How rampant are the internship work hour restrictions being violated?

[virie]

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So to be clear, the work hour restrictions are:
- Maximum 16 hour shift
- Minimum 10 hour between shifts

So, effectively, you have 14 hour shifts if you have to work the next day, but a 16 hour shift if you have the next day off. Or you can work 16 hours but come in late the next day. I have seen work hours being repeatedly violated in my upcoming internship and am worried about how I will deal with it. They told us not to violate it all costs and to report it to the PD if we do, but the actual situation I feel differs. Plus, if you have work to do/patients to admit and the time is up, what are you supposed to do?

 

[LucidSplash]

So to be clear, the work hour restrictions are:
- Maximum 16 hour shift
- Minimum 10 hour between shifts

So, effectively, you have 14 hour shifts if you have to work the next day, but a 16 hour shift if you have the next day off. Or you can work 16 hours but come in late the next day. I have seen work hours being repeatedly violated in my upcoming internship and am worried about how I will deal with it. They told us not to violate it all costs and to report it to the PD if we do, but the actual situation I feel differs. Plus, if you have work to do/patients to admit and the time is up, what are you supposed to do?

To be extra clear, the 16-hour rule only applies to PGY-1 and the rules actually state

VI.G.5.a) PGY-1 residents should have 10 hours, and must have eight
hours, free of duty between scheduled duty periods.

The same rules apply to PGY-2 and above, except after a 28-hour call, when you are supposed to have 14-hours off.

 

[agranulocytosis]

You lie.

 

[QofQuimica]

It depends on the specialty, the program, the rotation, and the individual resident. Some specialties, particularly surgical specialties, are always flirting with the limit to where it's easy to go over accidentally. Other specialties tend not to come anywhere near the limit. Same with rotations. You're much more likely to risk violating work hour rules if you're on an inpatient month versus if you're on a clinic month.

If you do go over, you either have to lie, or you have to report a violation, which will probably earn you a meeting with a not-very-happy PD at the very least. What you choose to do will depend in part on your program's culture and in part on your level of comfort with falsifying your records. Personally, I would not be comfortable with doing that and would accept the consequences of logging a violation. But being honest is easier at my program than it might be at some others since my PD is a straight-shooter who categorizes falsifying records as unprofessional behavior. It's not always easy though; I have had to be very conscientious about not going over. Sometimes I had to skip conference or otherwise manipulate my schedule in order to do this, but it *is* possible if you have your program's support and you report scheduling conflicts to your chiefs in a timely manner. I was able to make it through my entire intern year without a violation, even on my ICU months, and as far as I know all of my residency classmates did as well.

In your case, it sounds like the program is not going to be supportive, which is unfortunate. Try your best not to go over the limits as much as possible. But as the person above me said, you could lie if you are not able to stay within the hour rules. The only other option would be to take the risk of being sanctioned by your program in some way, including possibly being let go. If you're doing a prelim year, you might not feel that it's worth stirring the pot, and I for one certainly wouldn't pass judgment on you for that. You have so little control over your work life as an intern that, unless your program supports you, there may be little you can do to preserve your career short of falsifying your hours. That's a tough situation to be in, and I hope it won't be something you encounter frequently.

to you.

 

[Impromptu]

There is a silly violation built into the way hours are logged. For instance, you get done at 3 PM, but then have journal club from 4-5 PM. You don't come in until 0630 the next day. So plenty of time off. And assume the hours that week were a nice 65 or so, so no chance of going over. That 1 hour between 3 PM and 4 PM when you weren't working will count as a time violation.

 

[Tiburon]

So to be clear, the work hour restrictions are:
- Maximum 16 hour shift
- Minimum 8 hour between shifts

Fixed. Anyways, I think they probably get violated more than you think. But not HUGE violations, just a few extra hours here or there on some days when you have a longer shift scheduled and still have to round super early.

Nobody really wants to be the chump that says "Hey team, I have to go home now, please finish all my work for me that I could finish if I stayed an extra hour."

 

[mcl]

There is a silly violation built into the way hours are logged. For instance, you get done at 3 PM, but then have journal club from 4-5 PM. You don't come in until 0630 the next day. So plenty of time off. And assume the hours that week were a nice 65 or so, so no chance of going over. That 1 hour between 3 PM and 4 PM when you weren't working will count as a time violation.

My program uses a computerized tracking system that indicates a violation if residents have an hour between assigned duties. I tell our residents that during those breaks they should indicate "administrative time" in the log to avoid the violation. They can read, they can log cases, they can find a medical student to teach, they can go to the lounge and check emails for all I care. They aren't "off" until they are leaving the hospital at the end of their work day.

