I agree totally with the new 80 hour workweek...I'll explain why...

[OwlMyste]

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I agree totally with the new 80 hour workweek for residents! The same should be for doctors too! You hafta think of it the way of the patients view. Think of it as if that patient on the OR table/in trauma/ in general surgery/ etc. was someone YOU loved, a spouse, a child, or whatever. Then ask yourself this: "would I want MY loved one to be taken care of by a doctor who got a full night's rest (atleast 8-10 hours) God Knows When?! could be last year since a doctor got that much rest in a single night. But me myself personally, I would only want a doctor who got a full nights rest to be working on me! because its MY life they would be dealing with, and if they messed up, the lawsuits would fly! what do y'all think? any comments?

 

[maxheadroom]

If I recall, you're a high school student, so I'm not sure that you have the experience to form a true opinion on the matter.

1. There is no physician in the world (besides derm or rads) that gets 8-10 hours of sleep per night as you'd like to require. Most residents do quite well with 3-6 hours of sleep per night.

2. Regulating private practice physicians' hours in the logical next step in worlk-place hour regulation, but there are some massive problems. Say you're a surgeon who is called in in the middle of the night for a post-op complication on one of your patients. The care only takes a few hours, but by the time you're finished, you've violated the set "rest time". Do you cancel your next day's operating schedule, just because you were at the hospital for a few hours the night before? Not many physicians would like that. Tons of patients who get bumped from the schedule would be pissed.

3. An 80 hour work-week is considered to be insufficient time on the job for training surgeons. Why? Surgeons need to learn several aspects of patient care. First, surgery (usually three full days per week in the OR). Second, patient care outside the OR (need to take care of your cases when they're in the hospital). Third, outpatient care (need to know how to work effectively in clinic). If you add all of these up, it is very hard to squeeze them all in to 80 hours per week.

This being said, I'm in favor of work hour regulation for residents, but only reasonable cuts should be made.

 

[iamubiquitous]

A few random additions

In rural settings --no doc OFTEN means death ie there is no one else to cover (i have seen this).


concerning #2

if the surgeon does go to the OR the next day and there's a complication----he will be explaining to a jury why he thinks that he is exempt from the work hour restrictions that protect the innocent citizens of XXXXXX
and
why he put profits before patients

>>This situation is a trial lawyers wet dream.<<

Next--malp ins policies will have clauses absolving underwriters
anytime you are working outside prescribed limits

then someone will have to come out with a badge for doc to wear net to their RAD exposure pins--this one counting hours worn.

i went off a bit -- sorry

Me: Intern in three months (i hope) and very pro work hour limits.
but with care

 

[OwlMyste]

I may be only a HS Student, don't hold it against me. I'm 19 and going to go to college in the fall of 2003, so (not implying that you were, but just setting it clear) I don't want you to think that i am a 14-15 year old mouthing off... but I have read up on some of the stuff. There were studies shown that lack of sleep in Physicians were more likely to make them get errors. I'm sorry--I would rather have a fully awake doctor working on me that got atleast 8 hours sleep--no less than atleast 6-7 per night, than a doctor or surgeon that only got 2-3 hours of sleep that night. getting 2-3 hours of sleep in a night is okay to do OCCASIONALLY, but continuously overworking our doctors is just inhumane. After all, theyre human and make mistakes, and lack of sleep affects them over a period of time just as it would the rest of us. would you rather a doctor who had lack of sleep be driving and endangering the lives of more than just his patients by falling asleep at the wheel? Or would you prefer they would just get a few hours extra sleep per night? I'm sure that if alot more people didnt get by on just the minimum of sleep every night, that the accidents out there by falling asleep at the wheel would be signifigantly reduced! don't you agree?

 

[Purifyer]

Owlmyste, could you please write in the normal font and colours? It hurts my eyes to read your comments.

Yes, doctors are human. You may or may not be aware, that differing people need differing amounts of rest to stay alert over a given time. I think it is inhumane to impose limits set by the 'lowest common denominator' - ie. just because Joe Blogg needs 10 hours sleep or he gets cranky when he goes to his job at the supermarket, why should I be forced to sleep as much as him?

Another important argument against the imposition of regulations like this, is continuity of care. You talk of your family, yourself, wanting the best possible medical care.

If you come in at 5pm, admitted by an intern who goes home at eight, looked after by registrars who have to leave for home at midnight because of ridiculous restrictions on their ability to work, then cared for by a completely different group of doctors until the morning rounds the next day, do you think the group in the morning would know your case as well as those who admitted you, stayed with you the night, and were able to cohesively and succinctly tell your history to the attending in the morning? Of course not.

Doctors know what they are getting themselves into. Don't become a fireman if you are scared of fires. Don't become a surgeon if you want to sleep 12 hours a day. It's quite obvious really.

 

[ortho2003]

Strong work puryfier. There are many that are predicting that there will be more mistakes and bad patient outcomes after the switch. Lack of commmunication when transferring care is the number 1 cause of patient care mistakes, not tired residents.

The resident work hours didn't come through only to protect patients. It came through to protect residents. There are too many adverse sleep deprivation, auto accidents, depression, illness, etc...

I too am in favor of 80 hours, but I think there needs to be some wiggle room so patient care doesn't come second.

