How is your program adapting to the intern rules?

[Mr Cookie Pants]

As a rising 4th year, I'm starting to look at programs and of interest to me is how they're handling the intern situation. My home program currently has 2 call pools for interns (CT, Vasc, VA vascular and GI), so Q5 (2 interns on CT) and you cover 4 services. Theres another call pool (Onc, Transplant, VA general) that functions similarly. The juniors cover their service and then the PGY 2 and 3 have a shared "Surgical Services" which basically covers everything in the hospital. One giant call pool. Our PD wasn't a fan of dumping 75 patients from the CT/Vasc/GI service on an intern on July 1, so he was happy to see it go.

The new plan is that the interns will work their 16 (4a-8p) and then the junior and chief will alternate home call (yes, Q2 for life). Midway through the year, the interns will pass a competency exam and then staggered floating will happen. Not sure how it will work after that. The monster services are no more. So you will be more intimately involved with your own service, but daily hour long check outs should be gone.

I know other programs are already on a float system and most residents feel that our system probably won't work and we'll end up as a float either mid year or starting the 2012-13 year. Should be interesting. There will be much cursing.

Just curious your experiences.

---

Members don't see this ad.

 

[maxheadroom]

As a new faculty member, I'll tell you that most programs are still struggling with how we will achieve compliance with the *****ic new rules. I say "*****ic" because they go from a system that makes relative sense to a totally convoluted, incomprehensible set of rules that makes compliance almost impossible if patient care is anywhere near the top 5 goals of a resident.

 

[dynx]

As a rising 4th year, I'm starting to look at programs and of interest to me is how they're handling the intern situation. My home program currently has 2 call pools for interns (CT, Vasc, VA vascular and GI), so Q5 (2 interns on CT) and you cover 4 services. Theres another call pool (Onc, Transplant, VA general) that functions similarly. The juniors cover their service and then the PGY 2 and 3 have a shared "Surgical Services" which basically covers everything in the hospital. One giant call pool. Our PD wasn't a fan of dumping 75 patients from the CT/Vasc/GI service on an intern on July 1, so he was happy to see it go.

The new plan is that the interns will work their 16 (4a-8p) and then the junior and chief will alternate home call (yes, Q2 for life). Midway through the year, the interns will pass a competency exam and then staggered floating will happen. Not sure how it will work after that. The monster services are no more. So you will be more intimately involved with your own service, but daily hour long check outs should be gone.

I know other programs are already on a float system and most residents feel that our system probably won't work and we'll end up as a float either mid year or starting the 2012-13 year. Should be interesting. There will be much cursing.

Just curious your experiences.

Not sure your PD's plan will work. I think the interns are supposed to have 10 hours off inbetween shifts.
We're shifting to interns on during the day only. 6 days a week 5 of those days will be 13 hour days (5am to 6 pm) and one 15 hour shift staggered accross the weekend to cover the hospital around the clock. The call schedule will be filled in with PAs/NPs during the week.

I'll tell you what...if I was an intern I'd be pissed. My program used to have a decent call schedule. You'd get your one golden weekend and mostly a sat or sun the rest of the weekends with some exceptions. On the lucky days when it wasn't busy at 3 or 4 pm we'd round and you'd go home and the intern taking call would handle your pages. Not any more. Now you're going to stay your full day no matter if its busy or not because I don't want to be answering pages while im in the OR and the PA hasnt shown up for call yet. In addition, working 13 hour days every day of the week with a long shift over the weekend that can land anywhere in that 48 hour period is lame. You may end up with no "real" days off for 3 weeks straight. These limitations are going to make life worse in my opinion.

 

[LucidSplash]

I'll tell you what...if I was an intern I'd be pissed. My program used to have a decent call schedule. You'd get your one golden weekend and mostly a sat or sun the rest of the weekends with some exceptions. On the lucky days when it wasn't busy at 3 or 4 pm we'd round and you'd go home and the intern taking call would handle your pages. Not any more. Now you're going to stay your full day no matter if its busy or not because I don't want to be answering pages while im in the OR and the PA hasnt shown up for call yet. In addition, working 13 hour days every day of the week with a long shift over the weekend that can land anywhere in that 48 hour period is lame. You may end up with no "real" days off for 3 weeks straight. These limitations are going to make life worse in my opinion.

Agreed with making life worse. Our call schedule was somewhat similar as that described above - typically we'd have two weekends off each month, one weekend where we did Friday and Sunday call, and one weekend where we did Saturday call. During the week we typically had 1 weekday call. Similar to above if things weren't busy we'd try to get the precall guys out a little early and the oncall person takes the pager.

