How many hours do resident REALLY work??

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As a non-trad applying to med school, I'm leaving a corporate IT job where 80-90 hours is standard. In that field you put in the hours for nothing more than a paycheck at the end of the week. So the thought of putting in those hours for something that will affect my future career, and something that I'll learn from is a breath of fresh air.

Like I said I'm just applying to med school so these hours are completely different but long hours are standard in alot of corporate jobs too

 

[45408]

What do you think spurred tort reform?

I know what everyone says, but you keep dodging the question.

Well, obviously, that's an exception. I wasn't talking about outliers. I'm talking about the general rule.

It might be easy for you to parcel out some specialties into shifts (ER is clearly such a specialty), but I don't think it's as easy with surgical specialties.

 

[KnuxNole]

I DON'T agree that longer hours are good. Someone mentioned you learn MORE. LOL NO. I'd probably spend those extra hours counting down where I can go home and sleep. As far as learning goes, you learn a small amount at wards, but the bulk is at home anyway. I don't like the idea of longer than 24 hour shifts, primarily because of bad decision making and poor procedure techniques. If it's a 30 hour shift, but you can spend 12 or more hours not required to do much and just sit around, then maybe it's good, but otherwise, I can see tons of doctors not caring at all about their job and just pretending to work hard. I mean, there are tons of people who have this mentality with 12 hour shifts, imagine 30 😱

 

[JacobSilge]

As a non-trad applying to med school, I'm leaving a corporate IT job where 80-90 hours is standard. In that field you put in the hours for nothing more than a paycheck at the end of the week. So the thought of putting in those hours for something that will affect my future career, and something that I'll learn from is a breath of fresh air.

Like I said I'm just applying to med school so these hours are completely different but long hours are standard in alot of corporate jobs too

Long hours (70-90 hour weeks) are common in many other fields. Working 30 hours straight every 3-4 nights for long periods of time is not at all common outside of medicine.

That being said, I find this argument all the more strange because it isn't really about decreasing the number of hours worked, but rather reducing the length of shifts while maintaining the same number of hours. This shouldn't lead to back-loading of schedules for residents especially if interns continue to work nights and weekends at the rate that they previously had. The big losers from the current change are <i>small</i> surgical programs that don't have enough interns/residents to support a proper night float system. I've seen nightfloat work well in a large surgical program AND residents still complained about hitting 80 hours nearly every week.

 

[JacobSilge]

As far as learning goes, you learn a small amount at wards, but the bulk is at home anyway.

Don't take this the wrong way, but the only time this could be construed as being true would be during 3rd year, when you have to study for shelf exams for which your clinical time may or may not be completely relevant. However, when it comes to learning how to actually take care of patients, ward time is extremely high yield and there isn't much you can do at home.

 

[KnuxNole]

That's a good point, I guess that's how I feel now about 3rd year >__>

 

[Gabby]

I know what everyone says, but you keep dodging the question.

The question being what? You said this:

Back in the "old days," the residents worked more and did more cases, and they had a lot more autonomy. Attendings at some hospitals would just poke their head in to watch the chief do a fairly big case, but now that's very uncommon. I've never had one of my attendings leave until we were closing skin, and in med school, the only time I saw a big case being done without the attending was with a PGY-5 and PGY-6 doing a trauma.

I replied that I believe that's because people in the old days weren't as litigious as they are now and you want to see proof of that? Sorry, I don't have time to search for proof of something I believe to be common sense.

It might be easy for you to parcel out some specialties into shifts (ER is clearly such a specialty), but I don't think it's as easy with surgical specialties.

Which is why I said this, posts and posts ago:

I'm not going to dictate what surgeons should or shouldn't do because I know that there are marathon cases that you can't just scrub out of because you're off-duty. I'm talking more about other specialties.

You're arguing something that doesn't need to be argued.

 

[Law2Doc]

I DON'T agree that longer hours are good. Someone mentioned you learn MORE. LOL NO. I'd probably spend those extra hours counting down where I can go home and sleep. As far as learning goes, you learn a small amount at wards, but the bulk is at home anyway. I don't like the idea of longer than 24 hour shifts, primarily because of bad decision making and poor procedure techniques. If it's a 30 hour shift, but you can spend 12 or more hours not required to do much and just sit around, then maybe it's good, but otherwise, I can see tons of doctors not caring at all about their job and just pretending to work hard. I mean, there are tons of people who have this mentality with 12 hour shifts, imagine 30 😱

As a med student perhaps you learn more at home, and a lot of that is due to your holdover experiences from a predominantly classroom based education. But when you are a resident, you will see you learn almost zero at home. The wards are your classroom. You learn by doing, seeing. The training may be supplemented by reading up on things at home, but most of the time you will be learning things on the fly -- looking things up on uptodate or your PDA as you need them, never really sitting home with books. You will try to minimize what you are doing out of the hospital because hours out of the hospital are your own and very scant. There is huge learning value to following a patient longitudinally from admission or consult to discharge. (Sure there's scut you do along the way as well, but there's definitely a decent amount of value here as well). Shiftwork works great for fields where the average patient only stays for 5 hours or less (like EM), but makes less sense for a field where several days is the norm, because the windows to treatment are too small to learn much in terms of longterm care of a patient. Additionally for the surgical fields where operating room cases can be long, it's hard to get into a decent number of cases if the hours are short. So while nobody likes long hours, they are necessary during training.

As for 30 hour shifts, they can be high or low yield. I've had 30 hour shifts that were mad dashes where you spent the entire time living off adrenaline because all your patients were trying to die on you, and 30 hour shifts where you had time to get some reading done and just mind the fort. So the former was more of a learning opportunity than the latter, but I don't know that you can get the same former experience without stomaching a handful of the latter. I think the bulk of residents don't sit around not caring about their job and pretending to work hard, because to some extent every day in residency is an eye opening experience as to how much you have to learn. It's more humbling than anything else. Maybe 20 years down the road it becomes routine, but most residents are not at that stage yet. It's only my two cents, but I think you see things very differently once you get to residency and the patients become your responsibility. Even though I felt like I saw what residents did all night when I was a med student, it was very, very different when it was me. It's anything but boring, going through the motions.

I don't think you can make a serious argument that you aren't learning anything during long shifts. You can argue that the learning is lower yield when you are at the end of a long call shift, but sometimes low yield is still a valuable experience (at least better than "no yield"). In the wards, "seeing more" is money in the bank. You aren't going to go home and learn medicine from a book. You do that in med school for foundation, but the real learning takes place once you get out of school and the book learning mentality. It's truly an apprenticeship -- you learn by doing, and working with folks more experienced than you. Every time you see a new situation, a new disease presentation, or do a different OR case, or resolve a new complication, you are learning. The fewer hours in the hospital, the less you come across these. To have enough experiences, you need to log enough hours during your training. Whether you get these quickly in 80 hour/week spurts, or whether you get these over more years of residency probably doesn't matter much, but before you can consider yourself trained, you need to log enough hours, get enough experiences under your belt.