 

[ortho2003]

by the way...14, or 19...you are still in high school. You have not made it through college, much less you first two years in med school. If and when you do finally make it to your clinical rotations as an MS3, I think we will likely take your opinions on the work week a little more seriously.

 

[OwlMyste]

I may be in High School...like i said before and will say again..please dont hold it against me that I am in HS! I don't want to be looked down upon because of that...🙁 ...I get too much of that as it is...on IAU's comment...if I was a patient that was admitted at 5pm by a resident that would go home at 8 pm, etc. I would rather be cared for by residents and doctors that were well rested...even if it meant having many different doctors care for me at my time in the hospital. I have been a patient in a hospital before so I do have a say on that...atleast from the patients point of view...My life would be in the balance here...and I would rather be cared for by well rested doctors/residents/med school students than cared for by just one bleary eyed doctor that could make a mistake...sleep deprivation adds up over time...also let me present a hypothetical situation to you IAU...you may say this situation has nothing to do with medicine...but it does as far as sleep deprivation goes...well here goes:

Would you want to be on a plane flying from say...Maine to Hawaii..with a pilot that only had continual 2-3 hours of sleep and thought he was okay? would you want your life to be in a bleary eyed pilots hands?<i kno their hours are regulated..thats why its a hypothetical situation>..I know I wouldn't! what about you?

 

[Newdoc2002]

For a high school student, rather well stated and ortho2003, why does MS3 qualify someone to give an opinion on an 80 hour work week? Why don't you wait until your residency when you have real responsibility.

The 80 hour work week protects patients and residents. Attendings and private doc's aren't regulated but they have much more experience than interns and residents. I have seen even the best residents get a little "punch drunk" after 30+ hours of no sleep and I would rather have a well rested doc coming on for my care even if he or she doesn't know my case yet. And switching patients is common so you better learn how to do it.

I have even scared myself on care decisions I have made or didn't after some severe sleep loss.

The real problem comes when surgery, OB and internal medicine have to cover the patient care hours with people they have to pay. Those who predict adverse outcomes from lack of continuity are those facing the fall-out from the work week restrictions (i.e. administrators hiring PA's to cover gaps in hours).

 

[DrMom]

Originally posted by OwlMyste
I may be in High School...like i said before and will say again..please dont hold it against me that I am in HS! I don't want to be looked down upon because of that...🙁 ...I get too much of that as it is

Don't assume that you are being looked down upon. You simply don't have much life experience. You will find that some of your opinions will change after you have gotten older and had more experiences.

 

[12R34Y]

gotta agree with owlmyste and newdoc2002 on this one..........i may only be a first year medical student, but every argument and article i've read about the change to 80 hours is very convicing. there are some staggering statistics and data on how sleep deprivation (the kind that residents are put through) is very much a detriment in cognition, coordination etc......

why would anyone be opposed to this?

who wants to work more than 80 hours/week, honestly.......

 

[deleted4401]

I still don't get the macho tough guy stuff that is said about this stuff!

It's funny that for all these years, parents, teachers, and scientists tell us to get rest before you do important things - athletic events, tests, performing in a play. And none of those things involve life or death. Now we get to med school/medicine and people start saying you need to be sleep deprived to learn.

Ask a patient whether he/she would rather have a caffeine wired, sleep deprived doc or a well rested, well informed house officer who is working only nights that week.

With time given for team transition, night floats will work better. Just ask someone who is involved in it. And, yes, it will cost money. And, yes, we'll get a few less weekends off because of it. And, no, it won't be a pain-free process. All change requires us to get through inertia and close-mindedness.

Fact is, people who want an 80 hour week aren't lazy. Look, we all worked hard, went to med school, and want to help people. We're arent talking about 40 and 60 hour weeks. We'll still be working 60-80% more hours than the average person.

And to say that a surgeon "needs" more than 80 hours? Do one of those malignant 130 hour/week surgery internships and tell me how much time is spent scutting and how much time is spent actually 'learning to be a surgeon'.

I'm not saying that I know what the perfect system i, and I'm not saying "80 hours done, I'm going home." I'm just saying the current one sucks, and the reasons holding them up are becoming flimsier and flimsier with greater examination. Have womansurg or Kimberly Cox, surgery residents extraordinaire, tell you how effective it has been for them to work 130 hour weeks.

The best system I can imagine is a soft 80-90 cap (80 a week averaged over 4 weeks), and a soft 24 per call (averaged over a month of call). Not sure how to fit weekends in, but probably need one full a month, and a day off every 7-10. And, honestly, I'm concerned about community hospitals failing financially. If that were to happen, I guess I wouldn't be in favor of the changes, but that is purely to make sure that a patient is seeing a tired surgeon rather than no surgeon at all.

The educational benefits of working greater than 80 hours a week are, without doubt, nonexistent. No one wants federal regulations, so we gotta think about this and do it the right way ourselves, as students, residents, and doctors. I do not want legislation to get in the way of patient care, but I don't want sleep-deprived medical care on the people who need it the most.

Simul

 

[Brougham]

Hey Owl, don't let the "your only in HS"-thing get you down. I enjoy hearing everyone's opinion even when I don't agree with them. Besides this is an interesting topic. I am kinda torn on this topic. I definitely think well rested resident's will make less mistakes. This is a good thing when your a patient and a resident who doesn't want to kill anyone. However, it is not necessarily a good thing if your a doc....albeit for some very greedy and selfish reasons. I'll explain.

