How are the new work hour restriction working (or not) for you?

[rachmoninov3]

I know that we all absolutely love change, but I was wondering how your program is dealing with the new rules.

It's caused quite a few problems at my program, including very few interns showing up to specialty clinic b/c shift work doesn't allow for 'pre-rounding' and getting the work done quickly before the attendings get there to want to teach, and then get to said clinic. Also doesn't help that there used to be two interns when now there is but one. And this has been with a relatively LOW CENSUS!

Example: This rotation has two interns one working 6 night shifts (12s) and one working 6 day shifts with clinic. So about 72H for night and 70 for day. You would think that pre-rounding would be allowed with this but my PD doesn't like anyone coming in early (tho by the end of my day shifts I was to do the work) Report lets out between 0630 and 0700 and said clinic starts at 0800. How am I to see 3 different types of patients in two different locations in one hour, especially if there is an attending from a local clinic who wants to teach on their patients (which routinely happened), let alone if there is anything else going on procedure wise?

How's your program dealing with it? I don't care if it's good or bad, I'm interested in both rants and solutions.

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[Doctor4Life1769]

The IM folks at my program have clinic after AM rounds and noon conference (1pm).

The new work hours will basically make the weaker interns appear even weaker, and will force them to turn it up a notch quicker if they want to ever look good. So far, I've noticed a disparity in interns (I'm all off-service this year).

I turned medicine wards into a 7-4 gig unless I was on call. Most were working on typing up notes and discharges well into 6 or 7pm. "Call" will last until 8-10pm, again depending on how efficient you are. I typically didn't give a rats ass as to if I got out at 8 or 9, so I typically got out around 9ish when on "call."

2 interns on a service, each carrying 6 patients. Headed by a senior resident who is over us both. It shouldn't take too long to knock out 6 patients pre-rounding and then post-round notes, but too many make it a huge deal and cry when they are in the hospital for 12 hours daily.

 

[inspirationmd]

I have to say they have actually been kind of annoying. When I am on Gen Med or subspecialty Medicine rotations it very difficult to be a strong intern when you have senior residents saying you should be going home. People at my program are trying to make it like its strictly a 7-4 job (unless you are on call as Doc4Life says) when you can not really do it well if you strictly try to do it like that. The people who are scrambling to get out the quickest are some of the ones in my opinion who are notorious for leaving stuff for other people to do. You can get the rounding and all that done but talking to SW, arranging details, and staying up on all the things that are happening with your pt is much harder than when I was a student and able to take call. Attendings do not want to hear that you left at 4pm so you weren't aware that swallow study that was supposed to happen in the late afternoon did not get done until you got to work the next morning and it was too late to try to arrange a morning add-on so now she has to stay in the hospital longer.

Two other things really irritate me as well. Call sucks but you got to know your patients so you could answer attending questions about initial presentation and learn about the evolution of the disease process from the very beginning. I learn best from this. I hate taking care of pts the night team admitted the night before and having to rely on their H and P's to tell me what the pt looked like. Sometimes you would ask questions they did not and the answer is not always the same the next day or available if pt got intubated. Also we have a system where you essentially end up admitting to your service every day except the post call day which gets old sometimes as well.

The other thing is the duty hour restrictions + 4 days off bit which has effectively ended golden weekends. There is no longer flexibility in the schedule and so trading days to accomodate things you would like to attend is virtually impossible without a duty hour violation.

 

[Vee]

It's a non-issue for EM. Off service floor/ICU months are similar to what has been described above.

 

[Doctor Bagel]

For my specific program, I think it's worked out the well. The main benefit was that it might us closely evaluate our call system, and now we have a better system for all the residents, which is awesome. We've switched to pure nightfloat coverage on weekdays with call on weekends. The interns cover short call until 8 pm on weekdays and a 12 hour shift on Sundays. Interns don't have clinic, so there's no issues there. We have clinic, which we can do after nightfloat provided we don't see any patients after 10 am.

The medicine people here have switched to having 3 weeks on a rotation followed by one week of clinic, with the thought that an uninterrupted clinic period would be more beneficial than trying to fit in one clinic session a week. That sounds good, but their schedule in general sounds worse to me. Wards residents/interns now work until at least 7 pm every work day with one day off a week. Last year, you did q5 overnight call and q5 short call where you worked until about 8 pm. Other days, you were usually done by 5 or even earlier. 6 12 hour days with one day off seems worse to be than some shorter days mixed in with some call.