 

[gravitywave]

The need for regular, daily sleep is overplayed.

Stockholm Syndrome ftw

It is a stupid practice to have people awake for 30 hours making decisions that affect people's health.

Saying, "oh, we have to" is an excuse for lack of planning/resources.

Just like staying awake for 30 hours before taking an exam. You planned poorly the last however many months if you are pulling cramming sessions that long.

There are doctors in other countries that are not forced to work 30+ hours. There is research out there showing that decision making is much worse and errors increase after staying awake that long. But hey, it's doable! And we train much better mistake prone physicians. Education first.

this and all your other posts in this thread are arguing points that no one argues about in the real world. Everyone acknowledges now that sleep deprivation leads to errors. the questions now are whether or not (1) the educational experience of the resident is somehow degraded by working less and in shorter shifts, and (2) the presumed reduction in errors that lead to bad patient outcomes are outweighed by the errors that are made because of more frequent hand-offs and a narrower scope of experience gained during residency.

in the absence of good data (good data we are almost certain never to get), the issue ends up dominated by qualitative arguments. this issue is not nearly as black-and-white as you want it to be.

 

[gravitywave]

As a med student perhaps you learn more at home, and a lot of that is due to your holdover experiences from a predominantly classroom based education. But when you are a resident, you will see you learn almost zero at home. The wards are your classroom. You learn by doing, seeing. The training may be supplemented by reading up on things at home, but most of the time you will be learning things on the fly -- looking things up on uptodate or your PDA as you need them, never really sitting home with books. You will try to minimize what you are doing out of the hospital because hours out of the hospital are your own and very scant. There is huge learning value to following a patient longitudinally from admission or consult to discharge. *snip*

i really agree with this, not because i've done it (i'm a first year still) but because it intuitively makes a lot of sense to me. the attendings i've spoken to about this issue universally make the point that i've bolded in L2D's post - and i really don't think it's just because of the "effort justification" effect (although i don't deny that might be a factor.) I think they are honestly concerned about how the nature of the training affects the manner in which the resident will approach the work, particularly once they are out on their own as an attending.

someone else made the point above that they would much rather have a surgeon who hasn't been sleep deprived, and i agree - all things being equal. but that's not how it works. let's look at a potential situation in the real world: it's 2am, I need my appendix out, and the only surgeon available is one who's already been up for 21 hours straight. i'd rather have the surgeon who's done 1,000 appys literally in his sleep since residency than the one who's never had to function well in this type of scenario before because work hour restrictions robbed him of the experience he needed to be able to do well.

 

[MedStudentWanna]

i really agree with this, not because i've done it (i'm a first year still) but because it intuitively makes a lot of sense to me. the attendings i've spoken to about this issue universally make the point that i've bolded in L2D's post - and i really don't think it's just because of the "effort justification" effect (although i don't deny that might be a factor.) I think they are honestly concerned about how the nature of the training affects the manner in which the resident will approach the work, particularly once they are out on their own as an attending.

I don't think anyone argued that there isn't learning value if following a patient for admit to discharge. But what if the patient is there for five days. Are you going to say that whoever admitted him is required to stay up for five days straight to learn? There has to be a point where you say, even if I stay up that long, I won't learn a damn thing because physiologically, my mind wasn't meant to function on no sleep and that point is way before 30 hours. Sleep deprivation is real. This is basic science, folks. Some of you are willing to learn it in the first two years (and even spout it to your patients like hypocrites), then discard it for yourselves because of an ancient system that people have drilled into your heads can't be changed.

 

[gravitywave]

I don't think anyone argued that there isn't learning value if following a patient for admit to discharge. But what if the patient is there for five days. Are you going to say that whoever admitted him is required to stay up for five days straight to learn? There has to be a point where you say, even if I stay up that long, I won't learn a damn thing because physiologically, my mind wasn't meant to function on no sleep and that point is way before 30 hours. Sleep deprivation is real. This is basic science, folks. Some of you are willing to learn it in the first two years (and even spout it to your patients like hypocrites), then discard it for yourselves because of an ancient system that people have drilled into your heads can't be changed.

so there is learning value to following the patient continuously for 30 hours, but at the same time you claim you aren't learning anything in the 30th hour? you've contradicted yourself here, unless i misunderstood you.

it might be low yield time compared to the times when you plow through ten pages of Robbins in an hour and retain it well, but some skills can really only be learned well in one way: practice.

 

[Law2Doc]

I don't think anyone argued that there isn't learning value if following a patient for admit to discharge. But what if the patient is there for five days. Are you going to say that whoever admitted him is required to stay up for five days straight to learn?

You don't have to stay up for all 5 days. But if you are in the hospital a good chunk of that time, particularly in the first 24+ hours, that's pretty valuable. Thus in a 30 hour shift, the first 6 hours of admissions will be people you will cover for the initial, often most critical 24 hours. After that if they become "rocks" (ie patients who never move off of your list), you will see them on subsequent days and still have a good handle on what brought them in. You will find that on average the patient admitted at the end of your shift provides far less learning value/opportunity than that guy who you got at the beginning of your shift and you managed for the whole initial day.

There has to be a point where you say, even if I stay up that long, I won't learn a damn thing because physiologically, my mind wasn't meant to function on no sleep and that point is way before 30 hours. Sleep deprivation is real. This is basic science, folks. Some of you are willing to learn it in the first two years (and even spout it to your patients like hypocrites), then discard it for yourselves because of an ancient system that people have drilled into your heads can't be changed.

Sleep deprivation is real, but staying up one night every 4th or 5th nights is hardly impossible and certainly not as hard as some folks earlier on the path seem to think. Throwing around terms like "sleep deprivation", an inability to learn while tired, stockholm syndrome, drinking the koolaid, are all copouts, IMHO. You can still learn a lot when you are tired. You may be a bit punch drunk at times, but you absolutely come home having learned more than if you instead had a nice dinner, watched an hour of TV and went to bed early (which is what a lot of residents do whenever their schedules lighten up. It's really all about exposure after the second year of med school, not book learning. If you don't get exposed to things, it doesn't really matter how refreshed you are.

So the choices really truly are more hours or spread the residency over more years. You don't get exposed to enough otherwise. I think most people would opt for the intensity for a few years rather than drag things out. Even with crazy hours you still are going to be bumming that you missed seeing/doing X, Y and Z while you were postcall. When you are an attending, the exact same thing might walk in the door and unless you've seen/done it, you will feel unprepared. Until you get to residency, you only have a vague notion of how much you have to learn, see, do and how quickly the residency years fly by, with you getting that much closer to being an attending but not really feeling like you have a handle on everything you are going to need.

