How many gen surgery spots unfilled last year?

[SocialistMD]

She's told me stories of how shockingly lazy some of the residents have gotten - and how willing they are to dump sick patients in her lap just because "they're going to go over hours." Stories about how consults are left undone (once she got a consult that ended mid-sentence!), or how unstable patients are dumped into night float's lap.

Ask her to tell you the stories of the internists in private practice who do the exact same thing. I was working in an ICU last week and a patient came in with shortness of breath from a CHF exacerbation and his cardiologist wanted him in the ICU "to ward off bad things." Apparently, his coming in to see his patient and write orders are considered bad things. This is a person who did his residency and fellowship prior to the 80 hour rule. He was the most flagrant of the 5 people I had try to do it that night. Everyone at a tertiary care hospital knows Friday nights suck in terms of getting the trainwrecks dumped on you from outside hospitals simply because physicians don't want to take care of their patients over the weekend, so they cease to care for them and hand them off to someone else.

My point is that people are lazy and have been for a long time. Now they have an excuse behind which they can hide, but don't think for a second that lazy residents are something new.

Not necessarily directed at your comment as much as it is at that cardiologist who tried that ridiculous admit.

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[HouseHead]

The quote feature isn't working quite right; my apologies.

It hasn't done anything to it.

Can you point me to the study that shows that? I'd be curious to read it.
(I assumed that there was not enough concern for the health of the doctor to do such a study)

Where?

Percival made several such posts (admitting it doesn't make it any more palatable).
And so as not to shy away from the subject, one quote you wrote could seem that way too- has anyone really had that whole string of excuses capped off by showing you a picture of their kid? If so, they are so out of touch; frankly almost any excuse is unacceptable. But if not and it's a reflection of your personal attitude towards bringing motherhood into the hospital (as it could easily seem, given how common negative attitudes are towards the "inconveniences" of responsibilities that are uniquely maternal), then it was indeed sexist. But I don't know enough about the comment- or you- to judge that definitively.

About the 80 hr week: I think that one of the things that makes it work is, from my limited perspective, less malignancy and more kumbaya (in the words of one of my favorite residents). When senior residents do recognize that getting out early is ok on a slow day, it removes the all-around resentment of "I had to so you have to" thinking. And as mentioned by an earlier poster, there is less time for abuse of the residents' time.

Personal perspective: I'm one of those people- the 80 hr week has allowed me to consider a career in surgery. I had planned on going into surgery, beginning many years before I finally started medical school. I rethought everything after having my first child after my MS2 year, and decided I'd probably go for FM instead. But when I did my rotations, I hated FM, and surgery was the only thing I really loved- again and again, with each surgery elective I did. After talking to many residents and attendings, I saw that the hours are pretty close to the same for most residencies, it is just the number of years that vary. If 120 hr weeks were still commonplace, I could not do it. I don't want to be completely absent from my kids' lives, or be a heart attack waiting to happen because of 5 years without exercise. I will not be spending hrs 81-120 playing playstation or going to bars. I will be spending it with my family, trying to get some exercise in, and, most likely, reading- just like I always have. And I certainly hope to be a team player throughout, keeping my true lazy self under wraps

 

[SocialistMD]

Are you serious... How would that be even possible for everyone except maybe derm??

There is a movement that may or may not be gracing the surgical residency programs where you are not advanced based on the number of years you have served, but rather on *gasp* your knowledge and skill. Some of the leaders of the Association of Surgical Program Directors are trying to figure out how to make it work. Basically, if you suck or can't keep up, your residency won't be five years; it will be much longer. Likewise, if you are an all-star, your residency will be at or just under five years (there really isn't a way to compress all of residency into under five years). You will be evaluated on a core set of skills for each procedure performed/disease process encountered, and may not even be allowed in the OR until you have demonstrated proficiency in a cadaveric or simulated model. Safer for the patients that way.

Again, this is something that will likely not affect anyone currently in residency, but if they can figure out how to get it to work, it may be seen within the next decade.

 

[Celiac Plexus]

Today we were fed [a load of malarkey] by the GS dept of my school. The two speakers were an attending trauma surgeon and a 4th year GS resident. They both liked the 80 hour work week. The attending said that she trained at a time when they worked 110 hours. She said that the 80 hour work week has given her more time to do other things -- like go to the library and research. She said that back in her day, there was absolutely zero educational reading going on after work.

Talks like this aren't worth a whole lot. What you heard is the standard dog and pony routine. A surgery department isn't going to tell you how hard, and agonizing training is. I would be very suspicious of anyone who tries to make training sound pleasant.

As far as lazy, [80 hour johnny] residents/interns go, don't you think they'll get theirs in the end? I mean, don't the [80 hour johnnies] always get made known? Do you think they're really fooling anybody?

Heh.

I would imagine that a great part of the 80 hour work week is time management anyway. The leadership needs to not take the time of their students for granted as much as they maybe used to. Sure, there will be the patient that needs your attention at hour 79 of your work week, and I would not expect any doctor with a sense of duty to skip out on a situation like that. But for the most part, don't you think people could go home after 80 hours (give or take 5 hours or so) if they were efficient with their time?

This is the big lie. Your time management skills are not the rate-limiting time factor of residency training. It is the time management skills of sick patients, and other hospital employees that will dictate your workday. At some private institutions with adequate ancillary support, the 80 hour rule is potentially feasible. In the majority of state, and academic institutions, residents remain the net that catches (or not) all of the droppings of others.

The caveat was that you have to be flexible with your off-time. In their own words, "If you did a breast surgery on a lady and that night she develops a huge hematoma, it's your problem. You have to take ownership of your own work."

Hahahahahaaaaaa..... The problem is that as an intern/junior resident, you will not be getting the call. While you are at starbucks chatting up beautiful bookworms, your chief, or worse the night float team, will be the ones dealing with this.

Percival, don't take my comments personally. You have no way to know what training is like until you are actually doing it. I have a strong feeling that your views will change once you see the belly of the beast up close and personal. Training has wonderful aspects to it, and some very miserable ones too. The problem I encounter with most student perceptions is that they tend to focus only on only the positive ones/ones that are attractive to them. These days, that means gushing about the 80 hour work week, and how much free time you'll have as a general surgery resident. You have many general surgery residents here telling you their experiences... It is to your benefit to listen to them. Training isn't just about learning how to cut and sew. It's about learning professionalism, and practicing the level of dedication that you wrote about in your medical school application.

Human nature, being what it is, does not support the notion that people will use their "off-time" to read Cameron. Students now rave about "lifestyle", and family time, and other non-surgical activities. Does this mean students are worse than those of yesteryear? No, of course not. But in my estimation, it makes for inferior surgical product in the end. One of the things I admired most in medical school is the dedication, and professionalism of surgeons. Now those same people are given derogatory names like "workaholic", and "burn-out" by the 80 hour cheerleaders.

Enjoy all the free lunches that you get. But remember that the folks talking at those lunches are usually trying to sell you something. Thanks to all the drug companies for feeding me for the last few (er several) years.

disclaimer: the above is the view of a single, nameless, humble, imperfect, general surgery resident. the post is meant to communicate one viewpoint, and not meant to offend, or fuel a flame war. thank you, have a nice day.

 

[SoCuteMD]

Hold on there young stuff. This attending is bullcrapping you into thinking that attendings are limited to 80 hours of work per week over four weeks. The ACGME makes this provision for residents in training. NOT for attendings and certainly NOT for medical students. Attendings in private practice typically work well over 100 hours per week. Yes, that's right. Get used to it if being a surgeon is what you want to do

Now...hold on a minute there. I will openly admit that I have less exposure to general surgery than you do. However, I did my surgery rotation at a private hospital where the various general surgery practices were quite lucrative. The attendings ranged from fresh out of residency to 30+ years in the community. Not once did I see an attending in the hospital before 6:45 AM, and rarely before 7:30 AM. The only times an attending was in the hospital after 5 PM were related to two circumstances a) an OR case (planned or unplanned) went very late or showed up in the ER late in the day or b) a patient was crashing or dying . This was also a rare occurrence. My preceptor's office opened at 8 AM and closed at 5 PM so no one was seeing patients at odd hours, either. Weekends consisted of rounding with one attending from each group of surgeons as well as with whoever wasn't on call but decided to come in to see their patients (not uncommon). The total time investment for each attending in this circumstance was probably an hour or so. Attendings took general service call approximately q10 and had a 1 in 2 chance of coming in for an incarcerated hernia or an appy. Very little trauma ever required the OR.