Here it goes, just because residents start working 80 hrs/week doesn't mean that there is overall less work to do. It just means that every resident is now working less. The work is still there to do, which means someone will have to do it. This will likely lead to one of two things...either an increase in the number of residency spots (less likely as the population can only support so many physicians) or the hiring of more "mid-level" practicioners (i.e. PA's and NP's who make 80-120K a year vs. a residents 40K) who typically only work 40-50 hour work weeks. The hiring of more NP's and PA's will cost a lot, which will in turn decrease the revenue of hospitals and ultimately (more than likely) physicians....especially if these rules eventually encompass all of medicine and not just residents.

For years the system has been set up so that residents do most of the work while getting paid peanuts. This allows attendings to have more humane schedules and large paychecks. So my question to all of you is...would you rather suffer through 3-7 years of hell when you know the pay off is really sweet or would you simply be happy return on your investment down the road?

I know everything I just wrote sounds really, really greedy and is probably contrary to the "spirit of medicine" but it's something to think about. Despite the best intentions I doubt any of us can say that money is not a factor, especially with a large student loan burden. And owl, while I am sure you are looking in to ortho 'cause you think it's interesting, cool, etc I am willing to bet that the income of orthapods has at least a little bit to do with your interest (at least based on your previous post about incomes in the surgery forum).

In the end, none of this matters for me...at least not as a future resident (i guess it could effect me as a patient) 'cause I am going into path. I'll likely only crack 70 hours on a surg path rotation....and even that's pushing it.

 

[DoctorDoom]

Owl, you're not being looked down upon because of your age, but because of the foolishness of most of your statements, the near total lack of understanding of the realities of the profession, coupled with an apparently willful lack of understanding regarding the reasons for people like myself not taking you seriously.

As for Simul, it's not just about being a tough guy. The fact is 5 years is a long time, and if you don't cram work hours into those five years you'll end up with well-rested but less experienced and less well trained surgeons. Extending residency length is impossible. So which would you rather want, a well-rested resident who goes into private practice underprepared, or a tired resident who is well-supervised, responsible enough to know they are tired and so is more careful and asks for help, and has as great a breadth of clinical experience as possible?

I know which I would want to be.

That said, not every residency needs to be a gruelfest. And much of the tough guy aspect of surgery residency can be changed. It didn't get to this point because program directors prevented abuses, always made sure that their residents were doing useful work all the time, and were sleeping when necessary. I believe that the work hours limit is a good catalyst for change.

 

[12R34Y]

Doctordoom,

I would argue that spending 80 hours a week for 5 years and RETAINING SO mUCH MORE of your academic work and literature stuff because you are rested is better than 120-130 hour weeks and forgetting and hardly retaining anything beyond that initial 80 hours. I wish i could find the studies they've done.......they are astounding..........they've given residents identical exams and the ones who were just coming on did much better than the one's just getting off shift after no sleep the night before.

I'm simply saying that..........i think you are just beat to death after a certain point and you aren't retaining or learning anything that will stick. you will simply be doing just to do it.

I think it is the law of diminishing returns after a certain point.

just my opinion.

later,

 

[DoctorDoom]

Oh I agree, that's why I said that there has to be some control. And that there was abuse. So that's why work hours limitations are a good catalyst for change are probably a result of existing abuses. Reread my post.

My only point was that long hours are not just from some tough guy attitude. There is a good training reason behind it. And there are also plenty of studies that show physical and operative skills do not dimish as much as one would think, while mental skills definitely do. It's as much attitude as anything. Trying to read post call is very difficult. Seeing a rare case and scrubbing in is rejuvenating. Those studies regarding memory and academic perfomance after sleep deprivation are only one small part of the overall residency experience.

 

[sistermike]

I don't disagree or agree with the 80 hour restriction. I personally believe it should be based on an individual level. There are some people who can't even function properly with 8 hours of sleep a night, but then on the other hand, there are people who can fully function with as little as 4 or 5 hours of sleep a night (with the help of caffeine of course 😉 ). I personally think that the residents/doctors should be the ones to pick their type of hours.

Just this morning in fact I was observing an ultrasound and I walked by the radiologist's office and i noticed he had fallen asleep at his desk and I woke him and asked him how much sleep he had gotten the past evening, and he said 5 hours. So really it depends on the person. (But by the way I am not a doctor, nor a resident, nor a med student, so my views may change when I get to that point in my life.)

 

[DoctorDoom]

Individualized hours would be fine except that work has to be done, there has to be continuity of care, everyone has to be on the ball, and there have to be standards. Imagine a team in any residency that had some guys finish in 3 years and some finish in 9. The ones who finish faster work all the time and can pass the exam. The ones who finish later are well rested, lazed around and worked when they wanted to. It would be impossible to regulate and control. The guys who were there all the time would actually see the patients. The ones who lazed around would just be backup or take call. Standards for training would go out the window and proficiency would be wildly variant. Not possible.

Your views will definitely change, because it won't be as little as 4-5 hours of sleep, it wll be NO sleep. You will learn to treasure uninterrupted unconciousness like nothing you've ever known.

