'Murica.

http://en.wikipedia.org/wiki/Libby_Zion