Nobody disputes the built in conflict. Your goal for training as a resident is going to be to see and do as much as you can as often as you can. Your goal outside of the hospital is obviously to get decent sleep, maintain interpersonal relationships, and have a life. These goals often conflict. The opportunity to be adequately trained is the one that slips away faster though. You miss a night's sleep, you still function and will make it up later. You miss learning how to do X, you might never get that opportunity back before it's your own license on the line (not some attending's).

 

[MedStudentWanna]

so there is learning value to following the patient continuously for 30 hours, but at the same time you claim you aren't learning anything in the 30th hour? you've contradicted yourself here, unless i misunderstood you.

No, I didn't contradict myself. You just misquoted me. What I said is that there is learning value in following a patient from admit to discharge. Ideally, patients would be admitted and discharged all within 20 hours and you'd learn a great deal. But that isn't how it works, so at some point, you have to realize that the value of learning is diminished by the fact that you're sleep deprived.

it might be low yield time compared to the times when you plow through ten pages of Robbins in an hour and retain it well, but some skills can really only be learned well in one way: practice.

And, of course, practice only happens in the middle of the night on your 28th hour of work.

 

[Law2Doc]

...
And, of course, practice only happens in the middle of the night on your 28th hour of work.

You are underestimating the value of following a patient longitudinally for a long stretch of hours (even if they are in the hospital even longer than that). You can often accomplish and learn a lot with a patient in 20-30 hours even if their recovery takes a bit longer.

And as for "the middle of the night", the learning opportunities at night are often better because you have a lot less back-up -- and so you really learn without a net. Most people feel that after a few rough nights alone in an ICU they feel more confident that they can handle anything, and will become unflappable. Which is a good example of something very useful that you will learn in residency that you cannot get out of books.

And just to nitpic, in most (probably all) cases on a 30 hour shift you are going to be working from one morning to the next day at lunch time. So your 28th hour would never fall in the middle of the night. A typical 30 hour shift would more likely be eg 6 or 7 am one day to noon or 1pm the next. In most cases your 28th hour would be around 10 am.

 

[MedStudentWanna]

Sleep deprivation is real, but staying up one night every 4th or 5th nights is hardly impossible and certainly not as hard as some folks earlier on the path seem to think.

Who said it was impossible? It's not impossible to jump off a 12-story building either. Doesn't mean it's advantageous to do it.

Throwing around terms like "sleep deprivation", an inability to learn while tired, stockholm syndrome, drinking the koolaid, are all copouts, IMHO.

Why are they copouts? I honestly do believe that some have been so brainwashed by the theory that a doctor has to work these hours in order to be competent that they'll spout it, whether it's true or not.

You can still learn a lot when you are tired. You may be a bit punch drunk at times, but you absolutely come home having learned more than if you instead had a nice dinner, watched an hour of TV and went to bed early (which is what a lot of residents do whenever their schedules lighten up. It's really all about exposure after the second year of med school, not book learning. If you don't get exposed to things, it doesn't really matter how refreshed you are.

And exposure only happens on 30-hour shifts? As someone said earlier in this thread, you'd be exposed to lots of new things if you work the entire week, never sleep, eat, or go to the bathroom. Never miss a moment. So why don't we expect that if the goal is learning? Why is there a line drawn when the goal is exposure/learning?

So the choices really truly are more hours or spread the residency over more years. You don't get exposed to enough otherwise.

Outside of surgical specialties at major trauma centers and academic hospitals, I'd like to see some literature that says that. So far, I've only heard it from old-school docs and residents who believe them.

I think most people would opt for the intensity for a few years rather than drag things out.

I think most people would opt for one year of med school, living at school and never sleeping to get it over with. Doesn't mean it's the right thing to do.

Even with crazy hours you still are going to be bumming that you missed seeing/doing X, Y and Z while you were postcall. When you are an attending, the exact same thing might walk in the door and unless you've seen/done it, you will feel unprepared.

Again, you will never learn everything. So why not fight to make residency a life endeavor and require that residents go back to living in the hospital and never sleeping for fear that they may miss something?

Nobody disputes the built in conflict. Your goal for training as a resident is going to be to see and do as much as you can as often as you can.

And someone has determined that "often as you can" is a max of 80 hours a week.

You miss a night's sleep, you still function and will make it up later. You miss learning how to do X, you might never get that opportunity back before it's your own license on the line (not some attending's).

We're not talking about a night's sleep. Some residents are on call q3 for years. That isn't just one night's sleep. It builds up and it does damage your health.

 

[gravitywave]

No, I didn't contradict myself. You just misquoted me. What I said is that there is learning value in following a patient from admit to discharge. Ideally, patients would be admitted and discharged all within 20 hours and you'd learn a great deal. But that isn't how it works, so at some point, you have to realize that the value of learning is diminished by the fact that you're sleep deprived.

And, of course, practice only happens in the middle of the night on your 28th hour of work.

ideally, shmideally. the only way to practice that 28th hour is to live it. better to get that experience as a student doctor, than as an attending potentially functioning in the community with no backup. some of these folks do have to do that sometimes, even as attendings 😱 although i recognize that few of us could work effectively for five days straight, i do think there is something to what L2D has said about following someone for that whole first day. you'd see the whole diurnal rhythm.

for what it's worth, i support the old 80 hour rules because they curbed the programs that were clearly abusing residents to the point that people (patients and residents both) were dying. i am leary of the new regs, particularly the ones that restrict PGY-1s to 16 hour shifts.

@L2D: i was referring to Stockholm Syndrome in the context of your statement that the importance of good sleep was overplayed. it's not. the question as i see it, is whether or not the sleep deprivation is worth it from the perspective of good patient outcomes and physicians' professional development.

 

[MedStudentWanna]

You are underestimating the value of following a patient longitudinally for a long stretch of hours (even if they are in the hospital even longer than that). You can often accomplish and learn a lot with a patient in 20-30 hours even if their recovery takes a bit longer.

So have residents work 20 hours instead of 30.

And as for "the middle of the night", the learning opportunities at night are often better because you have a lot less back-up -- and so you really learn without a net. Most people feel that after a few rough nights alone in an ICU they feel more confident that they can handle anything, and will become unflappable. Which is a good example of something very useful that you will learn in residency that you cannot get out of books.

It's not like residents will never work nights if there's a change made. It's not like suddenly, residency becomes a 9-5 job. It's just that at 4 a.m. when you're "flying without a net," you will have only been up 8 hours instead of 28.

 

[Law2Doc]

...
It's not like residents will never work nights if there's a change made. It's not like suddenly, residency becomes a 9-5 job. It's just that at 4 a.m. when you're "flying without a net," you will have only been up 8 hours instead of 28.