 

[OwlMyste]

Originally posted by SimulD
I still don't get the macho tough guy stuff that is said about this stuff!

It's funny that for all these years, parents, teachers, and scientists tell us to get rest before you do important things - athletic events, tests, performing in a play. And none of those things involve life or death. Now we get to med school/medicine and people start saying you need to be sleep deprived to learn.

Ask a patient whether he/she would rather have a caffeine wired, sleep deprived doc or a well rested, well informed house officer who is working only nights that week.

With time given for team transition, night floats will work better. Just ask someone who is involved in it. And, yes, it will cost money. And, yes, we'll get a few less weekends off because of it. And, no, it won't be a pain-free process. All change requires us to get through inertia and close-mindedness.

Fact is, people who want an 80 hour week aren't lazy. Look, we all worked hard, went to med school, and want to help people. We're arent talking about 40 and 60 hour weeks. We'll still be working 60-80% more hours than the average person.

And to say that a surgeon "needs" more than 80 hours? Do one of those malignant 130 hour/week surgery internships and tell me how much time is spent scutting and how much time is spent actually 'learning to be a surgeon'.

I'm not saying that I know what the perfect system i, and I'm not saying "80 hours done, I'm going home." I'm just saying the current one sucks, and the reasons holding them up are becoming flimsier and flimsier with greater examination. Have womansurg or Kimberly Cox, surgery residents extraordinaire, tell you how effective it has been for them to work 130 hour weeks.

The best system I can imagine is a soft 80-90 cap (80 a week averaged over 4 weeks), and a soft 24 per call (averaged over a month of call). Not sure how to fit weekends in, but probably need one full a month, and a day off every 7-10. And, honestly, I'm concerned about community hospitals failing financially. If that were to happen, I guess I wouldn't be in favor of the changes, but that is purely to make sure that a patient is seeing a tired surgeon rather than no surgeon at all.

The educational benefits of working greater than 80 hours a week are, without doubt, nonexistent. No one wants federal regulations, so we gotta think about this and do it the right way ourselves, as students, residents, and doctors. I do not want legislation to get in the way of patient care, but I don't want sleep-deprived medical care on the people who need it the most.

Simul

I whole-heartedly agree 100%, Simul...I whole-heartedly agree...🙂

 

[DoctorDoom]

Dude, did you edit your post? Why do I remember it being shorter than this?

Originally posted by SimulD
I still don't get the macho tough guy stuff that is said about this stuff!

It's funny that for all these years, parents, teachers, and scientists tell us to get rest before you do important things - athletic events, tests, performing in a play. And none of those things involve life or death. Now we get to med school/medicine and people start saying you need to be sleep deprived to learn.

I don't think anyone is saying you need to be sleep deprived to learn. People are saying sleep deprivation is a necessary evil. And residency would be more comparable to all those rehearsals, practices, and cram sessions before your concert, game, or test. Rememeber how tired you got and how late you stayed up during those?

Ask a patient whether he/she would rather have a caffeine wired, sleep deprived doc or a well rested, well informed house officer who is working only nights that week.

Would that same patient want the doctor who saw them in the ER and operated on them, or would they want the night float who came on an hour ago and only knows them from the signout? It's a trade off.

With time given for team transition, night floats will work better. Just ask someone who is involved in it. And, yes, it will cost money. And, yes, we'll get a few less weekends off because of it. And, no, it won't be a pain-free process. All change requires us to get through inertia and close-mindedness.

Fact is, people who want an 80 hour week aren't lazy. Look, we all worked hard, went to med school, and want to help people. We're arent talking about 40 and 60 hour weeks. We'll still be working 60-80% more hours than the average person.

And to say that a surgeon "needs" more than 80 hours? Do one of those malignant 130 hour/week surgery internships and tell me how much time is spent scutting and how much time is spent actually 'learning to be a surgeon'.

You'll get no argument from me there.

I'm not saying that I know what the perfect system i, and I'm not saying "80 hours done, I'm going home." I'm just saying the current one sucks, and the reasons holding them up are becoming flimsier and flimsier with greater examination. Have womansurg or Kimberly Cox, surgery residents extraordinaire, tell you how effective it has been for them to work 130 hour weeks.

The best system I can imagine is a soft 80-90 cap (80 a week averaged over 4 weeks), and a soft 24 per call (averaged over a month of call). Not sure how to fit weekends in, but probably need one full a month, and a day off every 7-10. And, honestly, I'm concerned about community hospitals failing financially. If that were to happen, I guess I wouldn't be in favor of the changes, but that is purely to make sure that a patient is seeing a tired surgeon rather than no surgeon at all.

Again I second that emotion, Smokey. 🙂

The educational benefits of working greater than 80 hours a week are, without doubt, nonexistent. No one wants federal regulations, so we gotta think about this and do it the right way ourselves, as students, residents, and doctors. I do not want legislation to get in the way of patient care, but I don't want sleep-deprived medical care on the people who need it the most.