 

[SouthernSurgeon]

I think it has been a huge pain in the rear end. It has resulted so far in our interns feeling marginalized and dissatisfied. Working 12-14 hour days, 6 days in a row is, in my experience, more draining than the old system of call/post-call days. I don't have the full year's worth of data yet, but subjectively it seems like the hour restrictions are hurting the intern's ability to get cases (surgical residency).

 

[obgynintern]

I totally agree with it hurting numbers...for instance, I labor a patient all day and then my "shift" is over and I lose the delivery...or, I labor a patient all day and then we call a section near my changeover time and I don't get to do it. In the past, my program quoted great numbers for interns but sadly I don't think that will be the case this year.

 

[Doctor4Life1769]

I have to say they have actually been kind of annoying. When I am on Gen Med or subspecialty Medicine rotations it very difficult to be a strong intern when you have senior residents saying you should be going home. People at my program are trying to make it like its strictly a 7-4 job (unless you are on call as Doc4Life says) when you can not really do it well if you strictly try to do it like that. The people who are scrambling to get out the quickest are some of the ones in my opinion who are notorious for leaving stuff for other people to do. You can get the rounding and all that done but talking to SW, arranging details, and staying up on all the things that are happening with your pt is much harder than when I was a student and able to take call. Attendings do not want to hear that you left at 4pm so you weren't aware that swallow study that was supposed to happen in the late afternoon did not get done until you got to work the next morning and it was too late to try to arrange a morning add-on so now she has to stay in the hospital longer.

Two other things really irritate me as well. Call sucks but you got to know your patients so you could answer attending questions about initial presentation and learn about the evolution of the disease process from the very beginning. I learn best from this. I hate taking care of pts the night team admitted the night before and having to rely on their H and P's to tell me what the pt looked like. Sometimes you would ask questions they did not and the answer is not always the same the next day or available if pt got intubated. Also we have a system where you essentially end up admitting to your service every day except the post call day which gets old sometimes as well.

The other thing is the duty hour restrictions + 4 days off bit which has effectively ended golden weekends. There is no longer flexibility in the schedule and so trading days to accomodate things you would like to attend is virtually impossible without a duty hour violation.

That's the thing. I was able to knock out all the ancillary paperwork EARLY. That left me time to do the SW updates, to follow-up on my patient concerns, family concerns, to ensure that studies that NEEDED to be done and were ordered accordingly WERE DONE. If they weren't done, then I called radiology to get a time and ensure it would be done. To ensure that consults did happen as we requested, and if not, I contacted them and received a heads-up on approximate time they'd see the patient. I'd sign out to the NF resident to look out for a study and "if this, then that" and to follow-up on a consult note that should be left later in the evening (consultants are busy too, y'know). If things happened during my day shift, I followed up and ensured the recommendations were discussed and implemented. If a study was done, I followed up on them and made my senior aware. Discharges? I did them all. It's possible, you just have to be really efficient. I won't lie, I heard a lot of those similar complaints from other interns... yet, I was the one leaving at 4 and my senior could do nothing about it. Why? Because ALL the stuff was DONE. Don't hate, playa.

I do agree with your second paragraph. NF residents tend to give the worst sign out, so then I have to rely on what the patient looks like and their labs/vitals, etc, nursing updates from o/n, and the initial H/P. Either way, you do what you gotta do. No complaining. Just do it, it's the cards we've been dealt with.

I also agree with the loss of a golden being an issue. We work 1 weekend day/week. Either you are on call, or you are rounding until 4pm and sign out to NF. Very lame. Let the on-call resident be on call and cross-cover on your patients.

 

[inspirationmd]

That's the thing. I was able to knock out all the ancillary paperwork EARLY. That left me time to do the SW updates, to follow-up on my patient concerns, family concerns, to ensure that studies that NEEDED to be done and were ordered accordingly WERE DONE. If they weren't done, then I called radiology to get a time and ensure it would be done. To ensure that consults did happen as we requested, and if not, I contacted them and received a heads-up on approximate time they'd see the patient. I'd sign out to the NF resident to look out for a study and "if this, then that" and to follow-up on a consult note that should be left later in the evening (consultants are busy too, y'know). If things happened during my day shift, I followed up and ensured the recommendations were discussed and implemented. If a study was done, I followed up on them and made my senior aware. Discharges? I did them all. It's possible, you just have to be really efficient. I won't lie, I heard a lot of those similar complaints from other interns... yet, I was the one leaving at 4 and my senior could do nothing about it. Why? Because ALL the stuff was DONE. Don't hate, playa.