 

[Perrotfish]

If you do go over, you either have to lie, or you have to report a violation, which will probably earn you a meeting with a not-very-happy PD at the very least. What you choose to do will depend in part on your program's culture and in part on your level of comfort with falsifying your records..

I feel like EMR makes it a lot harder to lie. When all of your work is electronically time stamped you can't really fudge the numbers as much as when you're just putting paper notes in the chart.

 

[Chakrabs]

The internship hours are a complete joke. All it does is make you work more days of the week, make your schedule that much more unpredictable (as many programs are still figuring out how to incorporate this and keep manpower levels up) and leave you unprepared for the rigors of junior residency. Maybe its fine for huge medicine services where tons of signouts are the norm. But for surgical departments its really not very fun.

 

[cpants]

The internship hours are a complete joke. All it does is make you work more days of the week, make your schedule that much more unpredictable (as many programs are still figuring out how to incorporate this and keep manpower levels up) and leave you unprepared for the rigors of junior residency. Maybe its fine for huge medicine services where tons of signouts are the norm. But for surgical departments its really not very fun.

Agreed. It blows.

 

[jdh71]

The internship hours are a complete joke. All it does is make you work more days of the week, make your schedule that much more unpredictable (as many programs are still figuring out how to incorporate this and keep manpower levels up) and leave you unprepared for the rigors of junior residency. Maybe its fine for huge medicine services where tons of signouts are the norm. But for surgical departments its really not very fun.

agreed x 2

You used to have that "post-call" time + your day off, actually "off". Interns definitely have to actually work more now, but in strange funny shifts.

Anyway, from my perspective on the medicine side of things, and experience with three different medicine programs, and one FP program (my old shop, and some of the other sites where I rotate) - they've been VERY aggressive with the intern hours. Attendings will send interns home and the rest of us will finish the work.

 

[Law2Doc]

I feel like EMR makes it a lot harder to lie. When all of your work is electronically time stamped you can't really fudge the numbers as much as when you're just putting paper notes in the chart.

A lot of folks log into EMR from home. That doesn't count as being on the clock.

 

[BolderNewfy]

at our program and the others in my city violations are the norm. If you violate you get called in to the PD and yelled at. Everyone just lies now and doesnt log honestly. When we express that our system is not working and we are violating, nothing is done to change it, rather we are reprimanded. Basically a joke.

Here is a question; Is there a MINIMUM number of hours that people need to work to be an accredited program. lets say in a hypothetical world where PD's are not soul sucking vampires, and they decided everyone gets a golden weekend once a month, and the faculty actually have to do some work. Or in a completely fictional world where the PD actually read the IOM report on resident duty hours, and decided that residents should only work 65 hours a week. Would that be a violation of acgme curriculum or work hour standards. I guess my question is this, Is there minimum hours required to be accredited and is it not odd that residency programs were given a set of limits, and rather than setting reasonable work hours, they changed them as little as possible and push the residents to the very limit of what they are allowed to....

 

[inspirationmd]

You can log into the EMR from home which does not count so that it helpful for catching up on paperwork or prepping your charts for the next day.

Early on you will be inefficient and will probably violate so you can get the job done. I don't care what they say no attending wants to hear that a rock patient has to sit on the service over the weekend because you did not have time to push SW to get the nursing home to accept their rock back.

Later you will realize that you are being jipped of critical experience that you will need as a senior so you start to stay later of your own accord rather to see the end of that surgical case or to see that critical patient you just spent hours stabilizing beginning to turn around (ie. DKA, Septic Shock). Less of an issue after you have personally managed a few but practice is important in this field.

In both instances you lie if you want to keep your drama to a minimum because I will say most PDs are cracking down and trying to get people out on time. My personal view is that the ACGME has gone a bit overboard due to political/public pressure and I signed up to learn how to be a doctor not get more naps. You need to capitalize on that early on when the learning curve should be steepest. I don't believe you should just be learning things as a senior that you would have seen as an intern in years past. Later years are about picking up more advanced medicine, studying for boards, applying for fellowship, chilling, etc.

My personal opinion.

 

[Perrotfish]

A lot of folks log into EMR from home. That doesn't count as being on the clock.

My program says it does. I wonder if the ACGME has ever commented specifically on this issue.

 

[Dirt]

My program says it does. I wonder if the ACGME has ever commented specifically on this issue.

My program considers writing notes and entering orders as being on the clock and we were strictly told not to do it from home. Checking labs, consults, vitals or the like is ok.