Well now, not without a doubt non-existent, and the link between sleep deprivation and lower quality care is not as clear as many people believe. Even in the Libby Zion case, after all these years of Bell Commision, the biggest culprit being blamed for poor care is still most likely too high a patient load and insufficient supervision and attending backup. The medical profession has to do something about it ourselves, no doubt, but when it comes to balancing community hospital survival, controlling the number of physicians, ensuring proper healthcare access, ensuring excellent training in a reasonable amount of time, and making residency training less draconian or grueling, something has to give. So far it's been easy to make residents bear the load. I'm glad that it's starting to change, but still leery of possible dangers or peoblems down the road. I just don't think it's 'clearly' going to be better once work hours are reduced. The work is just beginning.

 

[Gradient Echo]

Originally posted by ortho2003
I too am in favor of 80 hours, but I think there needs to be some wiggle room so patient care doesn't come second. [/B]

Inadequate sleep already puts patient care second.

 

[Gradient Echo]

Originally posted by DoctorDoom
Oh I agree, that's why I said that there has to be some control. And that there was abuse. So that's why work hours limitations are a good catalyst for change are probably a result of existing abuses. Reread my post.

My only point was that long hours are not just from some tough guy attitude. There is a good training reason behind it. And there are also plenty of studies that show physical and operative skills do not dimish as much as one would think, while mental skills definitely do. It's as much attitude as anything. Trying to read post call is very difficult. Seeing a rare case and scrubbing in is rejuvenating. Those studies regarding memory and academic perfomance after sleep deprivation are only one small part of the overall residency experience.

I agree somewhat. If a patient comes in who is crashing and at serious risk of death, usually that will cause even sleep-deprived residents to perk up enough to treat them adequately.

But this is really besides the point. What about the non-critical patients or "non-interesting" surgeries? Do those patients deserve subpar care because the needed to be awake for 36 hours straight to treat "interesting" cases?

 

[Gradient Echo]

Originally posted by DoctorDoom
I don't think anyone is saying you need to be sleep deprived to learn. People are saying sleep deprivation is a necessary evil. And residency would be more comparable to all those rehearsals, practices, and cram sessions before your concert, game, or test. Rememeber how tired you got and how late you stayed up during those?

The downside of sleep deprivation (poor concentration and attention, cognitive defects, memory defects) far outweighs the "upside" in terms of continuity.

Would that same patient want the doctor who saw them in the ER and operated on them, or would they want the night float who came on an hour ago and only knows them from the signout? It's a trade off.

Depends on how the patient perceives the resident's condition. If its totally obvious that he's about to fall asleep where he stands, I think most patients would prefer the well-rested doc.

Well now, not without a doubt non-existent, and the link between sleep deprivation and lower quality care is not as clear as many people believe.

What is clear is that sleep deprivation causes:

1) global cognitive decline
2) poor concentration
3) poor attention
4) poor energy level
5) poor memory

Now, if you want to argue that none of those deficits impacts patient care, then go ahead but I think most people would make a logical connection between the two.

Even in the Libby Zion case, after all these years of Bell Commision, the biggest culprit being blamed for poor care is still most likely too high a patient load and insufficient supervision and attending backup. The medical profession has to do something about it ourselves, no doubt, but when it comes to balancing community hospital survival, controlling the number of physicians, ensuring proper healthcare access, ensuring excellent training in a reasonable amount of time, and making residency training less draconian or grueling, something has to give. So far it's been easy to make residents bear the load. I'm glad that it's starting to change, but still leery of possible dangers or peoblems down the road. I just don't think it's 'clearly' going to be better once work hours are reduced. The work is just beginning. [/B]

I agree for the most part. Nobody is saying that resident work hour restrictions is going to be a panacea for all medical system ills. However, I think its clear that patients and residents are better off with some kind of restrictions. Clearly, 130 hour work weeks give marginal results in terms of new learning, at best, while placing patients at substantially greater risks. The tradeoff balance clearly favors less hours in my opinion.

 

[globulin]

Here's my 2 cents. It seems to me that whenever there's some new idea or reform, its always met by opposition. When Copernicus said the earth wasn't the center, people were blasting him and saying what a stupid idea, blah blah blah. I was just reading about Fitz and how he discovered appendictis, and surgeons were blasting him and saying what a stuipid idea, blah blah blah. Basically, some people just don't like change and people like that are always gonna exist (which is probably a good thing). Why don't we just see what happens when they start this 80 hour work week and if it works out, great. If not, then I guess you can say you were right, and do something about it.

 

[DoctorDoom]

No doubt, if you assume that the standard is 130 hours, but it clearly isn't. I don't want to say that sleep deprivation has no effect on concentration and memory, etc. Nor am I saying patients should deal with me being sleep deprived if they're "boring" so that I can be around for the "cool" ones; that's obviously ridiculous. I only mean to say that equating ANY sleep deprivation with substandard or subpar care is not accurate. Sleep deprivation will reduce the level of highest performance, but let's be honest, not every patient care action or decision requires the utmost level of performance we can squeeze out of ourselves. Only severe sleep deprivation begins to impact basic decision making. And that absolutely should be eliminated.

It seems to me that you are making arguments based on the extremes, which isn't reflective of the actual situation. I just don't think that a little sleep deprivation is such a danger and equates automatically with poor care. I do agree that continuous severe sleep deprivation is totally unnecessary. Besides, it's just inhumane.

And if you read my previous posts, globulin, you'll see that I think that the work hour reductions are a good beginning, overdue, and a good catalyst for change. I'm for them. I just think they should be undertaken judiciously. And that the original intent for long work hours is not just a macho thing.