I do agree with your second paragraph. NF residents tend to give the worst sign out, so then I have to rely on what the patient looks like and their labs/vitals, etc, nursing updates from o/n, and the initial H/P. Either way, you do what you gotta do. No complaining. Just do it, it's the cards we've been dealt with.

I also agree with the loss of a golden being an issue. We work 1 weekend day/week. Either you are on call, or you are rounding until 4pm and sign out to NF. Very lame. Let the on-call resident be on call and cross-cover on your patients.

LOL..well if that is all true then I am definitely hating since I guess I am not that efficient yet. Guess I have to work to get on your level. Hell I am trying to keep up with all the extra reading and rotational requirements as well so for now I will just have to be a bit slower for now I suppose. Sometimes it feels like more academic work than when I was a 3rd year. Then you have to worry about ITE and such. Its not only the patient care that makes this job hard.

 

[NOsquid]

I like sleep. It makes me a better person and doctor. I took overnight call in med school q4 and it's ****, people actually complaining just speaks to terrible scheduling and unrealistic expectations from both programs and residents. Not so surprising in a specialty that's always especially reluctant to change. I just feel sorry for the seniors who still have to take call. Staying up all night all the time is not ok. In fact I think we medicate patients for that sort of thing.

 

[Buzz Me]

Not so good here. Interns all need in-house backup from midlevel residents (who then basically have non-operative night float rotations) and have become less independent in their thinking. All the work hours have shifted towards the PGY-2s and 3s. There's a set amount of work that needs to be done...take it away from the interns and it just gets moved to the other residents.

 

[Doctor4Life1769]

LOL..well if that is all true then I am definitely hating since I guess I am not that efficient yet. Guess I have to work to get on your level. Hell I am trying to keep up with all the extra reading and rotational requirements as well so for now I will just have to be a bit slower for now I suppose. Sometimes it feels like more academic work than when I was a 3rd year. Then you have to worry about ITE and such. Its not only the patient care that makes this job hard.

Hey, I'm not making it personal. You questioned those of us in terms of our work ethic and the way we care for our patients just because we work 7-4p. You do what you got to do, and I'll do what I'm doing.

At least your work as an intern will help you out on your ITE. My ITE is, for the most part, not really testing my intern year experience.

 

[Doctor4Life1769]

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[inspirationmd]

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Oh no problem man. I didn't take it personally at all. All I was saying is I will have to get more efficient so I can get out at a decent time and have the work done. Just hard to do at this point but it will get better as time goes on for sure.

 

[Law2Doc]

...I just feel sorry for the seniors who still have to take call. Staying up all night all the time is not ok...

it sucks while you are doing it, but that doesn't really mean it's not important to your education. Being there alone at night forces you to make decisions on your own. Until you do that, you are really just a med student with a longer coat. It's like learning to ride a bike -- sure you can go through the motions, but until those training wheels come off you aren't really riding a bike.

I think loss of golden weekends and use of post call days as your "day off" were obvious repercussions of the rule change even before it happened. I think a lot of us actually liked that under the old rules you could only have so many 30 hour shifts each week before you got to the 80 hour work week cap programs were using and thus ended up with a nice weekend to do other things. The old rules were more total hours, but they were better distributed for the work hard - play hard crowd. These days folks are protected from long hours but are also protected from days off. It's like taking a bandage off painfully slowly rather than just ripping it off quickly -- not everyone's cup of tea, and maybe not even objectively better.

Now im going to say something a bit unpopular, partially as devils advocate. As for lack of pre rounding and bad interns looking worse, I guess my response is that under the old rules not so long ago a lot of residents simply took the attitude that what a program didnt know about didn't hurt them, and programs knowingly willfully ignored what they had to realize was going on. If you really need that extra hour of prep to not get fired, maybe sneaking in to pre pre round and giving yourself the time you need to not be on the chopping block isn't a bad idea. Even under the old rules you saw people already pre rounding at times when they officially should just be showing up. The program can't legally force you to do more hours than scheduled, but you can bet that they will let an occasional "bad" "lazy" intern go now and then for things that could be resolved by knowing their patients better by coming in an hour earlier. So you do what's necessary for self preservation. My bet is there is actually more of this going on now that the maximum length of shifts for interns is only 16 hours instead of 30. I also suspect interns get a lot less pity from seniors for being unprepared given that these same seniors worked (and still work) much longer shifts. Basically, as with any job in or out of medicine, if you want to keep your job, you need to do what will keep you from being fired even if it exceeds the stated requirements of the job. Also bear in mind that there's lots of things you can check from home that aren't technically duty hour violations.