I'd guess that these surgeons worked, as a generous estimate, 60 hours a week and they all seemed to be doing very well for themselves.

 

[SocialistMD]

Now...hold on a minute there. I will openly admit that I have less exposure to general surgery than you do. However, I did my surgery rotation at a private hospital where the various general surgery practices were quite lucrative. The attendings ranged from fresh out of residency to 30+ years in the community. Not once did I see an attending in the hospital before 6:45 AM, and rarely before 7:30 AM. The only times an attending was in the hospital after 5 PM were related to two circumstances a) an OR case (planned or unplanned) went very late or showed up in the ER late in the day or b) a patient was crashing or dying . This was also a rare occurrence. My preceptor's office opened at 8 AM and closed at 5 PM so no one was seeing patients at odd hours, either. Weekends consisted of rounding with one attending from each group of surgeons as well as with whoever wasn't on call but decided to come in to see their patients (not uncommon). The total time investment for each attending in this circumstance was probably an hour or so. Attendings took general service call approximately q10 and had a 1 in 2 chance of coming in for an incarcerated hernia or an appy. Very little trauma ever required the OR.

I'd guess that these surgeons worked, as a generous estimate, 60 hours a week and they all seemed to be doing very well for themselves.

Based on my n=3 of private hospitals (read: no surgery residents and no university affiliation) where I have worked, I'd say your experience is not the norm. Residents at a hospital make all the difference in the world, even if it is at a "private hospital."

I recently saw the data from our attendings at my institution on reported weekly hours worked. It ranged anywhere from ~40 (a senior breast surgeon) to over 80 (the chairman, a trauma surgeon and a colorectal surgeon) with the average being around 63. That said, they can get home because they have residents to take care of the dirty work at less than desirable hours. In private practice, most places don't, so they have to at least field those calls, and if a patient is tanking, they are the first responders (only partially delayed if they have a physician extender that takes call overnight) rather than just showing up to the OR when their chief calls and says they are in the room. They don't have academic days and their food/house/BMW all depend on how busy they are, so I'd say that, on average, the private practice general surgeon is in the hospital more than the academic surgeon.

 

[SLUser11]

Graduated responsibility, not graduated bitching.

Ironic that you guys are b#tching about your co-residents' b#tching.

If you want to go into surgery, you need to do it like everyone before you did it.

That is a ridiculous, close-minded statement.

To the med students reading this thread: NOT ALL SURGERY RESIDENTS THINK LIKE THIS!


Also, I just can't feel too sorry for you guys about getting paged by medical students during a case.

--> You dramatically recount that when you were a med student thousands of years ago, you weren't allowed to even look at a senior resident, let alone initiate a conversation.

--> You therefore most likely provide little or no direction for the students, thus leaving them sitting in a corner for hours, waiting for you to be ready to round with absolutely no time frame to work with.

Paging you to ask about rounding isn't a sign of laziness or weakness. It's a sign that you're not communicating with your students.

 

[smq123]

Personal perspective: I'm one of those people- the 80 hr week has allowed me to consider a career in surgery. I had planned on going into surgery, beginning many years before I finally started medical school. I rethought everything after having my first child after my MS2 year, and decided I'd probably go for FM instead. But when I did my rotations, I hated FM, and surgery was the only thing I really loved- again and again, with each surgery elective I did. After talking to many residents and attendings, I saw that the hours are pretty close to the same for most residencies, it is just the number of years that vary. If 120 hr weeks were still commonplace, I could not do it. I don't want to be completely absent from my kids' lives, or be a heart attack waiting to happen because of 5 years without exercise. I will not be spending hrs 81-120 playing playstation or going to bars. I will be spending it with my family, trying to get some exercise in, and, most likely, reading- just like I always have. And I certainly hope to be a team player throughout, keeping my true lazy self under wraps

I wish you a lot of luck. I'm not optimistic enough to think that I'll be guaranteed an 80 hour work week all the time. I've seen enough residents (not saying at which hospital....) that were forced to go over 80 hours, or skated very close to 80 hours (i.e. 85-95). In addition to all their duties, like putting together M&M presentations and figuring out research, and then studying for the ABSITE, etc., I don't know how much free time they truly have. Particularly when they're PGY-4s or chiefs.

Plus, I think I'd like to do a fellowship, and the 80 hours rule will not apply to me anymore.

I don't know if things will work out as you envision it. I know that you did a lot of electives as a 4th year - but so did every other surgery resident that decided, ultimately, to drop out of residency. But I hope, for your sake, that you manage to find the balance that you're looking for, without screwing over your fellow residents and your patients.

Also, I just can't feel too sorry for you guys about getting paged by medical students during a case.

--> You dramatically recount that when you were a med student thousands of years ago, you weren't allowed to even look at a senior resident, let alone initiate a conversation.

--> You therefore most likely provide little or no direction for the students, thus leaving them sitting in a corner for hours, waiting for you to be ready to round with absolutely no time frame to work with.

Paging you to ask about rounding isn't a sign of laziness or weakness. It's a sign that you're not communicating with your students.

I agree that the old tradition of "med students being forced to walk at least 5 paces behind the chief, and at least 3 paces behind the PGY-3" is ridiculous. I was lucky enough to have chiefs who were extremely open to talking to students - they'd ask us about ourselves, where we went to school, what we wanted to do with our lives (and then strenuously try to switch our minds over to surgery! ), what our hobbies were, etc.

And I agree that chiefs should give all members of the team directions.

But, in all fairness to Castro, as a student there are better ways to find out if/when you're rounding:

• Ask the intern or PGY-3/4 first. If they don't know, then they can page the chief.
• I don't think it's too much to ask that a med student have a vague idea of where the chief is. I'd try to find out, first, if the chief was still in a case. If so, then don't page him - because, obviously, we're not going to round if he's in the middle of an operation! As students, we were (eventually) able to access the OR schedule and see which cases were going to go that day. At AM rounds, then, everyone (including the residents) would announce which cases they were going to go into. So, poking your head into the OR where the chief was supposed to be, and see if he's still there, isn't so hard.
• It's hard for the chief to "give direction" and tell students when he's going to round when he's still scrubbed in. So I don't think it's always laziness on the part of the chief.

Perhaps things are different at your program, and the options that I mentioned above are not possible. But that's how things were done at my rotation, so maybe it's the same at Castro's program as well.

 

[Blade28]

Interesting discussion in here.

I'm often torn on the issue of the 80-hour workweek.

On the one hand, I see its potential benefits - better quality of life, more rested residents, more time for social lives, studying, "recharging," etc. I understand the arguments that it'll make for more efficient residents, or that patients will receive better care (presumably because their residents will be less fatigued/exhausted).

But I can also see the disadvantages. 80 hours was rather arbitrarily chosen as the limits for a resident's average week - this is so much harder to achieve in procedure-based fields such as Surgery. Because in other fields, you can try to round more quickly, limit lengths of discussions, etc. But in Surgery you still need to do a certain number of each type of procedure to be competent and feel comfortable. You certainly can't "rush" just because you're under a time constraint now. And you don't want to graduate with a significantly decreased number of major cases under your belt.

So what's happening? Some programs are becoming top-heavy, because the senior residents are trying to get to the OR all the time, thus delegating all floor/ICU work to the juniors. (The juniors, in turn, become OR-hungry as they advance in PGY level.) When people (the juniors taking in-house call) are forced to leave after 80 hours for the week (or 30 hours for the shift), then their workload shifts to the seniors who stay behind. And often, when they have to leave, the attendings end up taking on a lot more work than previously.

