I love 80 hours

[SLUser11]

I love it because we now have the luxury to complain about 90-100 hour weeks instead of 120 hour weeks.

I love it because it forces us to be efficient with our time.

I love it because it allows us to study outside of work, and make room for academics.

I love the ACGME work hour restrictions for these and many other reasons. The Halstedian tradition worked for a long time, but it's not necessary to create excellent surgeons. I'm not going to be on my soapbox for very long, but we shouldn't resent the rule for robbing us of our education. We should resent the system that prevents us from getting our education in a healthy fashion.

By reducing or eliminating redundant/monotonous/menial/uneducational tasks from the resident's workday, you can easily become a phenominal physician and surgeon in 80 hours per week for 5 years.

Anyway, read this article for some perspective....things were not healthy before work-hour restrictions. We've already come a long way in just 4 years:

Unique Identifier 12799339
Niederee MJ. Knudtson JL. Byrnes MC. Helmer SD. Smith RS. A survey of residents and faculty regarding work hour limitations in surgical training programs. Archives of Surgery. 138(6):663-9; discussion 669-71, 2003 Jun.

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[Winged Scapula]

Anyway, read this article for some perspective....things were not healthy before work-hour restrictions. We've already come a long way in just 4 years:

Unique Identifier 12799339
Niederee MJ. Knudtson JL. Byrnes MC. Helmer SD. Smith RS. A survey of residents and faculty regarding work hour limitations in surgical training programs. Archives of Surgery. 138(6):663-9; discussion 669-71, 2003 Jun.

Perspective? I thought there were enough of us "old-timers" around here who remember and lived the pre-80 hr workweek to remind you young'uns!. Apparently we haven't been doing our job!!

 

[zinjanthropus]

education is not going to suffer because of the 80 hour work week, it will only get more efficient and our generation will be doctors and better people because of it...the 80 hour work week allows me to consider surgery as a realistic choice in the face of a wife and the propostion of a growing family and outside interests

medicine is a lifestyle - not a just a job - but I have to get out of the hospital enough to balance my life....there is nothing that can be done in 120 hours effectively that can't be done in 80 or less - with adequate sleep, exercise, nutrition, and social support added into the extra time.

many countries have training on par to us and have even tighter work hour restrictions - the UK will be going down to 48 hours soon.

when my attendings and residents who were around pre 80 work week start to brag about their street cred and toughness b/c they worked 120 hours, I just think to myself what suckers they were for doing so and then I remember the residents I saw standing in the snow, striking in 2002 for the new work hour rules to go into effect...those are the residents I respect. i understand that there wasn't much of a choice before that - but at least recognize that the change is for the better and end your nostalgia for a golden age that never existed.

 

[dawg44]

education is not going to suffer because of the 80 hour work week, it will only get more efficient and our generation will be doctors and better people because of it...the 80 hour work week allows me to consider surgery as a realistic choice in the face of a wife and the propostion of a growing family and outside interests

medicine is a lifestyle - not a just a job - but I have to get out of the hospital enough to balance my life....there is nothing that can be done in 120 hours effectively that can't be done in 80 or less - with adequate sleep, exercise, nutrition, and social support added into the extra time.

many countries have training on par to us and have even tighter work hour restrictions - the UK will be going down to 48 hours soon.

when my attendings and residents who were around pre 80 work week start to brag about their street cred and toughness b/c they worked 120 hours, I just think to myself what suckers they were for doing so and then I remember the residents I saw standing in the snow, striking in 2002 for the new work hour rules to go into effect...those are the residents I respect. i understand that there wasn't much of a choice before that - but at least recognize that the change is for the better and end your nostalgia for a golden age that never existed.

There is one way the training will suffer I won't give up the knife to anyone that quotes the rule. As an attending I'm telling you if a resident ever scrubbed out of a case quoting the 80 hr work week that just tells me they don't like surgery. There is no sense in letting someone perform surgery if they don't like it. I love surgery and I am more than happy to do every single one of my cases when that person is around. They would probably be excellent at closing a wound and that's about it.

 

[Zoom-Zoom]

There is one way the training will suffer I won't give up the knife to anyone that quotes the rule. As an attending I'm telling you if a resident ever scrubbed out of a case quoting the 80 hr work week that just tells me they don't like surgery. There is no sense in letting someone perform surgery if they don't like it. I love surgery and I am more than happy to do every single one of my cases when that person is around. They would probably be excellent at closing a wound and that's about it.