 

[Doctor4Life1769]

it sucks while you are doing it, but that doesn't really mean it's not important to your education. Being there alone at night forces you to make decisions on your own. Until you do that, you are really just a med student with a longer coat. It's like learning to ride a bike -- sure you can go through the motions, but until those training wheels come off you aren't really riding a bike.

I think loss of golden weekends and use of post call days as your "day off" were obvious repercussions of the rule change even before it happened. I think a lot of us actually liked that under the old rules you could only have so many 30 hour shifts each week before you got to the 80 hour work week cap programs were using and thus ended up with a nice weekend to do other things. The old rules were more total hours, but they were better distributed for the work hard - play hard crowd. These days folks are protected from long hours but are also protected from days off. It's like taking a bandage off painfully slowly rather than just ripping it off quickly -- not everyone's cup of tea, and maybe not even objectively better.

Now im going to say something a bit unpopular, partially as devils advocate. As for lack of pre rounding and bad interns looking worse, I guess my response is that under the old rules not so long ago a lot of residents simply took the attitude that what a program didnt know about didn't hurt them, and programs knowingly willfully ignored what they had to realize was going on. If you really need that extra hour of prep to not get fired, maybe sneaking in to pre pre round and giving yourself the time you need to not be on the chopping block isn't a bad idea. Even under the old rules you saw people already pre rounding at times when they officially should just be showing up. The program can't legally force you to do more hours than scheduled, but you can bet that they will let an occasional "bad" "lazy" intern go now and then for things that could be resolved by knowing their patients better by coming in an hour earlier. So you do what's necessary for self preservation. My bet is there is actually more of this going on now that the maximum length of shifts for interns is only 16 hours instead of 30. I also suspect interns get a lot less pity from seniors for being unprepared given that these same seniors worked (and still work) much longer shifts. Basically, as with any job in or out of medicine, if you want to keep your job, you need to do what will keep you from being fired even if it exceeds the stated requirements of the job. Also bear in mind that there's lots of things you can check from home that aren't technically duty hour violations.

This is what we did in surgery. 2-3 interns on a service, we'd round-robin around in terms of who came in real early for sign out and who left a little early prior to sign out, and if we were waiting on a study, we'd check to see if it was done.. call the other intern who's there to sign out, and make sure everyone was on the same page.

I feel that everyone will complain regardless. I actually am one of those who likes to work hard/play hard. I would prefer the q4 overnight calls so I COULD have post-call off and the goldens. Now, it's like what you said, a slow removal of a bandaid. Also, I'd say this accounts for quicker burn-out, too.

 

[dynx]

Not so good here. Interns all need in-house backup from midlevel residents (who then basically have non-operative night float rotations) and have become less independent in their thinking. All the work hours have shifted towards the PGY-2s and 3s. There's a set amount of work that needs to be done...take it away from the interns and it just gets moved to the other residents.

Exactly. I'm in my last year so it hasnt impacted me much but from what I see:
1. Less work for interns = more work for 2nd and 3rd years. Its just going to make it that much harder as this first year class goes through. They have a sh*tty first year with long days but no call and fewer days off...then they get pounded with call and continued over-flow scut work in 2nd and 3rd year as well.
2. Less operating for interns. We used to average about 250 cases for interns. They could take out an appendix, do a decent job at a gallbladder and take care of lumps and bumps by the end of first year. Now, I've ended up doing more appys this year than I think all the interns combined. They always come in at night, I'm not going to take the consult pager for damn sure, so I'll just come in for half an hour and get it done while the interns sleep.
3. Less critical thinking and elimination of ICU rotation for interns - the hour restrictions will have a major impact on critical thinking skills and evaluating sick patients. The 2/3rd years get SLAMMED at my program and if you cant knock-**** out in a timely fashion you'll get burried. beginning of next year is going to be a tough time...
glad I'll be gone.