Well the problem with this is that the dude who has already followed a patient for 20 hours at 4am is far less likely to not be familiar with the patient, and what has been tried before and what the plan is than someone fresh and rested who gets handed the pager and a list of cross coverage patients that evening. IMHO, and from experience, that is where the mistakes get made, not because you are tired. You don't really know the patients because you just got there and somebody in a rush to go home gave you a crummy sign out is far more dangerous than you being tired. There has to be a happy medium, and even if you argue that 30 hours isn't it, a stronger argument can be made that reducing hours to the point that there's an additional handoff each day is far more likely to create dangers for the patients. Every time you have a handoff, things get dropped, errors creep into the system. Someone who is groggy but has been there still knows the patient. You try to find a balance but the right balance both for educational purposes and for patient care unfortunately tends to be to have someone there a long stretch.

 

[Perrotfish]

And as for "the middle of the night", the learning opportunities at night are often better because you have a lot less back-up -- and so you really learn without a net. Most people feel that after a few rough nights alone in an ICU they feel more confident that they can handle anything, and will become unflappable. Which is a good example of something very useful that you will learn in residency that you cannot get out of books.
.

I've heard this often and never understood how it's an argument for a call system. I agree that it's important for the Intern to have a chance to manage the patient without someone to run to, but why is leaving the intern without backup related to making him work 30 hours in a row? If anything it seems like an Intern alone in the ICU would be the LAST person you'd want to be fighting sleep, he's barely competent to do the job when he's at his best. A night float system offers just as many opportunities for the Intern to be alone at night but with the advantage that he's also awake and alert.

Well the problem with this is that the dude who has already followed a patient for 20 hours at 4am is far less likely to not be familiar with the patient, and what has been tried before and what the plan is than someone fresh and rested who gets handed the pager and a list of cross coverage patients that evening. IMHO, and from experience, that is where the mistakes get made, not because you are tired. You don't really know the patients because you just got there and somebody in a rush to go home gave you a crummy sign out is far more dangerous than you being tired. There has to be a happy medium, and even if you argue that 30 hours isn't it, a stronger argument can be made that reducing hours to the point that there's an additional handoff each day is far more likely to create dangers for the patients. Every time you have a handoff, things get dropped, errors creep into the system. Someone who is groggy but has been there still knows the patient. You try to find a balance but the right balance both for educational purposes and for patient care unfortunately tends to be to have someone there a long stretch.

And again, if this is the case, why does it only apply to Interns and some senior residents? If thegoal of medicine is to minimize handoffs, why do attendings everywhere, even in private practice where there are no Interns for continuity, go home after 8-16 hours at work? They have the exact same issues: handoffs whenever they leave vs exhaustion if they stay. So why is it only one year (maybe two or three), out of our entire lifetime of practice, when handoffs are suddenly such a priority that we can't possibly allow them?

In any event, I hope that I won't be dealing with opinions of every Patty Hurst who has convinced themselves that this institutional abuse is for a good cause. By this time next year those opinions should have drowned in a sea of hard facts. I'm aware that the plethora of programs that have already switched to night float systems without any increase in patient morbidity weren't enough to convince some physicians that sleep deprivation is at least as important as handoffs. Neither was that fact that many foreign medical training systems get along fine without call. However I'm still hoping that when the entire United States has the exact same resullts, and patients under a night float system keep on dying at a rate that is, at least, no worse than we experienced with the old system, that will finally silence even the worst call apologists.

 

[Law2Doc]

...
We're not talking about a night's sleep. Some residents are on call q3 for years. That isn't just one night's sleep. It builds up and it does damage your health.

If you do the math, unless you are getting postcall days off, you really can't have q3 with 24+ hour shifts for any real stretch without running afoul of the 80 hour average week and the average of 1 day off in 7 rules. So you will, in fact, have periodic respite to "catch up" even if you are q3, although you will be sleeping during the postcall day sometimes. And if things are quiet and you do get to catch some sleep during your call, you will potentially have more days off a week under this schedule than you would even on schedule with fewer call days. Which is why in some programs folks aren't upset with q3.

By contrast, if you are doing night float, which is a shorter shift, you are generally expected to do your sleeping during the day, and folks get annoyed if you hit the call room. The expectation when you move to shift work is that you stay up all night. So you may end up with fewer days off and even more tired, actually, if you aren't good at sleeping during daylight hours.

 

[45408]

I replied that I believe that's because people in the old days weren't as litigious as they are now and you want to see proof of that? Sorry, I don't have time to search for proof of something I believe to be common sense.

Oh, then it must be true. I just spent a good 15-20 minutes looking for any hard data showing a significant increase in malpractice claims. Other than lots of lawyer blogs and articles, there's not much out there, and it certainly doesn't show a dramatic change in the last few decades.

Even the US DOJ doesn't have much out there, and it shows interesting facts like the median award in a malpractice suit is $425,000, which is a lot less than the multi-million dollar jackpots we always hear about. http://bjs.ojp.usdoj.gov/content/pub/pdf/mmtvlc01.pdf

This study, which followed recent trends, doesn't say much at all about significant increases - http://en.wikisource.org/wiki/Medical_Malpractice_Insurance_Claims_in_Seven_States,_2000-2004

This report notes a decline - http://www.healthcarefinancenews.com/news/medical-malpractice-claims-frequency-declining-report-says

And I didn't find anything showing significant increases of late. The big changes apparently happened in the late 60s, early 70s, which was well before many of the changes really started happening.

 

[Slack3r]

U

ideally, shmideally. the only way to practice that 28th hour is to live it. better to get that experience as a student doctor, than as an attending potentially functioning in the community with no backup. some of these folks do have to do that sometimes, even as attendings 😱 although i recognize that few of us could work effectively for five days straight, i do think there is something to what L2D has said about following someone for that whole first day. you'd see the whole diurnal rhythm.

for what it's worth, i support the old 80 hour rules because they curbed the programs that were clearly abusing residents to the point that people (patients and residents both) were dying. i am leary of the new regs, particularly the ones that restrict PGY-1s to 16 hour shifts.

@L2D: i was referring to Stockholm Syndrome in the context of your statement that the importance of good sleep was overplayed. it's not. the question as i see it, is whether or not the sleep deprivation is worth it from the perspective of good patient outcomes and physicians' professional development.

Someone's been drinking the Kool Aid early...

 

[Law2Doc]

I've heard this often and never understood how it's an argument for a call system. I agree that it's important for the Intern to have a chance to manage the patient without someone to run to, but why is leaving the intern without backup related to making him work 30 hours in a row? If anything it seems like an Intern alone in the ICU would be the LAST person you'd want to be fighting sleep, he's barely competent to do the job when he's at his best. A night float system offers just as many opportunities for the Intern to be alone at night but with the advantage that he's also awake and alert.