Many attendings feel that the 80-hour workweek is detrimental to residents' education (which, in the end, is one of the critical issues at hand here). You certainly don't have these restrictions as a fellow or attending. I won't even get into the hazards of more-frequent signouts and changes-of-shift.

It's a tough situation.

 

[ESU_MD]

To the med students reading this thread: NOT ALL SURGERY RESIDENTS THINK LIKE THIS!

well, they should, and most do. The 80hr week is progressively destroying surgery.

Medical students- do not come into surgery and think you are going to have it easy and have a nice lifestyle at the expense of dumping your patients. There are plenty of open er residency spots for you.
If you work with me, or any of my colleagues, you will be accountable for your patients no matter how much you worked or how tired you are.

I think that the horse is out of the barn now, so I know that I can't change the poor attitudes of the juniors and students. They have been empowered by the clip board advocates of work hour restriction, and they have told themselves that the old school was wrong.

I can only pity these poor souls who think that they will be surgeons by taking a shortcut.

It used to be that if you sent a resident home early for bad behavior or kicked out of conference for tardiness they were emotionally destroyed. not anymore, nobody cares. they are GLAD because they get to go home early.

The hierarchy has been eliminated and the animals are running the zoo- straight to hell.

As for me I will continue on in the footsteps of our forefathers. Those who wish to quote and live by the heretic principles of work hour restrictions can do so on their own.

 

[SLUser11]

As for me I will continue on in the footsteps of our forefathers. Those who wish to quote and live by the heretic principles of work hour restrictions can do so on their own.

Thank you for that histrionic rant, you noble, tortured soul.

I think your biggest problem with the 80 hour rule is that it gives you less time to hang from the cross.

 

[chrisisinnocent]

To the med students reading this thread: NOT ALL SURGERY RESIDENTS THINK LIKE THIS!

well, they should, and most do. The 80hr week is progressively destroying surgery.

Medical students- do not come into surgery and think you are going to have it easy and have a nice lifestyle at the expense of dumping your patients. There are plenty of open er residency spots for you.
If you work with me, or any of my colleagues, you will be accountable for your patients no matter how much you worked or how tired you are.

I think that the horse is out of the barn now, so I know that I can't change the poor attitudes of the juniors and students. They have been empowered by the clip board advocates of work hour restriction, and they have told themselves that the old school was wrong.

I can only pity these poor souls who think that they will be surgeons by taking a shortcut.

It used to be that if you sent a resident home early for bad behavior or kicked out of conference for tardiness they were emotionally destroyed. not anymore, nobody cares. they are GLAD because they get to go home early.

The hierarchy has been eliminated and the animals are running the zoo- straight to hell.

As for me I will continue on in the footsteps of our forefathers. Those who wish to quote and live by the heretic principles of work hour restrictions can do so on their own.

I bolded the relevant part of your post. You just sound like an angry petty tyrant that can no longer feel awesome for emotionally destroying your subordinates

 

[Castro Viejo]

Sorry to hear about your Whipple patient, though - it must have made for a pretty depressing Saturday evening.

It's a bad operation and sometimes it goes really bad.

What time are they allowed to go home post call? We were told by the rotation coordinator to leave by noon SHARP, but I never felt comfortable about speaking up and requesting to leave, so I usually stayed the full day the next day.

They're telling you that they've been instructed to leave by 4 if the team hasn't rounded yet? It sounds like you're hearing a well-coordinated lie by your group of med students. While the other stuff sounds plausible (i.e. I have heard of some rotations sites that put a limit on the number of overnight calls you can take - although this is generally more true of psych than of surgery - and of making students leave by noon post-call etc.), this sounds a little odd. This is ignoring the fact that you can't realistically expect every surgical service to start rounding by 4PM every day....

We're still waiting for the clerkship director at the med school to call us back about that one. We're not sure. So far none of the students have dared to leave at 4PM when rounds hadn't started.

 

[Castro Viejo]

Can you point me to the study that shows that? I'd be curious to read it.
(I assumed that there was not enough concern for the health of the doctor to do such a study)

I don't have the reference handy and tomorrow's the ABSITE, so I'd like to squeeze in a bit of rapid fire review before it. Afterwards I'll be more than happy to find it for you though. Sorry.

one quote you wrote could seem that way too- has anyone really had that whole string of excuses capped off by showing you a picture of their kid? If so, they are so out of touch;

Yes, my thoughts exactly. And the run on excuse thing is exactly what my fourth-year resident told me. As was the "yard sale" comment and why she couldn't come in on a Saturday morning for our Chairman's teaching rounds. Lame.

frankly almost any excuse is unacceptable. But if not and it's a reflection of your personal attitude towards bringing motherhood into the hospital (as it could easily seem, given how common negative attitudes are towards the "inconveniences" of responsibilities that are uniquely maternal), then it was indeed sexist.

I don't have anything against motherhood. I have a mother. What I do have a problem with is expecting everyone around you to jump to attention or to pull your weight for you, just because you decided to have a kid during residency training. It's really not fair to me or the other residents in the program when we have to pick up someone else's slack because she has to pump her breasts, pick up her kid from the babysitter, or take her kid to "his first day of school." Sorry. It may sound callous, but I wouldn't ever impose on my co-workers and colleagues when I have a kid.

About the 80 hr week: I think that one of the things that makes it work is, from my limited perspective, less malignancy and more kumbaya (in the words of one of my favorite residents). When senior residents do recognize that getting out early is ok on a slow day, it removes the all-around resentment of "I had to so you have to" thinking. And as mentioned by an earlier poster, there is less time for abuse of the residents' time.

Like I said. As a Chief Resident in General Surgery I recognize that people want to be home as much as possible. Fine. If there's nothing going on, take a day off. It doesn't bother me much. What does bother me is when I ask you to stay 'cause the fit hits the shan, then I don't want to hear complaining about how you're gonna "go over hours." It's a give and take, but usually with today's newer crop of residents, it's more take.

Personal perspective: I'm one of those people- the 80 hr week has allowed me to consider a career in surgery. I had planned on going into surgery, beginning many years before I finally started medical school. I rethought everything after having my first child after my MS2 year, and decided I'd probably go for FM instead. But when I did my rotations, I hated FM, and surgery was the only thing I really loved- again and again, with each surgery elective I did. After talking to many residents and attendings, I saw that the hours are pretty close to the same for most residencies, it is just the number of years that vary. If 120 hr weeks were still commonplace, I could not do it. I don't want to be completely absent from my kids' lives, or be a heart attack waiting to happen because of 5 years without exercise. I will not be spending hrs 81-120 playing playstation or going to bars. I will be spending it with my family, trying to get some exercise in, and, most likely, reading- just like I always have. And I certainly hope to be a team player throughout, keeping my true lazy self under wraps

Everyone is inherently lazy, but the degrees vary.

I just hope you understand that while resident work hours are limited to 80, your attendinghood career won't be protected in that way. And that means you may be joining a practice where it's busy and there's a heavy workload.

Please don't think that surgical residency is "so much more bearable" just because the work hours are restricted to 80. It's a hard 80 hours and it only gets harder with fellowship and later practice.

Good luck to you though.

 

[DoctorMunchkin]

Personal perspective: I'm one of those people- the 80 hr week has allowed me to consider a career in surgery. I had planned on going into surgery, beginning many years before I finally started medical school. I rethought everything after having my first child after my MS2 year, and decided I'd probably go for FM instead. But when I did my rotations, I hated FM, and surgery was the only thing I really loved- again and again, with each surgery elective I did. After talking to many residents and attendings, I saw that the hours are pretty close to the same for most residencies, it is just the number of years that vary. If 120 hr weeks were still commonplace, I could not do it. I don't want to be completely absent from my kids' lives, or be a heart attack waiting to happen because of 5 years without exercise. I will not be spending hrs 81-120 playing playstation or going to bars. I will be spending it with my family, trying to get some exercise in, and, most likely, reading- just like I always have. And I certainly hope to be a team player throughout, keeping my true lazy self under wraps

From a resident perspective, don't go into surgery because the 80 hour work week has now made it bearable. That is the wrong reason. Go into it for the love of it, for the patients, for the operations and because you couldn't imagine doing anything else with your life. I don't try to recruit people to surgery (with the exception of one. She is a surgeon and just hasn't realized it yet. But that's another story). I say that surgery is a field that you recruit yourself to. You either love it and can't imagine doing anything else with your life, or you think its OK, but you like some other things equally as well. Do the other things. You will be happier, as will your wife and your children. Surgery becomes your second wife/husband. It takes precedence over your family at times, regardless of its a birthday/Christmas/New Years/school play, etc. It just dose. And if you want to be a good surgeon, it should.