 

[45408]

I think it has been a huge pain in the rear end. It has resulted so far in our interns feeling marginalized and dissatisfied. Working 12-14 hour days, 6 days in a row is, in my experience, more draining than the old system of call/post-call days. I don't have the full year's worth of data yet, but subjectively it seems like the hour restrictions are hurting the intern's ability to get cases (surgical residency).

Also in surgery here, and it sucks. The senior residents are leaving earlier, and they can no longer do a few cases in the morning before they leave. This pulls others residents to cross-cover cases, leaving gaps on their team. Our interns now have a cushier schedule than all of the rest of us, so we're now all working harder than before.

1. Less work for interns = more work for 2nd and 3rd years. Its just going to make it that much harder as this first year class goes through. They have a sh*tty first year with long days but no call and fewer days off...then they get pounded with call and continued over-flow scut work in 2nd and 3rd year as well.

This, 100%.

 

[Janedoedoctor]

It's a mixed blessing in our case.

On the plus side, our program has hired more PA's to do the meaningless scut. Residents and fellows are now exclusively doing 'doctors' work'. Which is great.
Also, now that every hour counts, we are no longer expected to come in on saturdays to do stuff that can wait until monday. Thus doubling our number of 'golden weekends'. Overall, I feel that my time is considered something of value now.

On the downside, the call system is correct in the number of hours worked, but the way they are spread out over the week is downright sadistic. It seems designed to wreck maximal havoc on our biorhythm. A week of call is even more exhausting than it used to be.

 

[Buzz Me]

Also, now that every hour counts, we are no longer expected to come in on saturdays to do stuff that can wait until monday. Thus doubling our number of 'golden weekends'.

What field is this when you don't have to come in on Saturdays?

 

[Janedoedoctor]

That came out wrong. I didn't mean we never come in on saturdays.

Before the new rules there was a system where the junior people had to do a lot of administrative scut while they were in the hospital on saturday.

Then, all of a sudden, the new rules were there, and our PD had an epiphany that all this could also be done by a PA on monday without any impact on patient care. The amount of work that needed doing over the weekend decreased significantly.

 

[Neuronix]

Transitional year intern here. I love the new work hour rules. We have a night float system where the interns rotate through float. When on day team, interns admit Q4 until 9PM and the float picks up the rest and the cross cover. You get a full night's sleep every night (or day if you're on float). I think everyone is pretty happy with how things are going .

The only downside is you can stay a full day on your post-call day, as opposed to needing to leave by noon. But I'm fine with that. I like my sleep. Also, if you stay longer post-call you can often get a lot of patients discharged on your post-call afternoon.

 

[R-35]

PGY-1 here. I find the shifts annoying, working 70-80 hours a week in general, sometimes on for more than 10 days in a row. Cant really leave when you finish your work, have to stick around to sign out to the night intern. No post call day to recharge, catch up with everything. At this point I'm used to it, most days are very busy and times flies.

 

[Mattchiavelli]

PGY-1 and prelim neurology so I don't have the 1/2 day continuity clinic every week and have only done ICU and consults so far.. but when I was doing ICU it was nice, we did 7days 7a-8 or 9p, then a week of nights where we had 3 or 4 7p-9a shifts, and repeat. Our teams were 2 residents that alternated and an attending. I was over hours on days but with the nights week it evened out to be in line with hours restrictions. Actually was nice because when you covered nights you had some patients from your day service you were familiar with. Admitted like 1-3 people on days and usually 2-4 on nights, mix of local level 1 trauma ER admits, and OSH transfers for complexity or previous mismanagement. There are also a few non-teaching teams and extenders in the mix to help with workload.

On my consults what I've been noticing with the gen med teams is that the hours have reduced but the lecture/conference/morning report time has held steady and some places increased a little bit now that teleconferencing is working. We do a night float system too with short call while on general wards. From what I've heard from my friends, they like it, because you generally have some continuity with the patients you cover. I was a med student where I'm doing residency so I'm familiar with how things had been going before the hours change.