And again, if this is the case, why does it only apply to Interns? If thegoal of medicine is to minimize handoffs, why do attendings in private practice work 12 hour shifts instead of 30 hour shifts? They have the exact same issues: handoffs whenever they leave vs exhaustion if they stay. So why is it only one year, out of our entire lifetime of practice, when handoffs are suddenly such a priority that we can't possibly allow them?

While I have no problem with night float, I have to say from experience that it's probably more tiring than overnight call. It's very hard to switch your internal clock and become nocturnal for eg X days in a row, only to have to snap back right after. Most people have trouble sleeping the first couple of days, and by the time they get into the swing of a night shift, have to switch back. Staying up all night one night but staying on the same basic "sleep at night" schedule is actually much easier on your body. Additionally, as mentioned, when you are there for a 12 hour shift, the attendings, nurses, etc reasonably expect you to be awake and working the whole time. May places don't even give you a call room key for night float. When you are there for a 30 hour stretch by contrast, the notion is that if nothing is going on, you are allowed to go to the call room and catch a nap. So you are probably better off sleep/alertness-wise on a call schedule than night float. A lot of this sounds like you'd like it better one way than the other until you actually get to live this life. There are definitely proponents of call vs night float and vice versa, but I don't think too many are lining up to say you are well rested on one versus the other, and if they do, it's probably the reverse of what your instinct is.

FWIW, the 30 hour shift wasn't limited to interns. Under the new rules it is only interns who cannot do the 30 hour shifts. Senior residents still are allowed to do long shifts, and in many specialties they do. Interns have the most to learn though, so there's always an argument that they need to log more hours in the hospital before they are useful than anyone else. As for attendings not doing 30 hours, I actually have several times had to call in attendings at all hours of the night, and they show up without having had any more sleep than I, but the only difference is they didn't necessarily leave at the end of 30ish hours as I was expected to. In many specialties the emergencies are not 9-5 affairs, and I'm sleep deprived is not an accepted response, even for an attending. In many specialties, getting those late night calls comes with the territory, and you signed on to jump into scrubs and come running when the residents get in over their heads, even if it means you end up working 40+ hours in a row.

 

[Perrotfish]

May places don't even give you a call room key for night float. When you are there for a 30 hour stretch by contrast, the notion is that if nothing is going on, you are allowed to go to the call room and catch a nap. So you are probably better off sleep/alertness-wise on a call schedule than night float. A lot of this sounds like you'd like it better one way than the other until you actually get to live this life. There are definitely proponents of call vs night float and vice versa, but I don't think too many are lining up to say you are well rested on one versus the other, and if they do, it's probably the reverse of what your instinct is..

I feel like the 'nap' thing is a disingenuous argument from you, considering that that you post, often, about the fact that you never, ever get a significant amount of sleep on call. That's sort of the key issue that's killing call: the call room has become an empty gesture, a legalism that allows program directors to pretend that call is something other than a 30 hours shift. Honestly if they're going to keep call, even for senior residents, I wish they'd get rid of the call room and say that everyone needs to work all 30 hours, rather than just making that the de facto arrgangement and suggesting that the residents sleep strategically during their down time (which doesn't exist). If they can't be reasonable employers they could at least be honest a$sholes.

FWIW I just finished a month of 12 hour night shifts. It wasn't a hard transition to make. There is no situation where sleep is somehow less restful than no sleep.

 

[Law2Doc]

I feel like the 'nap' thing is a disingenuous argument from you, considering that that you post, often, about the fact that you never, ever get a significant amount of sleep on call. That's sort of the key issue that's killing call: the call room has become an empty gesture, a legalism that allows program directors to pretend that call is something other than a 30 hours shift. Honestly if they're going to keep call, even for senior residents, I wish they'd get rid of the call room and say that everyone needs to work all 30 hours, rather than just making that the de facto arrgangement and suggesting that the residents sleep strategically during their down time (which doesn't exist). If they can't be reasonable employers they could at least be honest a$sholes.

FWIW I just finished a month of 12 hour night shifts. It wasn't a hard transition to make. There is no situation where sleep is somehow less restful than no sleep.

Yeah, I can't really argue with the first part. I never got significant sleep on call as an intern -- but I certainly know folks in other specialties who seem to. I do agree that it is amusing how many places show off their call rooms to residency interviewees like they are places interns will spend significant times in.

Almost everyone I know who did night float had a much harder transition than you described, though. I still think it's a wash as to which is "better" for interns and truthfully on a call night that you do get some sleep, albeit rare in some fields, you are better off.

 

[MedStudentWanna]

Well the problem with this is that the dude who has already followed a patient for 20 hours at 4am is far less likely to not be familiar with the patient, and what has been tried before and what the plan is than someone fresh and rested who gets handed the pager and a list of cross coverage patients that evening. IMHO, and from experience, that is where the mistakes get made, not because you are tired. You don't really know the patients because you just got there and somebody in a rush to go home gave you a crummy sign out is far more dangerous than you being tired. There has to be a happy medium, and even if you argue that 30 hours isn't it, a stronger argument can be made that reducing hours to the point that there's an additional handoff each day is far more likely to create dangers for the patients. Every time you have a handoff, things get dropped, errors creep into the system. Someone who is groggy but has been there still knows the patient. You try to find a balance but the right balance both for educational purposes and for patient care unfortunately tends to be to have someone there a long stretch.

If that's the case, then the number of errors would have gone up after the 80-week limit was imposed. It stayed the same.

 

[medigull]

And again, if this is the case, why does it only apply to Interns and some senior residents? If thegoal of medicine is to minimize handoffs, why do attendings everywhere, even in private practice where there are no Interns for continuity, go home after 8-16 hours at work? They have the exact same issues: handoffs whenever they leave vs exhaustion if they stay. So why is it only one year (maybe two or three), out of our entire lifetime of practice, when handoffs are suddenly such a priority that we can't possibly allow them?

Have you ever been around non academic medicine? You do know that physicians get called out right? You do know that surgeon called out at 3 am after a days worth of work, operates for 3 hours on the gun shot wound and has a days worth of cases starting at 7 stays and does that days worth of cases? You know that Pulm/CC guy who gets called out because something is going on in the ICU has to manage the situation and then if he's on his way home at 3 am and gets a call because a patient in the ER needs to be admitted he has to go back. I may be a MS1 but I know these situations are real I have seen them working at the hospital and with my father. The work doesn't end with residency and sometimes neither does the 30 hour day. It may just be a 12 hour day and 14 hour day with a 4 hour break at home. There are no handoffs they just take their downtime at home instead of sitting around the on call room or nurses station

 

[gravitywave]

Have you ever been around non academic medicine? You do know that physicians get called out right? You do know that surgeon called out at 3 am after a days worth of work, operates for 3 hours on the gun shot wound and has a days worth of cases starting at 7 stays and does that days worth of cases? You know that Pulm/CC guy who gets called out because something is going on in the ICU has to manage the situation and then if he's on his way home at 3 am and gets a call because a patient in the ER needs to be admitted he has to go back. I may be a MS1 but I know these situations are real I have seen them working at the hospital and with my father. The work doesn't end with residency and sometimes neither does the 30 hour day. It may just be a 12 hour day and 14 hour day with a 4 hour break at home. There are no handoffs they just take their downtime at home instead of sitting around the on call room or nurses station

truth. these studies that people are quoting are only part of the story, because they've only looked at errors by residents. the bigger question is whether or not we do well by our patients when we reduce the breadth and depth of experience their attendings get in residency.