My program enacted the new rules early to try and get the kinks worked out of the new schedule before July 1 instead of having to deal with new interns and new schedules. I'm not complaining about that because I think it was smart and making the best of a bad situation. We now have nightfloat Sunday-Thursday night and then 16-hour shifts of "call" for interns on the weekends. Even though I won't be an intern anymore when the rules are official, the schedule will still affect me a little on the rare months I'm on a floor service during my 2 and 3 years because of having to stay until the night float person shows up - and also because based on our program size and needs, PGY-2s will probably need to do some night float. As an intern now, I really dislike the new schedule and I think its confusing as hell for our attendings to figure out who is covering their service on the weekends. I think my program has done a good job making the best schedule possible for our program within the constraints of the regs, but its very clear based on my experience over the last 2 months that the previous way of doing things was better for "lifestyle" and, more importantly, better for patient care. Maybe the incoming interns won't be as irritated as I am as they won't have experienced our previous (pretty terrific) schedule.

 

[europeman]

I'm in New York City, and we also have state rules that apply which sucks.

Namely, rather than 8 hours off between shifts as per the new ACGME rules, we have to have 10 hours off.

Also, we have to have a 24 hour off CALANDER day. So sunday 2am until saturday 2am doesn't count. It has to be midnight to midnight. so ******ed. This last rule, i'm not sure about, but, it's sorta how my program does it. maybe they will change.

Lastly, the new ACGME rules recognize chiefs need to violate once in a while and you are allowed to break hours for exceptions like a particularly good learning expereicne, or continuing a case in the OR, or whatever. In New york, we can't... we MUST SCRUB OUT.

and at my institution, we ACTUALLY SCRUB OUT. it's so ridiculous. we HAVE to because BIG BROTHER literally tracks us because the RN OR records are submitted weekly the hospital Hours police, so we can't lie. And if we login the computer from the hospital, that's also tracked. crazy.

People used to use other people's ID's... but, in the OR, the nurses know who we are, so we can't do that either. plus that's sorta a bad lie.


anyway, the way my instiution is dealing with it is mostly by hiring a ton more PA's and NPs.

ALso, on some rotations, like at the VA... we will no longer have ANY in house surgeon at night... rather, the in house medicine critical care attending will take care of the surgery patients as well as see new consults/ER admissions. crazy.

 

[45408]

I'll tell you what...if I was an intern I'd be pissed. My program used to have a decent call schedule.

Agreed. I doubt if they're ever going to have an entire weekend off for their whole intern year. I also like what I get to do on call, and I like the post-call day. Plus, with the additional supervision requirements, they're really going to feel like fifth-year med students. Plus, now that they can't take call, their PGY2-5 years are going to be that much worse.

I don't know how our program is going to handle it, but we've got a meeting tomorrow where we find out...

 

[dpmd]

We have tried out our plan for the new schedule and it is going ok, but then again I haven't actually been there for a while (on outside rotations). Instead of traditional call, we switched things to a day call and "night shift" schedule. Can't call it night float for some reason I didn't totally understand. What we have settled on is each junior does one week of nights plus one weekend of nights at a different time. The stay to round the next morning, but it basically means we have one less person each day. We had to fiddle with the yearly schedule to make sure we would always have enough people to participate, and if people want to take vacations it is going to make things tricky. We already had a night float system in place involving second years (in the second half of the year) through fourth years. The chiefs alternate back up call (there are only two, but we don't operate at night unless truly necessary. We are managing to keep our two complete weekends off for now, but we will see how it goes. I agree that there will be less getting out early especially since there will be fewer people to get the work done during the day (and more to do for the chiefs).

 

[Tired Pigeon]

Agree with those above who note that it will kind of suck to be an intern under the new system (even more than it kind of sucks to be an intern at baseline). We are doing a test run of the new rules right now and the biggest things I have noted are:

1. There seems to be much less flexibility all around -- it's like trying to solve some complicated logic puzzle just to get people slotted in to cover all the hours while simultaneously making sure none of the interns are in house >16 hours and everyone's getting one 24 hour period off per week. And God help us when someone goes on vacation. Overall the more rules and restrictions there are for scheduling, the less flexibility there will be. The days of trying to make sure everyone gets at least one, if not two, golden weekends per month will be gone.

2. During my intern year, the best operative experiences I had were usually on overnight calls. The way we're doing things, most of the night coverage will now be provided by PGY2 and up (maybe the thought is less supervision is required?). I know this isn't the way every place is doing it, just our experience.

3. With people working shorter shifts, the result is more handoffs. I recognize that the days of unlimited hours (and fewer handoffs) maybe weren't in the best interests of patients, but it seems we've gone too far in the other direction. Decent handoffs are also fairly time consuming on the busier services.

Maybe someone on here can fill me in: I'm wondering why the 16 hour rule was instituted for interns. Is the thought that they're not "up to" working our standard shifts and need to build up their stamina? Is it a question of supervision during off hours? What happens between the last day of intern year and the first day of PGY2 that suddenly makes someone able to work a 30 hour shift when the day before they were only "qualified" to work 16 hours? Is it some kind of licensing issue?