 

[dragonfly99]

It sucks on the cardiology service because there is now total night float and the signout is generally intern to intern with residents not signing out to each other sometimes, because some day residents are required to leave/be gone before the night resident every comes. Many of the interns seem not to know their patients well and do not follow up on tests/studies done during the day and often don't know the results on rounds the next day. Partly it is due to their inability to get their other work done in a timely fashion and having to be gone/out by a strict time. Also in the case of some people it is easy for them to let things slide because less accountability (if they don't do something then the night team/other team or the resident, fellow or attending who are not limited in hours will do the stuff for them). I think this system has some inherent problems for specialties like internal medicine or surgery (worse for surgery - they need to be there to do "x" number of cases). I think it will take interns longer to reach a certain level of clinical proficiency due to these new work hours rules - in internal med there is some benefit to seeing the "chronicity" of a newly admitted patient's illness over the next 18-24 hrs...and we have totally lost that now. On the plus side, I see that interns are less tired, and sometimes tired people make fewer mistakes, potentially. Also I don't think they are ever nearly as miserable as I was after a 30-32 hour shift...it's not really normal to be that sleep-deprived ona regular basis. The jury is still out...we will see.

The other thing is I see that some work is being just passed up the chain, to PGY2 and PGY3 residents and to some extent up to the fellows and attendings. As someone else pointed out, there is a set amount of work that has to be done,and if interns are not doing it then it has to be done by someone higher up. This sucks for us. Not infrequently, I feel like I've been forced back into the role of a 3rd year internal medicine resident, and that's not what I signed up to do (during fellowship...). We'll all survive, though.

 

[inspirationmd]

It sucks on the cardiology service because there is now total night float and the signout is generally intern to intern with residents not signing out to each other sometimes, because some day residents are required to leave/be gone before the night resident every comes. Many of the interns seem not to know their patients well and do not follow up on tests/studies done during the day and often don't know the results on rounds the next day. Partly it is due to their inability to get their other work done in a timely fashion and having to be gone/out by a strict time. Also in the case of some people it is easy for them to let things slide because less accountability (if they don't do something then the night team/other team or the resident, fellow or attending who are not limited in hours will do the stuff for them). I think this system has some inherent problems for specialties like internal medicine or surgery (worse for surgery - they need to be there to do "x" number of cases). I think it will take interns longer to reach a certain level of clinical proficiency due to these new work hours rules - in internal med there is some benefit to seeing the "chronicity" of a newly admitted patient's illness over the next 18-24 hrs...and we have totally lost that now. On the plus side, I see that interns are less tired, and sometimes tired people make fewer mistakes, potentially. Also I don't think they are ever nearly as miserable as I was after a 30-32 hour shift...it's not really normal to be that sleep-deprived ona regular basis. The jury is still out...we will see.

The other thing is I see that some work is being just passed up the chain, to PGY2 and PGY3 residents and to some extent up to the fellows and attendings. As someone else pointed out, there is a set amount of work that has to be done,and if interns are not doing it then it has to be done by someone higher up. This sucks for us. Not infrequently, I feel like I've been forced back into the role of a 3rd year internal medicine resident, and that's not what I signed up to do (during fellowship...). We'll all survive, though.

Dragonfly99 and anyone else....what do you think the odds are that they will end up needing to extend IM residency or residencies programs in general to get people to the same level of proficiency? The IM seniors have alluded that this is a distinct possibility since interns are not learning as much without call and that inferior docs will be graduated without more exposure.

 

[gutonc]

Dragonfly99 and anyone else....what do you think the odds are that they will end up needing to extend IM residency or residencies programs in general to get people to the same level of proficiency? The IM seniors have alluded that this is a distinct possibility since interns are not learning as much without call and that inferior docs will be graduated without more exposure.

Otherwise, not gonna happen.

 

[PharmaTope]

Otherwise, not gonna happen.

exactly also people fail to recognize that a lot of physicians were able to skip residency years ago and become a GP. they were able to practice just fine.

 

[ZagDoc]

It's miserable. I switch between night and day shifts multiple times a month. My circadian rhythm is all shot to shi*t. I don't feel more rested and I don't have more time to read. I feel like I provide crappy care because I cross cover so many services so sporadically I never get to know the patients. I spend 1/3 of the month on nights and don't get to operate as result.

But hey, at least I'm not taking dangerous patient-killing call!

 

[Law2Doc]

Otherwise, not gonna happen.

Actually it's pretty good sense financially. The whole reason some places use midlevels over residents is that they don't necessarily move elsewhere once they know what they are doing a couple of years in. An IM resident is just starting to be valuable in their final year, but unfortunately after 3 years they go off to fellowship or practice. So hospitals can get a lot of value extending these residents an extra year, even without the GME funding. In your 4th year you are probably worth more than the $100k the GME spends on you. Certainly a lot of hospitalists right out of IM residency get paid more than this. It's the interns that are the big cost. I'd be surprised if there isn't some push to extend some of the residencies in light of duty hours. Would not be surprised at all to see duty hours get chopped down to 70 and an extra year get tacked on in some fields.