 

[gravitywave]

If that's the case, then the number of errors would have gone up after the 80-week limit was imposed. It stayed the same.

errors didn't go down, either.

edit: patient outcomes didn't improve, anyway. which is really the measure we should be looking at.

 

[MedStudentWanna]

errors didn't go down, either.

edit: patient outcomes didn't improve, anyway. which is really the measure we should be looking at.

I'm well aware of that. So if nothing changed, why not go with a system that allows residents a little more rest?

 

[surftheiop]

I'm well aware of that. So if nothing changed, why not go with a system that allows residents a little more rest?

That wouldn't let people brag to all their (former) friends about how hardcore they are for enduring residency

 

[Gabby]

That wouldn't let people brag to all their (former) friends about how hardcore they are for enduring residency

I believe that deserves a round of applause for the best comment in this thread.

 

[Law2Doc]

I'm well aware of that. So if nothing changed, why not go with a system that allows residents a little more rest?

You are looking at it a bit differently than most. The original hypothesis was that all these errors were the result of sleep deprived folks. So that if hours were reduced, there would be fewer errors. In fact when hours got cut the errors didn't go down. The reason being either that sleep deprivation has nothing to do with errors (doubtful) or that there is another source of error (likely the handoff) that increases as you decrease the hours. So in fact what was proven was that a slight tinkering with the hours (to an 80 hours/week limit) didn't provide any benefit. Most suspect it's like a balance. If you lighten up on one side, the other takes more effect. Possibly something in the ballpark of 80 hours with 30 hour shifts is even balance. As we lighten up those requirements (eg getting rid of the 30 hour shifts) we will see if more errors in things like handoffs creep into the system and end up with worse results. There is often a cost of tinkering.

You have to decide what your goals are before you change things. If it was patient safety, which was the impetus for 80 hour limits after the Zion case, then it has been a complete and total failure -- errors havent' gone down. If it's giving residents a nicer schedule, then sure, maybe you accomplished something, but the cost there is that residents get less hours of training, which some feel is important.

 

[mrjohndaniels]

You are looking at it a bit differently than most. The original hypothesis was that all these errors were the result of sleep deprived folks. So that if hours were reduced, there would be fewer errors. In fact when hours got cut the errors didn't go down. The reason being either that sleep deprivation has nothing to do with errors (doubtful) or that there is another source of error (likely the handoff) that increases as you decrease the hours. So in fact what was proven was that a slight tinkering with the hours (to an 80 hours/week limit) didn't provide any benefit. Most suspect it's like a balance. If you lighten up on one side, the other takes more effect. Possibly something in the ballpark of 80 hours with 30 hour shifts is even balance. As we lighten up those requirements (eg getting rid of the 30 hour shifts) we will see if more errors in things like handoffs creep into the system and end up with worse results. There is often a cost of tinkering.

You have to decide what your goals are before you change things. If it was patient safety, which was the impetus for 80 hour limits after the Zion case, then it has been a complete and total failure -- errors havent' gone down. If it's giving residents a nicer schedule, then sure, maybe you accomplished something, but the cost there is that residents get less hours of training, which some feel is important.

I think this hits the nail on the head. Every change has been based around improving outcomes for patients, not giving residents a nicer schedule/lifestyle or more time to sleep. The problem with the new ACGME rules is that they are essentially made up. There is no evidence to suggest that these rules will actually improve patient safety. It's amazing to me that in every other aspect of medicine, we work so hard to make sure there is good evidence to support our decision making, but when it comes to this, we accept anecdotal ideas or weakly powered studies as support for change.

I've seen traditional overnight call systems and night-float only systems. Trust me, I liked sleeping more when I rotated in a night-float system, but the big problem is getting all the patients who came in the previous night in the morning and trying to figure out what is going on before rounds. It's like having to do additional H&Ps in the morning hours on top of preparing the patients you were already following. I think it's much more difficult to make good diagnoses and decisions when you don't have time to get to know a patient than it is to do it if you are available over the course of an entire day and night.

 

[MCAT guy]

.
You have to decide what your goals are before you change things. If it was patient safety, which was the impetus for 80 hour limits after the Zion case, then it has been a complete and total failure -- errors havent' gone down. If it's giving residents a nicer schedule, then sure, maybe you accomplished something, but the cost there is that residents get less hours of training, which some feel is important.

Same errors + more humane schedule. (Better language IMO. "Nicer" is making it sound like it is unreasonable to want to avoid 30 hour shifts that have proven to be a detriment to the resident's health and mental well-being).

So yeah, I'll take similar results with a more humane schedule over similar results with a work schedule that makes it dangerous to drive home after work, causes heart/digestive issues, and also can lead to depression.

Sleeping regularly is good, especially when we are creating the schedules years in advance. If that means all residencies are extended a year, I would be fine with that. Earning a few hundred thousand extra in a lifetime is more important than our health? Methinks not.

Oh and maybe we could spend a little more time with friends and family. That's not such a bad idea, is it?

 

[Droopy Snoopy]

Programs are capped with their number of residency positions. There is a set amount of work that needs to be done and a set amount of 'learnin' that needs to be accomplished, approximately 80 hours/week of it per resident. A program is going to get that 80 hours one way or another, so instead of having q3/q4 call and a day or two off during the week the program is going to call the post-call day the 'off day'. Thus you could find yourself working 12-hour+ days, every day of the week, for months on end - in complete compliance with ACGME regs. AND you'll see a cutback on electives in order to provide more coverage for the wards/OR/clinic/unit. There has already been a trend toward this in response to the 16-hour intern cap change.

Just sayin', be careful what you wish for.

 

[Law2Doc]

Same errors + more humane schedule. (Better language IMO. "Nicer" is making it sound like it is unreasonable to want to avoid 30 hour shifts that have proven to be a detriment to the resident's health and mental well-being).

So yeah, I'll take similar results with a more humane schedule over similar results with a work schedule that makes it dangerous to drive home after work, causes heart/digestive issues, and also can lead to depression.

Sleeping regularly is good, especially when we are creating the schedules years in advance. If that means all residencies are extended a year, I would be fine with that. Earning a few hundred thousand extra in a lifetime is more important than our health? Methinks not.