 

[badasshairday]

Maybe someone on here can fill me in: I'm wondering why the 16 hour rule was instituted for interns. Is the thought that they're not "up to" working our standard shifts and need to build up their stamina? Is it a question of supervision during off hours? What happens between the last day of intern year and the first day of PGY2 that suddenly makes someone able to work a 30 hour shift when the day before they were only "qualified" to work 16 hours? Is it some kind of licensing issue?

Who knows... One of the OB/GYN attendings told me that if the 16 hour rule is successful, the plan is to extend that to everyone.

 

[SouthernSurgeon]

1. There seems to be much less flexibility all around -- it's like trying to solve some complicated logic puzzle just to get people slotted in to cover all the hours while simultaneously making sure none of the interns are in house >16 hours and everyone's getting one 24 hour period off per week. And God help us when someone goes on vacation. Overall the more rules and restrictions there are for scheduling, the less flexibility there will be. The days of trying to make sure everyone gets at least one, if not two, golden weekends per month will be gone.

This is the part that frustrates me the most. With our old system, we actually had a nice bit of flexibility over our call schedules. Within reason, as long as everyone's hours averaged out the chiefs and program admins didn't care how we set things up. We were able to make sure people got specific weekends off for weddings, family events, etc, pretty easily.

I think those days will be behind us in the new system. Everything will be much more rigid due to the complexity involved.

 

[ESU_MD]

At the program level, who is coming up with actual schedules? The program director, coordinator? Or is the problem just passed down to the residents to get the program into compliance. A further unpaid responsibilty that takes away from education

 

[dpmd]

At my program the chiefs make the schedule. I actually prefer it that way, because I think we are better able to tailor it to our needs. We actually took over making the yearly schedule this year and it seems like it is going to work out much better (no more oops, too many people are on outside rotations so we don't have enough people to do night float-guess someone has to drive back one of the weekends). I guess it would be better if someone else who actually understood all the rules AND how the schedule affects our lives would come up with one and just present it for the chief's approval, but I would guess it would get screwed up more often than it has with our system.

 

[opr8n]

Let me just say that im soo glad to be done with this residency thing soon.
My program has no idea what they are doing with the interns, basically they will be useless. The 2nd/3rd years are exercising their hip flexors preparing for the future.

Even the 4/5s are going to be taking much more in house call
At one hospital the 4th year is on call 9 times in one month! What a waste

PDs need to understand that they need to preservce the operative experience for the 4/5s. These levels need to be a work everyday, running their service, not going home at 8am every third day like they did as an intern

Certain other hospitals are going to at home call for the upper levels, which is going to be painful. The nurses who refuse to put in orders over the phone for you will have to change their tune. It will be a huge culture shock

I honestly dont know how you train a general surgeon under these new rules without extending the residency. That or the general surgeons coming out are going to be just that more inexperienced.

 

[Chirurgia magna]

I honestly dont know how you train a general surgeon under these new rules without extending the residency. That or the general surgeons coming out are going to be just that more inexperienced.

I am a rising intern and I share your concerns.

However, I often wonder what is the value of doing 25 Whipples, 20 kidney transplants, 30 APR and LARs (just random examples) if you are going into CT, vascular, plastics, etc. With the majority of surgeons going into fellowships is it such a huge problem to be inexperienced in an area you will never have to work again. I am not putting you on the spot or anything, just trying to get your point of view especially since you are experienced.

 

[Pir8DeacDoc]

I am a rising intern and I share your concerns.

However, I often wonder what is the value of doing 25 Whipples, 20 kidney transplants, 30 APR and LARs (just random examples) if you are going into CT, vascular, plastics, etc. With the majority of surgeons going into fellowships is it such a huge problem to be inexperienced in an area you will never have to work again. I am not putting you on the spot or anything, just trying to get your point of view especially since you are experienced.

Things like this are said by people who don't understand the process. Each of those fields, cases, and the skills required to complete the case help create a surgeon. I'll use an example from my specific field. I do neck dissections and huge wacks on people all the time for cancer. Likely I'll do little if any of that in practice. But the appreciation for anatomy and the skills to do those surgeries make a submax gland excision, thyroidectomy, or an open neck lymph node biopsy that much easier for me. A case isn't useless just because you might not do it in the future. Very short sighted view.

 

[Buzz Me]

However, I often wonder what is the value of doing 25 Whipples, 20 kidney transplants, 30 APR and LARs (just random examples) if you are going into CT, vascular, plastics, etc.

Lots of practice doing anastomoses in kidney transplants (renal artery/vein, ureteroneocystostomy). Ditto with Whipples (especially the pancreatico-J and hepatico-J. This would be very helpful in Vascular and CT. Somewhat so for Plastics, if only to prepare for microsurgical techniques.