I think you're missing the point.

 

[Miami_med]

What has always worried me about 80 hours is not the time. I think consistently working greater than 80 hours a week is not really good for anybody. However, I think work hour limits detract from the professional aspect of being a doctor. As a professional, one would expect to take care of a problem whenever it came in. The real issue is with programs that hold surgical training captive and a gunner culture that pervades everything.

Think about it this way. If I went to law school, and I wanted to practice corporate law, I would have many options. I could join a large firm and learn on the job. I could get a master's degree in corporate law, or I could take special courses in corporate law. I could even go at it on my own (Though this would be hard to do in surgery). In medicine, everyone has to do one kind of training program in one format, through one accrediting body. Some competition would take care of the work hour problem. Those that wanted long hours could have them, but indentured servitude would not be a pre-requisite to surgery. Some of the elite academic programs could have a long traditional residency (That was the original point of residency), and the community could provide an easier way to teach basic community surgery. Maybe this is dumb, but it seems that everything may be TOO standardized.

 

[boston]

What has always worried me about 80 hours is not the time. I think consistently working greater than 80 hours a week is not really good for anybody. However, I think work hour limits detract from the professional aspect of being a doctor.

I agree. I think the whole "80 hours" debate misses the point. There is nothing magical about 80 hours. It doesn't necessarily make you a good or bad surgeon. There is nothing intrinsically good about long hard hours -- except maybe that it tends to select for those who are dedicated and hard-working and discourages those who are the opposite.

No matter what work hour restrictions you impose or how you divide up the work week, it's still the same amount of clinical work to be done by the same number of residents. The numerator and denominator do not change. Reduce the time in the hospital, and it means you are more busier, more stressed during the time you are in the hospital.

I think the real issue is reducing the amount of brainless scut and inefficiency in the system -- for example, transporting patients around, filling out redundant paperwork, calling CT and dogging the CT tech repeatedly to make sure that scan gets done on time, running to the OR to get a damned femoral a-line kit because none of the ICUs stock them, etc. Without reducing the inefficiencies of the system and exploitation of residents as cheap scut labor, I think limiting our hours will eventually cut into meaningful clinical and operative experience. The 80 hours restrictions have made me better rested and a happier person, but I am not sure I am a better doctor. I do read a bit more, but marginally so. (I hate to admit it, but mostly, I just sleep more.)

I think the key is making sure our time at the hospital is better spent, not making sure that it is long and hard. Imagine if all your orders were carried out correctly and in timely fashion, studies and procedures got done on time (no more begging IR), vitals and chart information was instantly electronically accessible anytime at your fingertips. Imagine if you spent the majority of your time just operating, doing clinical decision-making on the floor or in clinic, or reading.

But perhaps the first step in the direction toward that sort of utopia is to impose work hour restrictions.

 

[dawg44]

I think you're missing the point.

If I'm missing the point. I don't really care, because as an attending you don't have to. There is a heirarchy in medicine especially in highly sought after surgical fields and its going to continue regardless of what anyone thinks. Everyone will cross the T's and dot the I's in the paperwork. Bottomline is this though, gunners will always get ahead and gunners will always get those spots regardless of how many hours they log in a weeks time. We have about 500 american grads apply for 3 spots every year, so anyone is entirely replaceable in any residency. The sooner people in these positions realize this the better off they will be. So to keep your spot you have to keep gunning, otherwise just there are always plenty of ways to get rid of someone for any number of reasons and comply with the 80 hr work week.

 

[neutropeniaboy]

Well, personally I think you're a dinosaur -- a sad representation of an egalitarian and hierarchical system that for many years mentally and physically abused trainees. You're another example of "I was treated this way, so I'm going to treat you this way." You're part of the reason why nurses hate physicians. You're part of the reason why physicians tip-toe around each other, become passive aggressive, never unify on a common front, and why medicine will always an old boy's network. Physicians like yourself bitch and moan, but never really make a significant difference. I suppose it's all because "[you're] an attending." I suppose that's prerogative...oops, nay, privilege.

The ACGME regulations are what they are. There's no proven reason to demonstrate that an 80 hour week is better than a 100 or 120 hour week. Personally, I'm thankful that all my in-house call was done before the 80-hour week took effect. I stay late in the OR because it's my training that matters. I watch residents go home post call and miss out on great surgeries because they're doing what they are instructed to do. It's sad that they have to miss out on 25-33% of the surgical cases because of this.