80 hours has not made the time you dedicate to surgery less, it has simply switched where you dedicate your time. It used to be that you were in the hospital for 120 hours, learning there, seeing patients, etc. Now, reading isn't done in the hospital, but at home. Grand Rounds presentations are done at home, on my computer, fighting off my two year old who is trying to help me type! Yes I am home, but the learning must continue. I owe it to myself and my patients. Surgery is my craft and I should dedicate myself to it.

Now, I am not saying you shouldn't do surgery, but thinking that the 80 hour work restrictions has made it more palatable is the wrong reason to do it. I thought long and hard before choosing surgery. I decided that it would take a lot of my time, but I would be miserable doing anything else. If I was miserable at work I would be miserable at home, too. I love what I do and I think that is a much better example for my children, even if they have less quantity of time with me. They see a happy parent and not a miserable one.

Just my $.02 worth. Eighty hours means the education takes place out of the hospital (at least that is what it should mean.) Obviously the ABSITE score drop shows that other people don't think so.

 

[SocialistMD]

Plus, I think I'd like to do a fellowship, and the 80 hours rule will not apply to me anymore.

Depends on the fellowship. If it is ACGME certified, then 80-hours apply to it as well.

 

[XoQo]

Depends on the fellowship. If it is ACGME certified, then 80-hours apply to it as well.

Hmm. But i don't think any ACGME fellowships have lost accreditation as a result of not following the rule...have they?

Most fellows I have seen at my home institution are definitely above 80/week. And since their OR to scut ratio is definitely better than a GS residents -- it seems less likely that accurate hours are actually being recorded, and less likely fellows would be willing to give up their training time.


thoughts?

 

[SocialistMD]

Hmm. But i don't think any ACGME fellowships have lost accreditation as a result of not following the rule...have they?

Most fellows I have seen at my home institution are definitely above 80/week. And since their OR to scut ratio is definitely better than a GS residents -- it seems less likely that accurate hours are actually being recorded, and less likely fellows would be willing to give up their training time.


thoughts?

I don't know the answer to your first question. I know that our peds surg program was cited (not put on probation, just cited) for work hour violations and the call schedule was changed as a result. I know our fellows for everything else work basically the same schedule as our chiefs (or less for some fellowships), so they aren't really in danger of violations. It is easier to doctor your hours when you are always taking home call (which our peds fellows aren't), so there may be some truth in that, but you could make the same argument for residents fudging hours as well (again, something known to happen).

 

[Winged Scapula]

My thoughts on the misconception that if you don't see private practice surgeons in the hospital, the OR or their office, that they aren't working:

there is a heck of a lot of work in PP that you (as a medical student or resident) don't see. Even your academic surgeons have paperwork to be done, but in most cases they do not have the volume that a PP surgeon does.

For example, it is true that my days in the office are generally 8 - 5 seeing patients. But that doesn't mean that my work is over at 5 pm. Its 6 pm now and my last patient of the day just left...

1) she was scheduled for 4 pm, but showed up nearly a half hour late. In academics I could say, "F-her. Tell her to come back another day". In PP your actions toward patients can guide referrals and word of mouth. So I sent everyone home but the office manager. It was a new patient who needed a biopsy, so we are guaranteed about 45 minutes or more total with her. Add in the fact that she had not completed any of her pre-visit paperwork or scanned in her records, I didn't get in the room until around 4:45

2) but now all the patients are gone, so I can go home right? I could since we have an internet based EMR, but sometimes I choose to stay and do the work here.

That means...

a) I have to verify that all the H&P stuff entered into the EMR is correct. Yes, I trust my MA and most of the time it is correct, but the end product (a letter) has my name on it and I want it to be as detailed and correct as possible. So that may mean correcting a misspelling here or there, or adding in the 3 other surgeries that the patient forgot to list on the History form, and of course, putting my physical exam findings into the file.

2) Then I have to upload all the images I've taken from biposies or ultrasounds today to our server from the US machine and attach them to each patient's file.

3) Oh yeah...I'd better bill for the visit. We have people who do the billing but unless I put the codes in, no one knows what to bill for. Academic surgeons just place a few check marks on a sheet and then don't have to much worry whether or not the hospital gets accurately reimburse or at all. I do.

4) Let's see...that's done...now I have to return a few phone calls. Shouldn't take too long tonight because most people don't call on Fridays. Mondays seem to be the worst. I try to return them during the day but some patients aren't home or don't have cells and I can't call them at work, so I have to wait until after 5 or 6 pm to call them. But today a rep who is trying to sell us a cryo machine and a new type of vacuum assisted biopsy device called. So did the PI for a research project we're involved in. Oh yeah, and the Dean of the medical school returned my call about having some med students do some research with us.

5) While I'm at it, I now have to review my dictations. So as to limit the amount of data entry I and the staff do, I dictate all my assessment and plans. Sounds great, but you all have seen the crazy stuff that gets dictated...stuff you never said, misspellings, etc. I can't let that go out with my name.

6) Did I mention filling out forms from the insurance company? Usually the office manager can do it for me, but I always have to sign...at least most of the time they can use the stamper, but there are some things only I can do.

7) I didn't operate or do biopsies yesterday so there isn't any path to review, but there will be some back tomorrow, so I will spend part of the day doing the above, as well as calling patients with their path reports.

And so on it goes...I'm not even a practice owner yet...there will be even more responsibility and work when I am.

So just because you don't see us in the office, the OR on the hospital after 5 pm or before 8 am doesn't mean we aren't working.

 

[travoltage]

does anyone know where i can find unfilled gen surgery prelim spots per program...or at least explain to me how prelim works

 

[Amgen1]

Hmm. But i don't think any ACGME fellowships have lost accreditation as a result of not following the rule...have they?

Most fellows I have seen at my home institution are definitely above 80/week. And since their OR to scut ratio is definitely better than a GS residents -- it seems less likely that accurate hours are actually being recorded, and less likely fellows would be willing to give up their training time.


thoughts?

any fellowship that is ACGME approved is supposed to follow the 80hr work week. those programs get rrc visits just like the residency programs that are monitored by the rrc. whether or not the fellows follow those rules is probably just as variable as the residents that do/dont follow the rules.

there are however numerous non-acgme fellowships that exist, and they do not have any 80 hr work week.

 

[mytirf]

There are technical skills to be learned by repetition, which for some might validate the idea of spending every waking hour working (though the hour I once spent failing to place my 5th A line of the night- after hitting the first 3 flawlessly- might argue against that!). But personally I do find that things like moderate amounts of food, sleep, and exercise help for physical and intellectual stamina; these are all sacrificed when you're looking at having less that 48 hours a week for *everything* non-work related (as in the "good old days" of 120 hr weeks in surgery).

Interestingly enough, the studies that have looked at resident work hours, mistakes and exhaustion have found that technical skills are generally not as affected as much as mental skills such as diagnostic decisions. So there is something unique about repetition and possibly muscle memory etc., versus cognitive skills.

It is interesting listening to this discussion, given that some of the participants are medical students. No offense, but things do change when you are directly responsible for the patients that you care for. I'm not a surgeon, but when I admit a sick patient from the ED at 6pm I'm not just dropping them in the lap of my co-resident and signing out. It is not because I don't want to go home, or it's a great learning experience, but because I am the primary physician for that patient and their are relying on me for their care. I'm ambivalent about the 80 hour work week. I don't pay attention to it, for better or worse. In my program we do the work that needs to get done, take care of our patients, and get home as soon as is appropriate. Just my 2c.