Oh and maybe we could spend a little more time with friends and family. That's not such a bad idea, is it?

But again, it's not a two variable system. It's not just patient safety versus nicer schedule. It's patient safety versus nicer schedule versus adequate training and so on. When you fix one thing at the expense of others that's not always a win. I think you really need to be clear what "the" goal is before you start tinkering, because you always have to potential to make some things better, some worse. The previous set of tinkering was explicitly for patient safety, which didn't work. As a side benefit you got nicer schedules, but most feel you lost something in the training. Now they are changing the 30 hour shifts. It's unclear what "the" goal is here. If it's patient error, I suspect they are again going to be coming up short. Either way, they are sacrificing some value in terms of following patients longitudinally. But I think changing things to make them more humane, and let residents spend more time with friends and family is only fine if you take the position that that is the goal and that you don't really care as much about the patient safety or training etc components or impact. Which again I don't think is what is happening here.

As for your willingness to extend residency a year to get an easier schedule, I think you are probably in the very very small minority.

 

[Law2Doc]

Programs are capped with their number of residency positions. There is a set amount of work that needs to be done and a set amount of 'learnin' that needs to be accomplished, approximately 80 hours/week of it per resident. A program is going to get that 80 hours one way or another, so instead of having q3/q4 call and a day or two off during the week the program is going to call the post-call day the 'off day'. Thus you could find yourself working 12-hour+ days, every day of the week, for months on end - in complete compliance with ACGME regs. AND you'll see a cutback on electives in order to provide more coverage for the wards/OR/clinic/unit. There has already been a trend toward this in response to the 16-hour intern cap change.

Just sayin', be careful what you wish for.

I think the result of shortening intern year shifts to a max of 16 hours is going to have the most impact on the PGY2 year, who will be asked to pick up the bulk of the slack. So you end up with two moderately painful years instead of one severely painful one.

 

[Laryngophed]

Programs are capped with their number of residency positions.

I thought the 'cap' was a soft one, in that CMS only funds so many positions. The hospital may hire more 'terns or residents, but they have to foot the bill, no?


Unrelated to Tic's post: My question arises from fields that manage to adequately train their docs on the less than 80 hours/week average, like EM. How is it possible that they train their learners with even more restricted hours (I feel like there is a formal cap of 72 hours/week averaged but I may have made that up, but having talked to a couple of EM residents it seems like they work closer to 60 hours/week averaged on service) while other fields can not manage the same. Is it simple enough to say that there is more to know in the 'other' fields?

ETA - For the record, I recognize that the plural of anecdote is not data and I'm having some trouble finding a reference for that work hour restriction within EM. I'm definitely willing to concede that I may have been making that up.

 

[mrjohndaniels]

I thought the 'cap' was a soft one, in that CMS only funds so many positions. The hospital may hire more 'terns or residents, but they have to foot the bill, no?


Unrelated to Tic's post: My question arises from fields that manage to adequately train their docs on the less than 80 hours/week average, like EM. How is it possible that they train their learners with even more restricted hours (I feel like there is a formal cap of 72 hours/week averaged but I may have made that up, but having talked to a couple of EM residents it seems like they work closer to 60 hours/week averaged on service) while other fields can not manage the same. Is it simple enough to say that there is more to know in the 'other' fields?

ETA - For the record, I recognize that the plural of anecdote is not data and I'm having some trouble finding a reference for that work hour restriction within EM. I'm definitely willing to concede that I may have been making that up.

I think it has more to do with the nature of the work. EM is shift work by nature. You don't follow patients longitudinally, as opposed to a medical or surgical field where patients get admitted and become your patient until they're discharged. In EM, you assess the patient, treat their acute conditions and stabilize them as much as possible for admission or discharge. In radiology, as another example, you read the studies that are performed, but you don't have the responsibility of following the patient over time. It's not that there is less to learn, it's that your duty to the patient that is different. I think this is the reason they are able to adhere to regulations more easily.

 

[Alvarez13]

You are looking at it a bit differently than most. The original hypothesis was that all these errors were the result of sleep deprived folks. So that if hours were reduced, there would be fewer errors. In fact when hours got cut the errors didn't go down. The reason being either that sleep deprivation has nothing to do with errors (doubtful) or that there is another source of error (likely the handoff) that increases as you decrease the hours. So in fact what was proven was that a slight tinkering with the hours (to an 80 hours/week limit) didn't provide any benefit. Most suspect it's like a balance. If you lighten up on one side, the other takes more effect. Possibly something in the ballpark of 80 hours with 30 hour shifts is even balance. As we lighten up those requirements (eg getting rid of the 30 hour shifts) we will see if more errors in things like handoffs creep into the system and end up with worse results. There is often a cost of tinkering.

You have to decide what your goals are before you change things. If it was patient safety, which was the impetus for 80 hour limits after the Zion case, then it has been a complete and total failure -- errors havent' gone down. If it's giving residents a nicer schedule, then sure, maybe you accomplished something, but the cost there is that residents get less hours of training, which some feel is important.

I've heard the less training overall argument many times. In order to have a better schedule though, you'd have to cut some of those hrs off.

Have you ever heard anything about extending residency (don't kill me😱)? What if you did another year or however long of residency and just got paid at a higher level? Like a post-residency position at 100k oposed to the 50k intern and the 200 k attending. You'd have better hrs, a decent salary to get those loans down, and more time to learn. The hospital would get a more expereinced worker and not have to pay them as much as a full attending.

Just trying to come up with other ideas...My impression is that a lot of people want to do 120 hr/wk residencies and get over with them ASAP to start making the realy $ earlier.

 

[Gabby]

You are looking at it a bit differently than most. The original hypothesis was that all these errors were the result of sleep deprived folks. So that if hours were reduced, there would be fewer errors. In fact when hours got cut the errors didn't go down. The reason being either that sleep deprivation has nothing to do with errors (doubtful) or that there is another source of error (likely the handoff) that increases as you decrease the hours. So in fact what was proven was that a slight tinkering with the hours (to an 80 hours/week limit) didn't provide any benefit. Most suspect it's like a balance. If you lighten up on one side, the other takes more effect. Possibly something in the ballpark of 80 hours with 30 hour shifts is even balance. As we lighten up those requirements (eg getting rid of the 30 hour shifts) we will see if more errors in things like handoffs creep into the system and end up with worse results. There is often a cost of tinkering.

You have to decide what your goals are before you change things. If it was patient safety, which was the impetus for 80 hour limits after the Zion case, then it has been a complete and total failure -- errors havent' gone down. If it's giving residents a nicer schedule, then sure, maybe you accomplished something, but the cost there is that residents get less hours of training, which some feel is important.

Your post doesn't change anything at all. Regardless what the reason was, if residents can go from working over 100 hours a week to working 80 hours a week without it changing patient safety, then what's wrong with sticking to 80 hours a week?