 

[Gradient Echo]

Originally posted by DoctorDoom
No doubt, if you assume that the standard is 130 hours, but it clearly isn't. I don't want to say that sleep deprivation has no effect on concentration and memory, etc. Nor am I saying patients should deal with me being sleep deprived if they're "boring" so that I can be around for the "cool" ones; that's obviously ridiculous. I only mean to say that equating ANY sleep deprivation with substandard or subpar care is not accurate. Sleep deprivation will reduce the level of highest performance, but let's be honest, not every patient care action or decision requires the utmost level of performance we can squeeze out of ourselves. Only severe sleep deprivation begins to impact basic decision making. And that absolutely should be eliminated.

It seems to me that you are making arguments based on the extremes, which isn't reflective of the actual situation. I just don't think that a little sleep deprivation is such a danger and equates automatically with poor care. I do agree that continuous severe sleep deprivation is totally unnecessary. Besides, it's just inhumane.

And if you read my previous posts, globulin, you'll see that I think that the work hour reductions are a good beginning, overdue, and a good catalyst for change. I'm for them. I just think they should be undertaken judiciously. And that the original intent for long work hours is not just a macho thing.

well I agree 130 hours/week is a little extreme and not totally representative of the prior reality.

However, 36 hours straight with no sleep was a standard practice in many surgical specialties. I would argue that 36 hours without sleep is "severe" sleep deprivation and has a profound impact on patient care.

If you're talking 12, 15, 18 hours then its probably not that big a deal. But beyond that I would classify a person as severely sleep deprived.

 

[droliver]

Originally posted by Gradient Echo
The downside of sleep deprivation (poor concentration and attention, cognitive defects, memory defects) far outweighs the "upside" in terms of continuity.

As someone who is finishing their training prior to the new work hour rules, I will tell you flat out that this is wrong. Continuity errors are one of the most frequently identified sources of problems when you look at quality assurance on surgical services. I have seen this time & time again, & this type of error is only going to be more pronounced with the popularity of night float systems @ some institutions. When you get into a shift work mentality, you inevitably generate lapses in care around shift changes (just witness how many catastrophes happen during nursing shift changes).The effects of fatigue have assumed this a priori logic that they are the root of all evil and frequent source of patient mortality during training, when in fact there is not very good evidence that this is the case.

 

[Winged Scapula]

As someone who's experienced both sides (ie, 36+ hr "days" and work hour limits with cross-cover duties), I'll have to agree with droliver.

Cross-cover can be a nightmare - not purely because of the patient load (which might keep you without sleep all night) but because of the lack of detailed knowledge about those patients you're cross-covering. The easy stuff is figuring out what the patient is allergic to, what vent setting he's on, etc...the hard part comes when the attending for that patient has certain thoughts about treatment and those are not communicated to you as cross-cover...mistakes then happen. They also happen when you get a middle of the night phone call about said patient asking for a medication renewal...you have no idea that it was discontinued by the primary team for a good reason.

Anyway, I could go on and on...While I'm at the junior levels of training, I can't say that physically the hours are hard or that my skills, tentative as they may be, are as affected by the hours I keep. Rather its the cognitive skills that IMHO are more affected, and at least at my institution, I'm not making a boatload of independent, significant, middle of the night decisions on patients without running it past the Chief or the attending.

 

[nanato]

As a surgical resident, i'm in favor of limiting the work week, to break away from the 120-130 work week, but to feel confined to 80 is a little bothersome, to have to break scrub to go home to comply to the rules is ridiculous.... i don't want my training limited.
...and for Owl, it's amazing how you can train your mind (like a muscle) to run at 80-90% efficiency while putting in 40 straight hours.... you adapt... there has been many days i have gone home post call at 10pm and had to be back at 5:30am... the difference i think is that you have more of a responsibility to your pts. than say the medical residence... you have cut into some and if post op something goes wrong, you have to go in and inspect your own work, find out what's wrong, it's not like oh ****, this guys BUN just jumped, let me have the attending come in... they treat the lab and deal with it until the am.... if your patient is bleeding post op or crashing, you can't just say, transfuse and start a pressor until the am.... surgeons just don't work that way.

 

[MacGyver]

I dont understand why all these surgeons on here believe that sleep deprivation doesnt affect patient care. thats an incredibly arrogant attitude to have in my opinion.

I also question those who said there are studies showing that sleep is totally unrelated to patient care. I know studies exist which show it DOES have negative impact, so perhaps somebody can post a link to the other studies supposedly proving there is no impact.

There are no studies showing that pilots up for 40 hours straight cause decrease in safety either, so how many of you are willing to get rid of the pilot sleep restrictions? Thats what I thought.

Also, can somebody please explain how longer hours results in no continuity problems? If I'm working on a 36 hour rotation, there are plenty of patients coming in during my 30th hour. I will still have to transfer those patients over to the next resident regardless, so continuity problems still exist no matter how many hours you work.

For that matter, why not work 48 hours straight or 60 hours straight. You guys are saying it doesnt affect patient safety, so wouldnt continuity be even BETTER with even longer shifts than 36 hours?