-MT

 

[HouseHead]

From a resident perspective, don't go into surgery because the 80 hour work week has now made it bearable. <snip> You either love it and can't imagine doing anything else with your life, or you think its OK, but you like some other things equally as well. Do the other things. You will be happier, as will your wife and your children.

I haven't seen people choosing surgery BECAUSE of the 80 hr week. But I've seen people be ABLE to choose it because of that. By the time I start residency, I will have a 5 yo and a 2 yo, and as a mom I just couldn't do something- no matter how passionate I am about it- that did not allow me to spend any waking hours with my kids. As with the mom residents I've worked with, I don't expect to be making all my kids' recitals, but I do want to share a meal with them a few times a week.

I've tried, really tried, to love something else more, or even as much. But I really haven't even *liked* anything else, at least not enough to do it for the rest of my life (HATED EM, much to my disappointment!). I think that's the case for many people who go into surgery, especially those with families; even those without, from everything I've heard from residents.

80 hours has not made the time you dedicate to surgery less, it has simply switched where you dedicate your time. It used to be that you were in the hospital for 120 hours, learning there, seeing patients, etc. Now, reading isn't done in the hospital, but at home. Grand Rounds presentations are done at home, on my computer, fighting off my two year old who is trying to help me type!

That time home and awake is very valuable for your 2 yo. If
you were in the hospital for 120 hr weeks, s/he would not have that. That’s why I am ABLE to chose the field now.

Some posters seem to think that the MS posters have some romantic notion that all work ends at 80 hrs. Maybe some do. I have seen the hours spent writing up M&Ms in-house post-call, researching topics for last minute presentations, and just cleaning up loose ends- especially the chiefs- and I know that 80 is really just an ideal. But it is a FAR cry from what used to be. And the difference between the hours of different specialties has decreased, which really makes an impact on career decisions for many MS. (Attending hours are obviously different; my post-residency goals take that into account.)

Now, I am not saying you shouldn't do surgery, but thinking that the 80 hour work restrictions has made it more palatable is the wrong reason to do it. I thought long and hard before choosing surgery. I decided that it would take a lot of my time, but I would be miserable doing anything else. If I was miserable at work I would be miserable at home, too. I love what I do and I think that is a much better example for my children, even if they have less quantity of time with me. They see a happy parent and not a miserable one.

EXACTLY!

According to my husband, my surgery rotation was the only time in 3rd year that I wasn't a PITA to live with, because I was for once really happy and excited to be doing what I was doing.

Anyone who doesn't think long and hard about their residency choice is likely too young to know better!

 

[Castro Viejo]

The only times an attending was in the hospital after 5 PM were related to two circumstances a) an OR case (planned or unplanned) went very late or showed up in the ER late in the day or b) a patient was crashing or dying . This was also a rare occurrence. My preceptor's office opened at 8 AM and closed at 5 PM so no one was seeing patients at odd hours, either. Weekends consisted of rounding with one attending from each group of surgeons as well as with whoever wasn't on call but decided to come in to see their patients (not uncommon). The total time investment for each attending in this circumstance was probably an hour or so. Attendings took general service call approximately q10 and had a 1 in 2 chance of coming in for an incarcerated hernia or an appy. Very little trauma ever required the OR.

I'd guess that these surgeons worked, as a generous estimate, 60 hours a week and they all seemed to be doing very well for themselves.

Practice situations vary by institution and by group. What you saw at whatever hospital you were rotating through is, trust me, NOT typical of what a General Surgeon's day is like. What you probably may not have seen is that they're running to another hospital where they have privileges, or catching up on the mountains of bullcrap paperwork at the office, or just dealing with other crazyness in their lives. Sixty hours is unusual indeed.

 

[Castro Viejo]

Paging you to ask about rounding isn't a sign of laziness or weakness. It's a sign that you're not communicating with your students.

No, it's a sign that the medical student cares only about what revolves around him or her and not what his or her Chief Resident may be doing in or out of the OR. It's bullcrap that a student, who's so damn itchy to know when we're gonna round, can't ask the juniors, "Hey, where's Castro 'cause I'd like to speak with him," and proceed to the OR.

I wouldn't have as much of an issue with them actually coming to the OR (perhaps to watch the case and learn a thing or two?) than paging me while stationed in the call room or the floor just tapping their fingers away, "Oh where or where the hell is Castro to round?!"

YOU may not understand, but just wait until it's YOUR turn to start sewing in a graft during a AAA repair or doing the pancreaticojejunostomy and the circulator asks, "Dr. SLUser, the medical student would like to know when you're going to be out to round so he can go home."

I would bet a few four-letter words might just come out of your mouth.

 

[Castro Viejo]

Perhaps things are different at your program, and the options that I mentioned above are not possible. But that's how things were done at my rotation, so maybe it's the same at Castro's program as well.

I make rounds at 6AM every morning. We then have morning report with the service attendings from 7AM to approximately 7:30AM. Then I have to rush over to the preop holding area to introduce myself to the patient, make a note attesting to this fact, mark my patient, sign away my right to not get named in a lawsuit from the pending operation, and get the patient into the room promptly to get the case ready for the attending (who tend to stroll in by about 8AM since they know the standard MAFAT for 7:30AM cases tends to be about 30-45 minutes).

Then I'm in the OR for most of the day.

So I'm not really always around to "give direction" to medical students if they're gonna hang out on the floor all day.

But I'd argue, where the heck are they when we've got a billion cases going and everyone on the team is in the OR, including the PA?

This is what I've heard:

• "Updating the lab book."
• "Updating the list."
• "I was in on the other Chief's case."
• "I had asked the clerkship site director if it was okay for me to go to a [insert your favorite surgical subspecialty here] case, so that's where I was."
• "We had a meeting at school."
• "We had a lecture at school."
• "The school called us back for some paperwork stuff -- you know how it is."

What really happened?

• They're sleeping in the call room.
• They're out in the parking lot smoking with the other med students from other services.
• They're out in the parking lot smoking with the ancillary staff.
• They're in the medical library studying for their shelf.
• They just didn't feel like showing up to work today.

It's hard to want to teach med students who do this consistently. I've been doing this for almost five years now and I can count the number of students I thought who really wanted this and really enjoyed the rotation. You don't have to want to be a surgeon when you come rotating with me, but at least try and learn as much as possible. Just because you wanna be a this doc or that doc, doesn't mean your ENTIRE medical education should be tailored to that.

HELL, I even took a Pediatric Endocrinology elective when I was a fourth year. Hated every minute of it but thought the review would be good for my boards, so I bit the bullet.

But anyway, I welcome medical students all the time into the OR. I'll even teach them how to tie and sew and stuff, no matter how much Anesthesia or the ancillary staff wants me to hurry the case up. I've even let a medical student fire a stapler. And I do get to know the ones who want to learn. The other ones, I really haven't the foggiest idea what their names were.

 

[Castro Viejo]

I bolded the relevant part of your post. You just sound like an angry petty tyrant that can no longer feel awesome for emotionally destroying your subordinates

It's not about destroying people willy nilly. It's about junior residents caring about their training, education, their patients, and the service.

It was seen as punishment if you were banned from the OR by your Chief or thrown off rounds. They were lessons learned well when I was an intern, and you knew not to do whatever it was that pissed your Chief Resident off.

If I were to take a junior off all his cases for the day or told him to leave rounds, he'd be HAPPY and ENJOY his day thinking he got off! So he learns nothing and never realizes that his infraction was really bad for the service or patient care.

And I'm not talking about small things. When I was a third-year medical student I saw a Generaly Surgery Chief Resident go nuts on the intern because the attending's name on the list was misspelled. Now THAT's a little overboard. I'm talking about things like NOT pre-rounding and when the Chief arrives for rounds, the patient's actively trying to have an MI and the intern knew NOTHING about it because he ignored his pager ("It's almost 6AM and we're gonna round, so I figured the floor can't possibly have anything important to tell me now.")