 

[mrjohndaniels]

Same errors + more humane schedule. (Better language IMO. "Nicer" is making it sound like it is unreasonable to want to avoid 30 hour shifts that have proven to be a detriment to the resident's health and mental well-being).

So yeah, I'll take similar results with a more humane schedule over similar results with a work schedule that makes it dangerous to drive home after work, causes heart/digestive issues, and also can lead to depression.

Sleeping regularly is good, especially when we are creating the schedules years in advance. If that means all residencies are extended a year, I would be fine with that. Earning a few hundred thousand extra in a lifetime is more important than our health? Methinks not.

Oh and maybe we could spend a little more time with friends and family. That's not such a bad idea, is it?

Have you ever actually done a q3 or q4 call month? It's not as detrimental to your well-being as you make it sound (assuming you have basic organizational competencies). At first, you have to learn how to adjust, but I found it easier to exercise, spend time with family, and maintain a more normal lifestyle during call months where I was guaranteed to go home by noon post-call than I did when I did a rotation with a night-float and had to stay 12 - 16 hours in the hospital every day. It also won't last forever. You won't suffer an MI because you spent 10 months of your life during intern year on call. The reality of the world is that some occupations by the nature of their work have hours that are not ideal. We're one of them. Get used to it.

I also would never want to prolong residency another year. I went into med school straight out of college, but for people who waited a few years, it would make a big difference to prolong the start of their career. As it is, a 26 year-old completing a 5 or more year training period will be in his/her early 30's when they start practice. A 30 year-old will be in his/her mid-late 30's. Assuming one practices until age 65, some people may not be able to work 30 years as it is. The present value of a few hundred thousand dollars actually matters for them, especially if their education was financed off of loans.

I'm pretty sure I have an excellent relationship with all of my family, my wife, and friends. I make sacrifices but make up for it by utilizing the time I do have. I don't think that a non 30-hour call schedule will change this.

 

[Gabby]

Programs are capped with their number of residency positions. There is a set amount of work that needs to be done and a set amount of 'learnin' that needs to be accomplished, approximately 80 hours/week of it per resident. A program is going to get that 80 hours one way or another, so instead of having q3/q4 call and a day or two off during the week the program is going to call the post-call day the 'off day'. Thus you could find yourself working 12-hour+ days, every day of the week, for months on end - in complete compliance with ACGME regs. AND you'll see a cutback on electives in order to provide more coverage for the wards/OR/clinic/unit. There has already been a trend toward this in response to the 16-hour intern cap change.

Just sayin', be careful what you wish for.

Then they'd have to get rid of the one-day-off-in-seven rule too and I don't see that happening. I can tell you that everyone should be in fear of me working 30 hours and making critical decisions. I know myself and my mental cognitive functions just aren't there when I go 24 hours without sleep.

 

[Gabby]

I thought the 'cap' was a soft one, in that CMS only funds so many positions. The hospital may hire more 'terns or residents, but they have to foot the bill, no?


Unrelated to Tic's post: My question arises from fields that manage to adequately train their docs on the less than 80 hours/week average, like EM. How is it possible that they train their learners with even more restricted hours (I feel like there is a formal cap of 72 hours/week averaged but I may have made that up, but having talked to a couple of EM residents it seems like they work closer to 60 hours/week averaged on service) while other fields can not manage the same. Is it simple enough to say that there is more to know in the 'other' fields?

ETA - For the record, I recognize that the plural of anecdote is not data and I'm having some trouble finding a reference for that work hour restriction within EM. I'm definitely willing to concede that I may have been making that up.

Exactly! I'm so sick of hearing "it just isn't possible" by people who're obviously drunk on the Kool-Aid while some fields manage just fine. And again, I'm not referring to surgery.

 

[mrjohndaniels]

I've heard the less training overall argument many times. In order to have a better schedule though, you'd have to cut some of those hrs off.

Have you ever heard anything about extending residency (don't kill me😱)? What if you did another year or however long of residency and just got paid at a higher level? Like a post-residency position at 100k oposed to the 50k intern and the 200 k attending. You'd have better hrs, a decent salary to get those loans down, and more time to learn. The hospital would get a more expereinced worker and not have to pay them as much as a full attending.

Just trying to come up with other ideas...My impression is that a lot of people want to do 120 hr/wk residencies and get over with them ASAP to start making the realy $ earlier.

Hospitals can't just pay residents more because we want it. It all has to do with reimbursement for providing services. I'm sure everyone in here would love to make more money, but it's not something we can just materialize. There is a finite amount in the system, and unless you increase the amount of money hospitals are paid (unlikely) or take it from another source (someone else's salary, which you could imagine would also be unlikely), we aren't getting paid anymore. Are we undervalued as residents? Absolutely, but we don't really have bargaining power since we need to train to be competent and certified as experts in our fields.

 

[mrjohndaniels]

Then they'd have to get rid of the one-day-off-in-seven rule too and I don't see that happening. I can tell you that everyone should be in fear of me working 30 hours and making critical decisions. I know myself and my mental cognitive functions just aren't there when I go 24 hours without sleep.

The point is in a functioning system you aren't alone and have complete autonomy at that point. By the time the next morning rolls around, you will have an attending who has been sleeping all night to make decisions.

 

[Law2Doc]

Your post doesn't change anything at all. Regardless what the reason was, if residents can go from working over 100 hours a week to working 80 hours a week without it changing patient safety, then what's wrong with sticking to 80 hours a week?

Not a thing. But the problem is that they made the change, didn't get the result they hypothesized, and then the ACGME enacted yet another change, without new evidence that they were going in the right direction, which now limits intern hours, etc. If it was one change, didn't work, they said okay let's sit pat, I'd agree with you. That hasn't happened. The changes keep coming notwithstanding no evidence supporting the stated goals.

 

[Law2Doc]

I've heard the less training overall argument many times. In order to have a better schedule though, you'd have to cut some of those hrs off.

Have you ever heard anything about extending residency (don't kill me😱)? What if you did another year or however long of residency and just got paid at a higher level? Like a post-residency position at 100k oposed to the 50k intern and the 200 k attending. You'd have better hrs, a decent salary to get those loans down, and more time to learn. The hospital would get a more expereinced worker and not have to pay them as much as a full attending.

Just trying to come up with other ideas...My impression is that a lot of people want to do 120 hr/wk residencies and get over with them ASAP to start making the realy $ earlier.

There's no funding out there to pay residents six digits. Once you get boarded, the only options for working with a net (ie not at the attending level) are fellowships, and they tend not to pay much better than the more senior residents. There is one NY program which is somewhat experimental that pays residents a lot for a longer commitment, but that is the exception to the rule. I think the options are to do a lot of hours and get the residency over with quickly, or spread it out over more years. Few people are enthusiastic about the latter, so I'd say folks should just plow through.