 

[NotAProgDirector]

All of these activities count. The ACGME is very clear about this:

What is included in the definition of duty hours under the requirement "duty hours must
be limited to 80 hours per week."?
Duty hours are defined as all clinical and academic activities related to the residency
program. This includes inpatient and outpatient clinical care, in-house call, short call,
night float and day float, transfer of patient care, and administrative activities related to
patient care such as completing medical records, ordering and reviewing lab tests, and
signing verbal orders. For call from home, only the hours spent in the hospital after being
called in to provide care count toward the 80-hour weekly limit.
Hours spent on activities that are required by the accreditation standards, such as
membership on a hospital committee, or that are accepted practice in residency
programs, such as residents' participation in interviewing residency candidates, must be
included in the count of duty hours. It is not acceptable to expect residents to participate
in these activities on their own hours; nor should residents be prohibited from taking part
in them.
Duty hours do not include reading, studying, and academic preparation time, such as
time spent away from the patient care unit preparing for presentations or journal club.

The entire FAQ is here.

 

[Law2Doc]

All of these activities count. The ACGME is very clear about this:

What is included in the definition of duty hours under the requirement “duty hours must
be limited to 80 hours per week.”?
Duty hours are defined as all clinical and academic activities related to the residency
program. This includes inpatient and outpatient clinical care, in-house call, short call,
night float and day float, transfer of patient care, and administrative activities related to
patient care such as completing medical records, ordering and reviewing lab tests, and
signing verbal orders. For call from home, only the hours spent in the hospital after being
called in to provide care count toward the 80-hour weekly limit.
Hours spent on activities that are required by the accreditation standards, such as
membership on a hospital committee, or that are accepted practice in residency
programs, such as residents’ participation in interviewing residency candidates, must be
included in the count of duty hours. It is not acceptable to expect residents to participate
in these activities on their own hours; nor should residents be prohibited from taking part
in them.
Duty hours do not include reading, studying, and academic preparation time, such as
time spent away from the patient care unit preparing for presentations or journal club.

The entire FAQ is here.

I think it's a much grayer area than you suggest. If after my shift I wake up in the middle if the night and say, "oh crap did I forget to order X", and so I log in and look, and see that X was ordered, but Y was not, so I ordered Y. Did I violate duty hours? I doubt it. Even under the old rules, there were plenty of middle of the night "did I do X, did I remember to sign out Y " moments where you called the next shift person to fix an oversight, and avoid an error in patient care. No way the rules make this a violation -- if they do, they are saying abiding by the rules are more important than preventing errors/oversights, which sort of misses the point of the rules. You won't get in trouble for doing this, and won't include this in your time cards.
(FWIW, the FAQ are not the rules themselves, they are just meant to aid in understanding the rules).

 

[BolderNewfy]

Again I must ask is there a MINIMUM of work hours, ie if suddenly program directors decided to give everyone an extra day off per week would that come under scrutiny. Would there be a question of whether residents are getting enough hours? Im just curious is all.

 

[Perrotfish]

I think it's a much grayer area than you suggest. If after my shift I wake up in the middle if the night and say, "oh crap did I forget to order X", and so I log in and look, and see that X was ordered, but Y was not, so I ordered Y. Did I violate duty hours? I doubt it. Even under the old rules, there were plenty of middle of the night "did I do X, did I remember to sign out Y " moments where you called the next shift person to fix an oversight, and avoid an error in patient care. No way the rules make this a violation -- if they do, they are saying abiding by the rules are more important than preventing errors/oversights, which sort of misses the point of the rules. You won't get in trouble for doing this, and won't include this in your time cards.
(FWIW, the FAQ are not the rules themselves, they are just meant to aid in understanding the rules).

I think what you're describing is technically a violation, but no sane person would report it. Logging a forgotten order, though, isn't what we're talking about. We're talking about going home and finishing notes, a significant time commitment. I think that's a clear violation.

 

[Law2Doc]

... Logging a forgotten order, though, isn't what we're talking about. We're talking about going home and finishing notes, a significant time commitment. I think that's a clear violation.

Well, you suggested that using the EMR use would document when you were working, (and thus violating duty hours) and this is an example of EMR use during off hours that wouldn't really be such.

And it's kind of a fine line between logging in to fix one oversight versus two, versus a dozen...

 

[Law2Doc]

Again I must ask is there a MINIMUM of work hours, ie if suddenly program directors decided to give everyone an extra day off per week would that come under scrutiny. Would there be a question of whether residents are getting enough hours? Im just curious is all.

There is no explicit minimum. However hospitals need the labor and residents need the training. If a resident didn't learn squat in residency, the jobs and fellowships for graduates of those programs would dry up very rapidly. Word of mouth is quick and speaks volumes in this field. Employers knows which programs are solid or very weak. And few hospitals are going to pay $50k a year to someone working 20 hours a week when their counterparts across the street are working 80 for the same salary. So basic workforce economics creates the floor -- the ACGME doesn't have to.