 

[SierraPoppa]

Transitional year intern here. I love the new work hour rules. We have a night float system where the interns rotate through float. When on day team, interns admit Q4 until 9PM and the float picks up the rest and the cross cover. You get a full night's sleep every night (or day if you're on float). I think everyone is pretty happy with how things are going .

The only downside is you can stay a full day on your post-call day, as opposed to needing to leave by noon. But I'm fine with that. I like my sleep. Also, if you stay longer post-call you can often get a lot of patients discharged on your post-call afternoon.

I agree with you. I'm a prelim, but we have a system similar to yours. I simply DO NOT function without sleep. All our residents rotate through night float, handoff is efficient, and our team caps are reasonable. Almost all of our attendings have gone to sit-down rounds, which I personally think is much better anyway. Attendings here are reasonable and don't get all upset if you don't have time to see all of your patients because of a complicated discharge or something similar. All our upper levels and attendings carry spectralink phones, so keeping in contact with each other is very easy and I usually talk to my attending 5-6 times a day before and after rounds.

I guess we're in the minority.

 

[Neuronix]

Never confuse a vocal minority for the majority.

 

[Mattchiavelli]

Otherwise, not gonna happen.

Lol I love it! I actually would replace "money" with "data" though, if there seems to be a drop off of step 3 pass rates or first year in-service exams etc, then there could be some reason to change things up. I could see an argument on extending residencies because of the advancements in medical science- think of how many new diagnoses, therapies, therapeutic modalities, diseases, pathophysiological processes, and medico-legal realities of practice there are.

 

[inspirationmd]

Gutonc...absolutely hilarious, lol. The same arguments above are the reasons that I have heard from senior residents. Less cases and exposure to the "chronicity" of medicine. As unpleasant an idea it is I do feel like if they keep it up with changes its only a matter of time before it becomes seriously considered though. For example, wasn't there a rumor about them potentially expanding the 16 hr rule to more senior classes as well if this year goes well? If that happened without additional spaces to bring in more residents I could see how PDs could get desperate enough. As Law2Doc said a 3rd year resident that is forced to stay a 4th year to become board eligible would be very useful especially in such a scenario.

 

[rachmoninov3]

The lack of exposure was brought up in our intern forum, and all of us are scared that we're not going to get our numbers. Low SVD numbers, and ocassionally we even had more interns than pts on our medicine service! All this on top of these work-hour restrictions! We were told that our PD is even more worried than were, which of course ups our own anxiety.

As to L2D's comments, yes I do feel like a medical student with a longer coat! And I will come in extra as long as I'm keeping my 16 hour max and making sure If I violate 80h one week that I'm under the next.

Yet in truth, I should be in the OR right now with some pretty awesome cases but since I'm on call for the residency next weekend and was scheduled for a golden this weekend, I am gladly staying home and the surgeon I'm with can take call by himself. Yes, I may very well be contributing to the social promotion of physicians!

 

[Arcan57]

That came out wrong. I didn't mean we never come in on saturdays.

Before the new rules there was a system where the junior people had to do a lot of administrative scut while they were in the hospital on saturday.

Then, all of a sudden, the new rules were there, and our PD had an epiphany that all this could also be done by a PA on monday without any impact on patient care. The amount of work that needed doing over the weekend decreased significantly.

Off topic, but how much did that hose the length of stay?

 

[Mattchiavelli]

Off topic, but how much did that hose the length of stay?

I think it's not that off-topic, LOS has impact on patients and puts them at risk for nosocomial infection, medication errors, etc. I think it's important enough and consuming enough that a person can make a career out of just the nuts and bolts of the discharge planning and some places do- we have a county hospital where physicians do all discharge planning etc and another community that uses social work/discharge nursing etc to do things like that.

Hours are a lot tighter at the county hospital because you're basically playing poor man's social worker as compared to "is this a heart attack or PE or panic attack" kind of diagnostic/therapeutic/procedural stuff which is what most of us are are trying to accomplish with residency.

 

[SouthernSurgeon]

Never confuse a vocal minority for the majority.

I think it is very different dependent on your field.

For my friends in medicine and family practice, it seems to have been an easier transition and has been well received for the most part. But their programs had been preparing for the most recent set of rule changes for a few years, whereas the surgical specialties had buried their heads in the sand and repeatedly said they'd never pass these new rules.