However, they do it because they have to, not because they dislike surgery. If you're going to look the other way with respect to dotting the I's and crossing the T's, I wonder what else you conveniently overlook.

If I'm missing the point. I don't really care if I'm missing the point because as an attending you don't have to. There is a heirarchy in medicine especially in highly sought after surgical fields and its going to continue regardless of what anyone thinks. Everyone will cross the T's and dot the I's in the paperwork. Bottomline is this though gunners will always get ahead and gunners will always get those spots regardless of how many hours they log in a weeks time. We have about 500 american grads apply for 3 spots every year, so anyone is entirely replacable in any residency. The sooner people in these positions realize this the better off they will be. So to keep your spot you have to keep gunning, otherwise just there are always plenty of ways to get rid of someone for any number of reasons and comply with the 80 hr work week.

 

[Surgeon24]

The thing is you may wish the system will become more efficient by forcing the 80hour a week rule, but I doubt it would. Seems like with that kind of rule, the only thing that will change is that the job during the day is not complete, but that's my humble opinion.

I'm happy that we don't have this 'rule' in canada, at least not in Quebec. I get out of the hospital when my work is done, not when my watch tells me to. When I applied in surgery, I knew that I was flushing down my social life, but that was a decision I made and I don't regret it at all.

By the way, what happens when you're an attending? Especially if you're practicing in a community hospital? There's no 80 hour week rule. If you have to wake up at 3:00 AM for an appendicitis, then you have to do it.

There's a big difference between working a lot and doing something to improve yourself (i.e. open/close an abdomen if you've never done it before), and working a lot to do some BS work (filling out prescriptions when you don't even know the patient).

 

[SLUser11]

If I'm missing the point. I don't really care if I'm missing the point because as an attending you don't have to. There is a heirarchy in medicine especially in highly sought after surgical fields and its going to continue regardless of what anyone thinks. Everyone will cross the T's and dot the I's in the paperwork. Bottomline is this though gunners will always get ahead and gunners will always get those spots regardless of how many hours they log in a weeks time. We have about 500 american grads apply for 3 spots every year, so anyone is entirely replacable in any residency. The sooner people in these positions realize this the better off they will be. So to keep your spot you have to keep gunning, otherwise just there are always plenty of ways to get rid of someone for any number of reasons and comply with the 80 hr work week.

Everyone is entitled to their opinion, even if their grammar sucks big-time.

I think that a lot of attendings with a desire to teach are going to have to change their attitude. There are going to be many fresh, well-trained surgeons graduating from residencies under the current rule that have a positive attitude, and are easy to work with.

Keep your current attitude, and you might find yourself R-E-P-L-A-C-E-A-B-L-E. Sorry, dawg.

 

[Apollyon]

By the way, what happens when you're an attending? Especially if you're practicing in a community hospital? There's no 80 hour week rule. If you have to wake up at 3:00 AM for an appendicitis, then you have to do it.

But, at the same time, you go in at 3am, there's no putzing around - YOU are the rate-limiting step, so, once you put the cam in, insufflate, locate, free up, ligate, extract, and ensure hemostasis, you're done (mind you, I'm not a surgeon - that is for dramatic effect). As a resident, it's a lot of hurry up and wait. Surgery is bad enough - IM is absolute TORTURE.

When I was at Duke, there was a vascular surgeon whose code words were "I'm on the way in", which meant he rolled over in the sack. The residents knew with him that they could start the case, do it, and finish, while "waiting" for him. However, that is atypical - as a resident, you are putzing around as the staff jerks you around, and you are scrubbed and waiting tableside for the attending to get there - whenever they do. That wasted time is time you would have to yourself as the attending - sooner you cut, sooner you're done.

 

[dawg44]

Well, personally I think you're a dinosaur -- a sad representation of an egalitarian and hierarchical system that for many years mentally and physically abused trainees. You're another example of "I was treated this way, so I'm going to treat you this way." You're part of the reason why nurses hate physicians. You're part of the reason why physicians tip-toe around each other, become passive aggressive, never unify on a common front, and why medicine will always an old boy's network. Physicians like yourself bitch and moan, but never really make a significant difference. I suppose it's all because "[you're] an attending." I suppose that's prerogative...oops, nay, privilege.