Being able to dissect and handle tissues well (for other big abdominal cases, like the aforementioned APR and LAR) would help in any fellowship field.

I'm a firm believer that the switching to an all-integrated system for the vast majority of these surgical fellowships is a bad idea. You'd also lose out on the senior PGY-4 and PGY-5 years, which is when you learn to be a chief and run the service. Your clinical decision-making will suffer.

 

[Ronin2258]

I will have to agree with this being a huge suck factor, as well as sacrificing flexibility.

The 2003 rules were a much needed thing to correct a lot of the abuses that happened. The old school folks would probably testify to some of it.

***WARNING: Speculative Thinking***
I am wondering if this is a reaction to something deeper. Everything would be fine IMO, if all the reporting is above the board. As many of us know, there were hours that were considered "not official work hours," or off the books. ACGME struck back with limiting the hours of a key member of the team (yes, regardless of the amount of BS work one does, interns are critical,) forcing a radical change. A lot of programs are set in their ways, and have to be forced by rules to change (one of the reasons you saw big name programs get in trouble initially in 2003. If a big program got busted, a small, community program is not immune. Change had to occur.)
***End Speculative Thinking***

As to senior surgical residents being forced to scrub out of cases at the limits of hours...sorry, I call BS. I don't know if any of my seniors/chiefs would EVER do that. They knew they were a few months away from being attendings themselves, and would want to start working towards that goal, complete with longer hours.

 

[ESU_MD]

What attending would kick out a good helper anyway? Unless he already had someone to assist him or close, then theres no point in staying anyway

 

[Chirurgia magna]

Things like this are said by people who don't understand the process. Each of those fields, cases, and the skills required to complete the case help create a surgeon. I'll use an example from my specific field. I do neck dissections and huge wacks on people all the time for cancer. Likely I'll do little if any of that in practice. But the appreciation for anatomy and the skills to do those surgeries make a submax gland excision, thyroidectomy, or an open neck lymph node biopsy that much easier for me. A case isn't useless just because you might not do it in the future. Very short sighted view.

It's funny you use the example of neck dissection because I was thinking about it. ENT surgeons do amazing neck dissections all the time without having extensive training in massive abdominal cases just to build surgical skills. They are just one example of a surgical subspecialty where not having general surgery training has not resulted in inferior surgeons.

I guess whether the new generation of surgeons will be superior or inferior only time will tell. I do however believe we as a generation have undergone a shift in values. My generation places a lot of value on lifestyle when choosing a career and unless general surgery training can accommodate that and keep up with current culture it will have a hard time attracting talent. The attitude of "I never left the hospital and neither should you" will not make for better training, that's for sure. I truly believe the future will be a lot better, not worse and in the long run the 5 year training with the 80 hour work week will be a thing of the past. We will see more and more 3+3 programs. Plastics, Vascular, CT are just some examples.

Finally, let me quickly give you a quote by a famous surgeon:

"Surgery of the heart has probably reached the limits set by nature, no new methods and no new discovery can overcome the natural difficulties that attend a wound of the heart."

Boy, was he shortsighted.

 

[Pir8DeacDoc]

Your point is a good one. I don't think we as ENT's have to muck around in the belly to learn to operate. However, my point remains the same. There are plenty of cases that are done to refine and perfect a skill set, whether or not you'll ever do it in practice. You probably don't need 5 years to learn the cases I'll do in practice, but to shorten that time would make it harder to deal with complications and make you a less confident and technically skilled surgeon.

 

[Chirurgia magna]

Your point is a good one. I don't think we as ENT's have to muck around in the belly to learn to operate. However, my point remains the same. There are plenty of cases that are done to refine and perfect a skill set, whether or not you'll ever do it in practice. You probably don't need 5 years to learn the cases I'll do in practice, but to shorten that time would make it harder to deal with complications and make you a less confident and technically skilled surgeon.

Stated that way, I agree with you 100%.

I have worked in the OR for 8 years now and one of the general surgeons said that when we has training he could not understand why his seniors kept saying that you need 15 years of experience (5 training + 10 practice) to be a good surgeon. He said once he hit 15 years he had experienced almost every emergency imaginable, could answer calls without even waking up and his surgical skills were so much more refined.

I guess my question was, in your opinion as senior residents and attendings would one be a better heart surgeon (just an example) by spending 5+ years doing lung cases, CABGs, aneurysms, transplants and valves as a CT resident or would one be a better heart surgeon by doing 4-5 years of general surgery and then transfer to 3 years of CT with the same number of total cases done during residency.

 

[Pir8DeacDoc]

Sounds like we were on the same page, I may not have clearly articulated my point initially.

I can't really provide much useful information as it relates to general surgery training as it's out of my scope of knowledge. I only know my intern stuff and the stuff I hear from my friends in GS.