 

[Castro Viejo]

Hmm. But i don't think any ACGME fellowships have lost accreditation as a result of not following the rule...have they?

Most fellows I have seen at my home institution are definitely above 80/week. And since their OR to scut ratio is definitely better than a GS residents -- it seems less likely that accurate hours are actually being recorded, and less likely fellows would be willing to give up their training time.


thoughts?

It's tough to nail a fellowship on work hours violations as many fellows tend to take home call. So who's really doing the counting? The RRC comes by and the PDs submit whatever call schedule they've got made up for the month. And that's documentation that the fellow does about 60 hours during the work week and maybe another 12 hours on the weekends? What's home call? The fellow, if asked, may not even 'fess up to staying over 80 hours. I mean, part of it is the loss of anonymity. In a fellowship of one, if your program gets cited, guess who's the one who blew the whistle? And the other part of it probably has to do with the fact that by the time you're a fellow, hopefully you'll understand why limiting life and your career and patient care activities to 80 hours is very unreasonable.

Then again, maybe this will never sink in...

 

[SoCuteMD]

Practice situations vary by institution and by group. What you saw at whatever hospital you were rotating through is, trust me, NOT typical of what a General Surgeon's day is like. What you probably may not have seen is that they're running to another hospital where they have privileges, or catching up on the mountains of bullcrap paperwork at the office, or just dealing with other crazyness in their lives. Sixty hours is unusual indeed.

I understand that my n=1, but it seemed that these particular groups actually didn't work more than 60 hours/week. Most of the attendings did not have privileges at another hospital (this is actually something I asked about). Now, this particular hospital happens to have an excellent payor mix and I would put the trauma service at moderately busy, with most traumas easily handled by the residents. I know that the surgeons were not regularly staying in the office after it closed since my preceptor and I often locked up his office together. His two partners always left earlier than him and I'd listen to them sign out as they left.

I make rounds at 6AM every morning. We then have morning report with the service attendings from 7AM to approximately 7:30AM. Then I have to rush over to the preop holding area to introduce myself to the patient, make a note attesting to this fact, mark my patient, sign away my right to not get named in a lawsuit from the pending operation, and get the patient into the room promptly to get the case ready for the attending (who tend to stroll in by about 8AM since they know the standard MAFAT for 7:30AM cases tends to be about 30-45 minutes).

Then I'm in the OR for most of the day.

So I'm not really always around to "give direction" to medical students if they're gonna hang out on the floor all day.

But I'd argue, where the heck are they when we've got a billion cases going and everyone on the team is in the OR, including the PA?

This is what I've heard:

• "Updating the lab book."
• "Updating the list."
• "I was in on the other Chief's case."
• "I had asked the clerkship site director if it was okay for me to go to a [insert your favorite surgical subspecialty here] case, so that's where I was."
• "We had a meeting at school."
• "We had a lecture at school."
• "The school called us back for some paperwork stuff -- you know how it is."

What really happened?

• They're sleeping in the call room.
• They're out in the parking lot smoking with the other med students from other services.
• They're out in the parking lot smoking with the ancillary staff.
• They're in the medical library studying for their shelf.
• They just didn't feel like showing up to work today.

It's hard to want to teach med students who do this consistently. I've been doing this for almost five years now and I can count the number of students I thought who really wanted this and really enjoyed the rotation. You don't have to want to be a surgeon when you come rotating with me, but at least try and learn as much as possible. Just because you wanna be a this doc or that doc, doesn't mean your ENTIRE medical education should be tailored to that.

HELL, I even took a Pediatric Endocrinology elective when I was a fourth year. Hated every minute of it but thought the review would be good for my boards, so I bit the bullet.

But anyway, I welcome medical students all the time into the OR. I'll even teach them how to tie and sew and stuff, no matter how much Anesthesia or the ancillary staff wants me to hurry the case up. I've even let a medical student fire a stapler. And I do get to know the ones who want to learn. The other ones, I really haven't the foggiest idea what their names were.

I find it interesting that some residents seem to come across so many lazy med students. I've encountered a few this year. One of my classmates is alternately called "Ghost" and "Stealth" due to his activities (or lack thereof) on the wards. There were 4 of us on my general surgery rotation and we ALL worked our butts off. We all arrived at the hospital in time to preround before rounds at 6 AM; some did a better job of prerounding than others, but it always got done. We never paged the chief to ask to sign out, but our hours got so long (stretching to 15 hours or longer) that our course director decided that we could sign out to anyone who was present at 6 PM. This effectively limited our non-call days to 13.5 hours.

If you have a problem with medical students not going to the OR, might I suggest assigning cases or having them divide cases at sign out the night before? We were then responsible for the patients whose cases we scrubbed for the remainder of their hospital stay - everything from updating them on the list, prerounding, writing notes, doing afternoon chart checks, and following up on labs. It helped to take some "ownership" and I was always secretly pleased when one of the interns would ask me to update them on my patient.

 

[Castro Viejo]

There were 4 of us on my general surgery rotation and we ALL worked our butts off. We all arrived at the hospital in time to preround before rounds at 6 AM; some did a better job of prerounding than others, but it always got done. We never paged the chief to ask to sign out

God bless you guys.

If you have a problem with medical students not going to the OR, might I suggest assigning cases or having them divide cases at sign out the night before? We were then responsible for the patients whose cases we scrubbed for the remainder of their hospital stay - everything from updating them on the list, prerounding, writing notes, doing afternoon chart checks, and following up on labs. It helped to take some "ownership" and I was always secretly pleased when one of the interns would ask me to update them on my patient.

Been there, done that. I'm telling you, I've tried EVERYTHING in the last four and a half years of doing this.

I meet with the med students on their first day EVERY rotation, and I say the same things.

I want them to be in the OR when there's a major case. I want them to decide what cases they'd like to see the next day, divide them up equally, and read about them the night before. I want them to follow the patients they "operated on" for the rest of their hospital stay (i.e., write a note, follow studies, labs, and have the intern co-sign all orders). In return I'll teach them to tie, sew, and will let them do a chest tube or a central line should one come up if they demonstrate proficiency. And when they're done with their cases in the OR, I tell them to be on the floor helping the intern.

So I give them an out, right? I'm telling them they don't have to be on the floor at all. Just be in the OR and observe the case. Then follow the patient. I don't even really want them interacting with the intern who can't teach them anything. At least I can talk to them about this thing or that thing and make it rather educational for their shelf exam.

But other than the very first July med students, have any others followed these simple bylaws of the House of Viejo? No. They alternately tell me about some bullcrap rule about med student "work hours" from the home institution to "emergency" student affairs meetings by their Dean to the home base's Department of Surgery having some major "Grand Rounds" thing every week, JUST SO THEY CAN SKIP OUTTA WORK.

So I ignore them now, the minute they stop following those rules because I know it'll just end with me a little more frustrated over what the system's become and my psyche just wants to be zen when I'm in the OR or studying for my boards.

 

[smq123]

But I'd argue, where the heck are they when we've got a billion cases going and everyone on the team is in the OR, including the PA?

What really happened?

• They're sleeping in the call room.
• They're out in the parking lot smoking with the other med students from other services.
• They're out in the parking lot smoking with the ancillary staff.
• They're in the medical library studying for their shelf.
• They just didn't feel like showing up to work today.

Sorry to hear that you had such crappy med students. I'm sure that you were bluntly honest on your evals - if a med student isn't working hard, then PDs deserve to know that. Even if you're not going into surgery, your performance on your gen surg rotation, in my opinion, demonstrates your work ethic.

I know it doesn't make a difference to you - since this is your last year - but some suggestions to other residents who read this and have issues with lazy students:

• "Updating the lab book."
• "Updating the list."

Tell them that you appreciate them taking the initiative, but you'd rather update the list and lab books at PM signout - i.e when the whole team is around to know what's going on.