 

[fourthyear]

Can anyone name another profession in which work hours are this out of control? I mean, no other job is expected to work 120 hours a week - certainly no job where lives are at risk if mistakes are made. Do we think we are so much stronger than all other human beings on earth that we should expect ourselves to work those hours for 5 years straight?

I do think the 80 hour absolute rule is too restrictive - there should be some room for stretching when appropriate. However, I really, really like the idea behind this reform.

I am sure every surgery resident can identify quite a few hours a day spent on activities they have to do, but which do not contribute to their education very much. These tasks could be performed by ancillary staff, PA's, NP's, RN's, ect. Why arent' they already? B/c it costs $70k/year to pay a PA for 40-50 hours a week, and it costs $35K/year for a resident to work unlimited hours. This cost-savings for the hospital is bad for patients as well as residents. If it takes enforcing these work hours for changes to be made, then I'm all for it!

 

[MacGyver]

Originally posted by fourthyear
Can anyone name another profession in which work hours are this out of control? I mean, no other job is expected to work 120 hours a week - certainly no job where lives are at risk if mistakes are made. Do we think we are so much stronger than all other human beings on earth that we should expect ourselves to work those hours for 5 years straight?

I agree... its a paternalistic attitude coupled with a god complex by which surgeons and other docs feel they are somehow superior to other people

I am sure every surgery resident can identify quite a few hours a day spent on activities they have to do, but which do not contribute to their education very much.

Exactly. there is a significant amount of fluff/scut in a 120 hour work week which involves ABSOLUTELY ZERO EDUCATIONAL BENEFIT.

These tasks could be performed by ancillary staff, PA's, NP's, RN's, ect. Why arent' they already? B/c it costs $70k/year to pay a PA for 40-50 hours a week, and it costs $35K/year for a resident to work unlimited hours. This cost-savings for the hospital is bad for patients as well as residents. If it takes enforcing these work hours for changes to be made, then I'm all for it!

Actually, the hospital itself pays NOTHING for the resident services. Medicare funds all resident salaries. Indeed, most hospitals make a profit off resident slots paid by Medicare and use those excess funds to pay for patients who dont have insurance.

Its a 35k-75k per year cost compared to a ZERO dollar cost for resident slave labor

 

[DoctorDoom]

You are overstating the claims of the surgery residents who have posted here, and not giving credit to those of us who have made measured and qualified statements regarding work hours and patient care. Broadly accusing surgeons of arrogance clearly indicates that maybe you should look at what people have actually said, instead of haranguing us based on your preconceptions and prejudices.

 

[::Seabass::]

Originally posted by DrMom
Don't assume that you are being looked down upon. You simply don't have much life experience. You will find that some of your opinions will change after you have gotten older and had more experiences.

you will be very surprised how differently you look at things 2 years from now, and how they will change again 2 years from that, and 2 years from that. I would never have guessed. oh, and I also agree with Dr. Mom, come back and re-read your stuff in a couple years and you might be surprised.

 

[shag]

I'm with MacGyver on this one... The continuity arguement just doesn't make sense. If you take q4 call, then your patients get overnight continuity exactly 1/4 of the time... The only way to ensure true continuity would be for the primary team to work 24/7... Even "macho" surgeons would find this to be a hard pill to swallow 🙂 .

As a mere third year student, I have taken 27 weeks of q4 call. I have only worked one 130 hour week, but have many 115 -120 hr weeks under my belt. It is true that you must adapt to survive, and I have, but to deny that you are compromised is absurd.

An analogy: I can drink 4 beers in 2 hours and feel perfectly sober. I notice no impairment in my ability to operate a motor vehicle. The person riding shotgun probably wouldn't even guess that I had been drinking if he/she hadn't been drinking with me. I can even perk up during an "interesting case", like when a police officer is behind me. If you tested my reaction times and coordination, though, you would likely see impairment. Now imagine this scenerio after 12 beers. This is how I feel after a 42 hour shift (my longest so far, and I haven't even done surgery yet 🙂 ).

Take a wild guess where I stand on this issue...

 

[BCE]

I agree with Shag on this.

The Anaesthetists have studied this the most. The evidence is very clear and reproducible

Cognitive and psychomotor skills decline with period of time awake and with cumulative sleep debt - in an almost identical way to being intoxicated.

There is a certain degree of individual variation to it - those that need 5-6 hours sleep / 24 hours incur their sleep debt more slowly - so some people have a resistance to it

These same studies show consistent lack of insight into their impairment by the doctors concerned - they continue to rate their performance well above what it actually was - and a significant proportion perceive it actually improved.

This last point is the most important one - if you dont percieve the impairment why would you perceive the need to change your practice ?

As for a code waking you-up - it dosnt seem to - a PhD student locally has just finished prospectively looking at codes at night and found medication errors, negative variations from guidelines and slow decision times in those who were on 36 hours shifts vs. those on 10 hour night shifts.

The evidence is there and only a few minutes on medline turns it up.


I dont know that the correct answer for training - surgical in particular - is, because clearly sometimes the hours are the only way to get the experience. But I think we should be careful we dont kid ourselves too much that there is anything special or particularly safe about our performance after 30+ hours at work. It might be a necessary evil for some parts of residency - but its not a good thing - and those that think it is are ignoring the rapidly expanding body of evidence to the contrary

BCE

 

[Winged Scapula]

I define the issue of continuity of care differently, perhaps because things work differently in my program, or at least it appears to from the comments above.