Additionally, for a system like medicine where teams only admit every 4 days, they have caps, etc - it probably does make life easier...as you said you stay til 9pm one in every 4 days and get to sleep in your own bed every night.

In surgery you admit every day, there are frequently emergency cases, interns are expected to do floor work andget to the OR - the reality for our interns has been that they have been staying til 8-9pm nearly EVERY day rather than every 4th day.

I've lived both systems, and I can say that this year has been much more exhausting and emotionally draining than last year.

 

[gutonc]

I think it is very different dependent on your field.

For my friends in medicine and family practice, it seems to have been an easier transition and has been well received for the most part. But their programs had been preparing for the most recent set of rule changes for a few years, whereas the surgical specialties had buried their heads in the sand and repeatedly said they'd never pass these new rules.

Additionally, for a system like medicine where teams only admit every 4 days, they have caps, etc - it probably does make life easier...as you said you stay til 9pm one in every 4 days and get to sleep in your own bed every night.

In surgery you admit every day, there are frequently emergency cases, interns are expected to do floor work andget to the OR - the reality for our interns has been that they have been staying til 8-9pm nearly EVERY day rather than every 4th day.

I've lived both systems, and I can say that this year has been much more exhausting and emotionally draining than last year.

Interestingly, a lot of IM programs (the one I went to included) have switched to a "trickle" admit system this year so that there isn't really a "QX" system anymore. All of the teams admit every day in a rotating fashion. There is an "on call team" who's responsible for all admits from (roughly) 5-9pm and then NF picks up at that point. I'm not entirely certain how it's working out for them since I'm not in the middle of it.

 

[Mattchiavelli]

In surgery you admit every day, there are frequently emergency cases, interns are expected to do floor work andget to the OR - the reality for our interns has been that they have been staying til 8-9pm nearly EVERY day rather than every 4th day.

ACGME should recognize that a surgery resident has a bigger obligation of duties and allow for looser rules or a modified system I think

 

[SouthernSurgeon]

ACGME should recognize that a surgery resident has a bigger obligation of duties and allow for looser rules or a modified system I think

I don't think this is the case, and if my post came across as saying that a surgery residency is innately "harder" than other fields, that wasn't my intent.

I think a large part of the problem is that most surgery programs are run bass-ackwards, with little to no thought into how to efficiently train a modern surgeon. The PDs as a whole were unprepared for the new duty hour restrictions, and have been scrambling to find solutions at the last minute (most of which involve unfairly penalizing the junior and mid-level residents).

 

[Neuronix]

Interestingly, a lot of IM programs (the one I went to included) have switched to a "trickle" admit system this year so that there isn't really a "QX" system anymore. All of the teams admit every day in a rotating fashion. There is an "on call team" who's responsible for all admits from (roughly) 5-9pm and then NF picks up at that point. I'm not entirely certain how it's working out for them since I'm not in the middle of it.

My sub-I did it that way. It was miserable.

From the hospital's standpoint, if the residents admit every day or nearly every day, the census stays very full. From my standpoint, that is one way to still be over 80 hours a week working six days a week and not doing overnights. Those interns often were capped for much of the month, and were often over day length and weekly hours. The problem is that managing a capped service of sick patients and admitting late in the day often pushes one over the 9PM time limit. Teaching or rounding was virtually non-existent as the interns worked constantly. There was a lot of pressure not to say anything externally about those aspects.

 

[Doctor Bagel]

Interestingly, a lot of IM programs (the one I went to included) have switched to a "trickle" admit system this year so that there isn't really a "QX" system anymore. All of the teams admit every day in a rotating fashion. There is an "on call team" who's responsible for all admits from (roughly) 5-9pm and then NF picks up at that point. I'm not entirely certain how it's working out for them since I'm not in the middle of it.

Admitting everyday on a medicine service sounds so miserable to me. It's like the short call of the old system everyday, and short call was always my least favorite day.

 

[SierraPoppa]

Admitting everyday on a medicine service sounds so miserable to me. It's like the short call of the old system everyday, and short call was always my least favorite day.

This is how we do it and it's not bad. One team takes admits from 8-noon, one team from noon to 4, then the call team takes the rest until 7 when the NF gets in There's a built in 2 hours for the call team to finish up before 9 when they can actually leave. Each team is only admitting until 7 for 5 shifts per month.