That seems like such a risky lie, though - "Uhhh...you said you updated the signout list, but...it looks EXACTLY the same as it did this morning!?!"

• "I was in on the other Chief's case."

Have the students divide up cases in the AM, just as SoCuteMD suggested. Then you should know where each student is.

If this is really what students are doing though - scrubbing in on other service cases - this is sheer BS. They're taking away a case from another student who was actually assigned to that Chief, and I hated that. If I'm on plastics, and you're on general, just waltzing in and scrubbing in on the TRAM flap that I was supposed to scrub in on makes me look bad and makes you look like a selfish gunner. Bad idea.

Also, this again seems like a risky lie - "Hey, I bet you were glad that one of my med students helped you with that breast reduction today, huh?" "What? I did the case with my resident and the PA. What med student?"

• "We had a meeting at school."
• "We had a lecture at school."

While this sounds draconian, have one of the med students photocopy their lecture schedule and hang it in the call room/locker rooms. They did this on our ob/gyn rotation, and it helped both the students and the residents - the residents would be aware of when we had class, so they didn't hold us in the OR when they knew we needed to go, and the residents also knew that we wouldn't lie to them about having class or meetings.

 

[Pir8DeacDoc]

I am often surprised about the work ethic and sense of entitlement that many students seem to show. However, I think sometimes as residents we forget how much "stuff" the clerkship directors try and squeeze in to that 8 week window. I know our students have oral exams, written exams, lectures, etc. It's much more about education for them than work, which is as it should be. That mindset changes as a resident when it's much more about work and hopefully somehow education works its way in along the way. I appreciate that the students want to study for their shelf or oral exam and I think if things are slow it's a nice time to let them do that.

What drives me nuts is when I'm told "oh I didn't want to go to that lap chole as I've already seen one of those so I didn't think it would be educational" HUH? I learn something every single time I walk into an OR. As soon as I think I have something figured out and mastered, I'm sure to f&$k it up. Plus, how can a student decide what is and isn't educational? For me as a student I could rarely see what was going on and sometimes had only vague ideas exactly what the surgeons were doing, but I was damn sure in the OR until all the cases were done. People seemed to appreciate that.

We as residents have a duty to help and teach the students to do a good job, but if you don't act at all interested then don't expect me to care either.

 

[BlondeDocteur]

I don't know the answer to your first question. I know that our peds surg program was cited (not put on probation, just cited) for work hour violations and the call schedule was changed as a result. I know our fellows for everything else work basically the same schedule as our chiefs (or less for some fellowships), so they aren't really in danger of violations. It is easier to doctor your hours when you are always taking home call (which our peds fellows aren't), so there may be some truth in that, but you could make the same argument for residents fudging hours as well (again, something known to happen).

The peds fellows at our program-- which I believe is exceptionally busy, though I obviously have a n of 1-- are q2, in house, for the entire two years of their fellowship. And they operate *a lot* at night.

 

[BlondeDocteur]

I've loved every minute of general surgery, and was blessed as a student to have a great cadre of residents. But talking with the intern is a very different game than talking with the senior/chief. The intern is busy juggling the list and mastering perioperative care; it's the senior who can really discuss the fine point of surgery, can really teach, and who is a joy to go into the OR with.

I for one think it's great that some of the old notions of hierarchy are breaking down. I've learnt a tremendous amount from seniors who didn't think it was beneath them to teach me.

 

[Blade28]

I for one think it's great that some of the old notions of hierarchy are breaking down. I've learnt a tremendous amount from seniors who didn't think it was beneath them to teach me.

 

[DNASplicer]

I have mixed emotions about the 80 hr work week too.

Good example:
I had ONE bad run in with a very bad senior resident post call. He is transferred from a different program - doesn't know what we Turns go through when we are on call. He got abusive towards me and I was able to stick up for myself (b/c of the 80 hr work week). As I got to know him (for the jerk he is) I have NO PROBLEM telling him what I think. BUt I am a very hard worker, and have much respect for the top-down order of things in surgery... but I also deserve respect.

However, I think the rules have gone out of control. If I need to take care of something for my patient... I don't sign it out to the on-call person... I don't think that's what they are there for. I have a lot of respect in the job I do and I do not appreciate having to run around and hide while trying to do it. I also don't like upper level residents telling me to 'get out of the hospital'. Cause you know they talk about you if the job's not done. AND your patient is not well taken care of.

I think it is a hard spot. I would routinely go over my hours weekly just to get a chance to get into the OR. Hey... I'm the one that is working with this steep learning curve. I HAVE to have basic OR skills by next year... and it ain't gonna happen by WATCHING!

 

[SocialistMD]

The peds fellows at our program-- which I believe is exceptionally busy, though I obviously have a n of 1-- are q2, in house, for the entire two years of their fellowship. And they operate *a lot* at night.

That is a clear work-hours violation. If they submit an in-house q2 call schedule to the ACGME they will be, at the very least, looking at probation because of the length of time this rule has been in place. Our fellows take in-house call q7. They take home call with a moonlighting resident in house 2 nights a week (one night per fellow). The R-4 on service takes call two nights a week and a cross-covering R-3/4 covers the other night (with a fellow on backup/home call).

 

[Castro Viejo]

While this sounds draconian, have one of the med students photocopy their lecture schedule and hang it in the call room/locker rooms. They did this on our ob/gyn rotation, and it helped both the students and the residents - the residents would be aware of when we had class, so they didn't hold us in the OR when they knew we needed to go, and the residents also knew that we wouldn't lie to them about having class or meetings.

The thing is an enterprising medical student who wants to cut outta work will always find a way, NO MATTER THE COST. So unless they wanna learn, I don't see any poking or prodding is going to help.

When I was younger in the program as an R3 and R4 I did a lot of policing of medical students. Found out where they were, what they were up to, and generally keeping tabs on them at all hours. The end result was just an escalation in the elaborateness of the lies they told. "Risky" doesn't begin to describe some of the things these kids did.

One student who grew up in the Bronx, went to college in Upper Manhattan (non-gentrified Harlem), and at the time attended medical school in the roughest-ass part of Brooklyn. He never had an ounce of trouble in all those environments. Comes to rotate at my institution which arguably is the safest area of New York City, within two weeks of slacking at the rotation, one day DISAPPEARS from the hospital in the middle of the morning. Around 10AM. "Where they heck did the med student go?" "I dunno. I haven't seen him around since the morning."

This was the week leading up to the shelf exam.

He comes back at the end of the week. Just pops up on rounds one day in the morning around 6:30AM (we start at 6AM).

"Where the hell have you been?"

"Oh, Dr. Viejo, you wouldn't believe it. The other day after M&M I went outside to get something at my car. I parked it on that street," which is a big, broad avenue with constant traffic in front of the hospital, oh and by the way, we have a parking lot for all the staff including medical students, "and when I went to my car I got jumped by these two guys. They beat me up, broke my nose and everything. Afterwards I just wigged out and went home and I've been just stunned and shell shocked the whole week."

Please. Great story. Stuff of legends. But I don't believe a single friggin' word.

So when I hit this year and my responsibilities and paperwork all of a sudden started piling up, I decided I couldn't police everyone. Not even interns all the time. So I rely on the R4s and R3s to do that. Obviously it hasn't gone exactly to plan.

Some of these medical students are second-career people, in their mid 30s (older than me generally) who WANTED to switch careers and go into medicine, and this is how they're going to behave on rotation? Yeah right. Why are they worth my time if they don't care enough about themselves and THEIR education and training?

Last night the R3 and I took someone to the OR for dead gut. During the case I talked the R3 through it but also involved the medical student. It was sometime around midnight this case went. The medical student had NO interest whatsoever. Kept yawning. Kept talking to the tech. Kept talking to the Anesthesia resident (who was kinda hot, but still...). I mean, c'mon! As a medical student I would've loved it if a resident talked to me about every little thing that happened during the case. I even got on the R3s ass a bit about how he tied... All to make it a little more fun (mainly for me) for everyone who wanted to sleep (mostly me). I even let the med student fire the GIA and stitch something. I think that's kinda neat.