I define continuity of care as someone who is familiar with the patient doing the patient care. If I have a team, then *I* don't have to be on 24/7 but rather we divide the call and someone from the team is on every night - just not the same person. These are the same group of people who round on the patients in the morning/evening, who operate on the patients and follow them post-op (although obviously not every team member will have operated on every patient on the service).

To reduce hours, we have had to go to a cross-cover approach. While the same team is rounding on the patients during the day, after hours and on weekends, the "cover" may very well be someone who has little to no exposure to the patients. Therefore, in order to protect the hours we have lost continuity of care. As droliver and I have noted before, while I don't doubt that mistakes are made when physicians are working extreme hours, I'll bet my life that *more* mistakes are made when using a coverage system and people who don't know the patients or the attendings are on.

Frankly, I've spent the last month covering at night for another Surgical Service - I don't get sign-out, am not given a list of the patients (supposedly because of HIPPA concerns) and have met only 1 of that team's attendings. Lord knows one of these days something is going to happen to a patient because I don't know anything about them and am trying to do the right thing...but didn't know the necessary details to be able to figure that out.

 

[MacGyver]

Lets be real here. There are going to be continuity problems REGARDLESS, unless you plan on working 24/7 at the hospital.

Even if you work 68 hours straight, eventually you have to hand off those patients to another doc, and theres a continuity shift.

The main problem I have is with people who pretend that continuity was never a problem before and it just sprung up all of a sudden.

 

[neilc]

hey there mac..as i have been reading this, i have understood people to be saying that both inadequate rest and continuity have been a problem. but, continuity has been a bigger problem, and that problem will get worse with the change. i personally would much rather have a tired doc that knows me work on me than some bright eyed and bushy tailed doc that slept an extra hour or two, but has no knowledge of my case.

i am not really for or against the regs. the way i look at residency is that it is my time to learn what i need to be an excellent surgeon. when i get to that point, i don't want to be worked to death, but i do want to be able to spend every hour that i need to learn to be the best doc i can.

 

[lizzied2003]

neilc
just sent PM. hopefully you got it. lizzie

 

[neilc]

lizzie, i never got a pm! send it again if you can. thanks!

 

[lizzied]

neil, try now

 

[DoctorDoom]

I think you are interpreting our posts properly neilc, for a change. Currrent work hours are often excessive, change should take place, cognitive abilities are diminished by sleep deprivation. This does not mean that work hour reform should not be carefully weighed, especially in surgery residency, against a more significant continuity problem. Physical skills are not necessarily diminished either. A sleep deprived surgery resident may make decisions slower and deviate from protocols, but does that mean the patient would have been better off with a well-rested resident who knows nothing about him/her, but sticks to protocols? Or even no resident at all? I think not.

No one says 40 hours straight is good. No one says 120 hours of scut a week for 5 years is good. No one disputes that after working those kinds of hours patient care and resident life takes a toll. What we are saying is that reducing work hours is no panacea, and it does present problems of it's own. If anything I am impressed by the balance and willingness to change of the surgery residents here, rather than feeling overwhelmed by their arrogance. Amazing what happens when you actually read peoples' posts, MacGyver...

 

[OwlMyste]

Originally posted by lizzied
neil, try now

Lizzied...do you also have the name lizzied2003? if so, im curious as to why you have 2 screennames? if you forgot your password to one of them, then im sure theres a password remember thingy on this site somewhere....anyhow, just curious...thats all...

thanks,

 

[mcataz]

I'm glad the 80 hour work week was imposed. I would much rather have a well rested physician even if he wasn't the same one who prepped me earlier. As a former surgical tech who worked with surgeons on an intimate basis, I know a lot about their lifestyle. NO, they don't work 80+ hours a week outside of residency. In fact, many of them have excellent lifestyles. Sure, they may be forced to doing a case on an instant notice particularly if you are an orthopedic surgeon. But to suggest that surgeons don't sleep over 8 hours is ridiculous. They get plenty of rest.

The excessive hours is a rite of passage and nothing else. It's there to test your endurance as to somehow suggest you will be a better surgeon if you can last in the wee hours with no rest. Unfortunately, you aren't operating on androids so your patient could be harmed at the expense of testing your endurance.

I agree in that there should be some wiggle room to the 80 hours. Patients don't want to feel like they are being abandoned. But none of you would want your mother operated on by a physician who hasn't slept in 30 hours despite the bravado you are professing here.

 

[lizzied2003]

good observation owl. yes, you will see that lizzed actuallyhas 4 posts. when the search function was down i believed it was my computer and tried to reregister. i did not think i posted anything under lizzied but when i logged on from our cable site to SDN it came up with lizzied. hope this helps satisfy your question. by the way owl, funny i just checked this board. i sent you a PM earlier today.

 

[OwlMyste]

Thanks lizzied...

I got your PM....thanks for not thinking of me as a troll...🙂😎

 

[OwlMyste]

Originally posted by mcataz
But none of you would want your mother operated on by a physician who hasn't slept in 30 hours despite the bravado you are professing here.

well said....took the words right out of my mouth......😎 🙂