 

[Dr. USMLE]

And few hospitals are going to pay $50k a year to someone working 20 hours a week when their counterparts across the street are working 80 for the same salary. So basic workforce economics creates the floor -- the ACGME doesn't have to.

That's not true at all. There are plenty of TYs where you work 20 hours/wk for 1/4 to 1/2 of the year. There are also a ton of ROAD programs where you work 40-50 hours/wk. They're all making the same salary as those neurosurg and ortho residents with a special 88 hour cap (who routinely go beyond that extended cap anyway)...often >100h/wk on trauma.

 

[Doctor4Life1769]

There is no explicit minimum. However hospitals need the labor and residents need the training. If a resident didn't learn squat in residency, the jobs and fellowships for graduates of those programs would dry up very rapidly. Word of mouth is quick and speaks volumes in this field. Employers knows which programs are solid or very weak. And few hospitals are going to pay $50k a year to someone working 20 hours a week when their counterparts across the street are working 80 for the same salary. So basic workforce economics creates the floor -- the ACGME doesn't have to.

I'd like to know who the **** is working 20hrs/week in residency. Nobody. Again, you spit out stuff that makes no sense. Typical day and a typical post from L2D.

 

[Dr. USMLE]

I'd like to know who the **** is working 20hrs/week in residency. Nobody. Again, you spit out stuff that makes no sense. Typical day and a typical post from L2D.

I'll be working less than that during my electives. Granted its not for an entire residency but for a good half year.

 

[Law2Doc]

I'd like to know who the **** is working 20hrs/week in residency. Nobody. Again, you spit out stuff that makes no sense. Typical day and a typical post from L2D.

Um I actually didn't say anyone worked 20 hours in residency. I said market forces generally prevented it. (In response to a poster asking if there was a minimum.) It might pay to read a post before attacking it. Typical Day and typical waste of a post from Doctor4Life. Cheers.

 

[Doctor4Life1769]

Um I actually didn't say anyone worked 20 hours in residency. I said market forces generally prevented it. (In response to a poster asking if there was a minimum.) It might pay to read a post before attacking it. Typical Day and typical waste of a post from Doctor4Life. Cheers.

You sound butt hurt.

 

[smq123]

Please stop with the back-and-forthing. If you must continue it, do it by PM.

Many thanks.

 

[BolderNewfy]

um sure. whatever you say. the "market" determines that we work as much as we do...you just keep telling your self that.

 

[45408]

I'd like to know who the **** is working 20hrs/week in residency. Nobody. Again, you spit out stuff that makes no sense. Typical day and a typical post from L2D.

And that's exactly what he was getting at.

 

[Law2Doc]

um sure. whatever you say. the "market" determines that we work as much as we do...you just keep telling your self that.

You didn't read my post either. In response to YOUR question, I said there is no real rule creating a duty hour "floor", but there doesn't need to be -- no program is going to underutilize its residents too much because (1) they are already paying them (2) they have work that needs to get done, (3) as a teaching institution they have a need to be well regarded in terms of training. These are all "market forces" that are going to prevent a program from sending its residents off to the beach every weekend. There is simply no danger of that happening. So there is really no need for the ACGME to set a floor -- the demands of the market create a system where residents are used by hospitals who opt to have residency programs. You only need to set a ceiling because places are prone to overutilize, not underutilize this relatively cheap resource.

If you didn't want an answer, I'm not sure why you asked the question.

 

[HiddenGentleman]

My first week of internship (last week) I worked a little over 100 hours. Long call nights (q4) i got about 7 hours between shifts. Most patients I had at a time was 9. I got done with my work faster than the other intern so I can't imagine how many hours they worked. I tend to get done with my work early but no one offers to let me sign out to them on my supposed "short" days. I feel like I should not bother them because they are already freaking out that they can't get their work done and so I have to wait a couple hours until they catch up. I can't wait to be done with medicine.

 

[Dr. USMLE]

My first week of internship (last week) I worked a little over 100 hours. Long call nights (q4) i got about 7 hours between shifts. Most patients I had at a time was 9. I got done with my work faster than the other intern so I can't imagine how many hours they worked. I tend to get done with my work early but no one offers to let me sign out to them on my supposed "short" days. I feel like I should not bother them because they are already freaking out that they can't get their work done and so I have to wait a couple hours until they catch up. I can't wait to be done with medicine.

Wow...I thought you were doing a surg prelim until I read that last line. Just goes to show how variable hours are and that the "floor" and "ceiling" depends more on patient flow and hospital dynamics than any invisible hand. You could well be "across the street" from another hospital where terns are working less than half the hours for the same or even higher salary.