But he kept talking and talking. So I asked him to leave the case if he wasn't interested and go back up to the floors. He scrubbed out without a word. The intern said the med student never went to the floors. My guess is that he went to the callroom to sleep. Big surprise.

 

[Castro Viejo]

We as residents have a duty to help and teach the students to do a good job, but if you don't act at all interested then don't expect me to care either.

Right on.

 

[HouseHead]

Last night the R3 and I took someone to the OR for dead gut. During the case I talked the R3 through it but also involved the medical student. It was sometime around midnight this case went. The medical student had NO interest whatsoever. Kept yawning. Kept talking to the tech. Kept talking to the Anesthesia resident (who was kinda hot, but still...). I mean, c'mon! As a medical student I would've loved it if a resident talked to me about every little thing that happened during the case. I even got on the R3s ass a bit about how he tied... All to make it a little more fun (mainly for me) for everyone who wanted to sleep (mostly me). I even let the med student fire the GIA and stitch something. I think that's kinda neat.

Ok, now I wish I had the chance to do an away with you as chief...

 

[Hoo\/er]

No, I'm not surprised people want to have a life. I want to have a life too. But I have an obligation to my patients and to my team to help out as much as I can before I even begin thinking of going home.

It's also becoming more and more firmly established that since the implementation of ACGME work hour rules, medical ERRORS and patient MORTALITY have NOT improved. So you can subjectively believe that working more than 80 hours per week is going to negatively impact patient care, but the data wouldn't support your claim.

And you can subjectively believe that working more than 80 hours per week is going to positively impact patient care? Where's that data?

Blah blah ...patient care... blah blah. Just more brainwashed nonsense. They've trained you well.

 

[smq123]

I even let the med student fire the GIA and stitch something. I think that's kinda neat.

"Kinda" neat? That's really, really cool. And it's great that you let the med student stitch, even though it was very late and I'm sure you were ready to sleep. It would have been faster if you and the PGY-3 did it, but you still let the med student try it. That's fantastic.

Are you sure you want to go to Chicago? You wouldn't think about coming to Philadelphia for a bit and helping out some med students who REALLY want to become surgeons?

 

[Blade28]

Unfortunately, the average surgical resident/fellow/attending here on SDN is much kinder, friendlier, and more interested in medical student education than their non-SDN counterparts.

 

[smq123]

Unfortunately, the average surgical resident/fellow/attending here on SDN is much kinder, friendlier, and more interested in medical student education than their non-SDN counterparts.

This is true. (I've actually been very lucky in that regard, and had some amazing surgery residents and attendings who were naturally talented teachers. But I know that not everyone has been that lucky.)

So, I guess the moral of the thread is - if you're a student and you get a good resident/attending...don't mess up and waste the great opportunity!! And don't make your resident bitter and cynical (when it comes to trying to teach med students), and screw it up for the students that come after you.

P.S. Blade28 - you seem really into med student education. Have you thought about coming up to Philadelphia for fellowship? You'd be a rockstar among the med students!

 

[Castro Viejo]

Philly? Hmmm... I did rank one of the programs there higher in the match for Vascular Surgery actually. They had other plans.

Anyway, residents I think are always willing if the med student shows some interest and at least looks like he or she knows what they heck they're doing. It's kinda how the older attendings are like. You've gotta be the one who goes downstairs to the ED, does part of the workup, gets the patient ready for the OR, and in some cases, push the patient up to the OR yourself before they let you go to town on someone's belly. It's just the way it is, for better or for worse.

This medical student that was with me was always up my butt, however not in that brown-nosing way. He always wanted to learn. Always wanted someone to show him something -- anything -- and never got annoying about it. Asked appropriate questions. Helpful to everyone. Truly a gem from the local dump that sends their students to us. I don't know if he really wants surgery, nor does it really matter to me (he could go into EM if he wanted... ).

I think residents who don't teach may not want to because the attending might get annoyed with it, the gas passer attending may get annoyed, and sometimes the nursing staff belly aches because they wanna get out to their 15 minute breaks. Screw 'em.

 

[Blade28]

P.S. Blade28 - you seem really into med student education. Have you thought about coming up to Philadelphia for fellowship? You'd be a rockstar among the med students!

I am indeed very interested in med student education! Teaching is something I really enjoy - I was a TA for 3 years in high school and for all 4 years of undergrad.

Interestingly enough, my research/CT mentor here actually did his training in Philly, and is trying to get me to consider going there for fellowship.

 

[SoCuteMD]

Last night the R3 and I took someone to the OR for dead gut. During the case I talked the R3 through it but also involved the medical student. It was sometime around midnight this case went. The medical student had NO interest whatsoever. Kept yawning. Kept talking to the tech. Kept talking to the Anesthesia resident (who was kinda hot, but still...). I mean, c'mon! As a medical student I would've loved it if a resident talked to me about every little thing that happened during the case. I even got on the R3s ass a bit about how he tied... All to make it a little more fun (mainly for me) for everyone who wanted to sleep (mostly me). I even let the med student fire the GIA and stitch something. I think that's kinda neat.

But he kept talking and talking. So I asked him to leave the case if he wasn't interested and go back up to the floors. He scrubbed out without a word. The intern said the med student never went to the floors. My guess is that he went to the callroom to sleep. Big surprise.

Wow. Had I been asked to leave "if I wasn't interested" I think I would have DIED right then and there.

PS I WOULD HAVE LOVED TO FIRE THE GIA.

PPS I REALLY LIKE SUTURING

 

[Biscuit799]

And you can subjectively believe that working more than 80 hours per week is going to positively impact patient care? Where's that data?

Blah blah ...patient care... blah blah. Just more brainwashed nonsense. They've trained you well.

Exactly. I mean God forbid residents actually get some sleep. Why don't residents just not eat, I'm sure lunch hours take away otherwise valuable patient care time.

 

[Miami_med]

You know, the 80 hour work week is really a poor response to a problem that is really not going away. Residents are often used as a mechanism to keep dysfunctional hospital systems afloat. They put in twice the hours and work twice as hard as most of the staff for half of the pay after putting in twice as long in schooling. In many of the old school traditions, residents were treated like slaves by their attendings. In the past, they held some sway elsewhere in the hospital, but now the resident is often at the mercy of every lazy nurse and X-ray tech in the hospital. Attendings don't protect them, their programs don't protect them, and they are often hung out to dry.

The real problem is that these same inefficient hospitals impose unreasonable expectations on their residents. 80 hours was the random response to fears about patient safety in that environment. None of this came about because anyone actually cared about the residents. It is unfortunate that anyone would shirk responsibilty, as has become the norm, but the mechanism that they use to do it is the result of many generations of senior residents and attendings shirking their responsibility to nurture and guide those below them. It's not universal, but you know, a few bad apples....

It is unreasonable to expect that the resident will sacrifice all that he is to save the hospital, which will abandon him in a second, or the patients, who are often worse than the hospital. He should be treated with respect. He shouldn't have to worry about how he is going to feed his family, because he owes a lot of money and he is too busy filling out reams of unneccessary paperwork to find a side job that might actually make his loan payments. If the resident is expected to always be the one who takes care of everyone, someone should actually be taking care of the resident.

That being said, I always stay from beginning to end through all of my OR cases, I attend cases all day when they are scheduled, and I've been fortunate to work with many seniors who let me fire the stapler or throw the final sutures.

 

[ESU_MD]

Unfortunately, most students dont want to go into surgery.

I stopped tracking them down unless I need them to hold hook on cases. They are all grown-ups, and if they want to slack off, then I would rather not have them around.

On the other hand, there is nothing more fun than to have a student who loves surgery. I routinely will find some gomer for them to put a line in or something, at the very least. Someone in our SICU always has an indication for a bronch/BAL. and of course the students ALWAYS close the skin. staples are NEVER allowed when a student is in the OR, no matter what the gasman or OR staff says.

It will be interesting to see what happens with surgical education over time