The ACGME regulations are what they are. There's no proven reason to demonstrate that an 80 hour week is better than a 100 or 120 hour week. Personally, I'm thankful that all my in-house call was done before the 80-hour week took effect. I stay late in the OR because it's my training that matters. I watch residents go home post call and miss out on great surgeries because they're doing what they are instructed to do. It's sad that they have to miss out on 25-33% of the surgical cases because of this.

However, they do it because they have to, not because they dislike surgery. If you're going to look the other way with respect to dotting the I's and crossing the T's, I wonder what else you conveniently overlook.

Ortho is absolutely an old boy network. I think 99% of the programs are actually proud of that fact as well. It's hard to let someone else do a surgery. It increases your stress level and it slows you down. So if you don't think someone's putting out the effort that another person is, it is very easy to not let them do a thing and not think twice about it. The bottom line is this, all patients are the attending's patients, so anything you are allowed to do is an absolute privilege. Too many residents take that for granted. As far as their dislike for surgery, it's all a matter of perception.

 

[dawg44]

Everyone is entitled to their opinion, even if their grammar sucks big-time.

I think that a lot of attendings with a desire to teach are going to have to change their attitude. There are going to be many fresh, well-trained surgeons graduating from residencies under the current rule that have a positive attitude, and are easy to work with.

Keep your current attitude, and you might find yourself R-E-P-L-A-C-E-A-B-L-E. Sorry, dawg.

I didn't have time to spell check my post last night because that would have put me over the 80 minute a week message board rule.

 

[dawg44]

Teaching is a great thing, but you demand to see the same type of passion and effort that you put into your training. When you put the 80 hr work week into effect, and you have residents scrubbing out of cases, it just makes them look absolutely lazy. You can't fight that perception. When I said anyone is replaceable I meant attendings too. The only difference though is this. They can sort through a half a dozen 500,000 dollar a year jobs and will definitely make more and work less than they were at a teaching facility. Instead of having residents, they can have a PA to essentially function as a resident. The only difference is this, they can make money on a PA. A resident finding another residency, that's a little harder job search. You can't just look those up on Monster.com.

 

[Faebinder]

Teaching is a great thing, but you demand to see the same type of passion and effort that you put into your training. When you put the 80 hr work week into effect, and you have residents scrubbing out of cases, it just makes them look absolutely lazy. You can't fight that perception. When I said anyone is replaceable I meant attendings too. The only difference though is this. They can sort through a half a dozen 500,000 dollar a year jobs and will definitely make more and work less than they were at a teaching facility. Instead of having residents, they can have a PA to essentially function as a resident. The only difference is this, they can make money on a PA. A resident finding another residency, that's a little harder job search. You can't just look those up on Monster.com.

Are we really comparing how profitable is a PA compared to a resident? Seriously? Ortho PA gets paid what? 100k? Resident gets paid what? 50k which is actually from the government and the hospital pockets another 60k from the government? Not to mention the PA is not going to work after 5 or weekends.

Yes you can have a PA.. but its not as profitable.

 

[Debridement]

Ifso anyone is entirely replaceable in any residency. .

I think that should be your opening slide at the next morning conference you give.

Better yet, you should try to fire 1 resident per class per year. Be sure to put that in the .PPT that you show the prospectives on interview day. That will do wonders for your program.

Seriously though, do you really believe that? Where are you going to find a PGY-4 in October?

Bottom line is that residents make a program, during and after, and a good Chair knows that and breeds graduates that will reflect well on the Dept. Firing residents is not good for business. Picking good ones is. Engendering them with bitterness is not.

Think about that Talus-man,

D-bag

 

[dawg44]

Are we really comparing how profitable is a PA compared to a resident? Seriously? Ortho PA gets paid what? 100k? Resident gets paid what? 50k which is actually from the government and the hospital pockets another 60k from the government? Not to mention the PA is not going to work after 5 or weekends.

Yes you can have a PA.. but its not as profitable.

I don't understand that you don't get this. Its as simple as this, you can bill insurance for a PA. You can't bill for a resident. You will make more from being more efficient and the billing you receive for having a PA. If you do high volume they will make the surgeon money.

 

[dawg44]

I think that should be your opening slide at the next morning conference you give.

Better yet, you should try to fire 1 resident per class per year. Be sure to put that in the .PPT that you show the prospectives on interview day. That will do wonders for your program.

Seriously though, do you really believe that? Where are you going to find a PGY-4 in October?

Bottom line is that residents make a program, during and after, and a good Chair knows that and breeds graduates that will reflect well on the Dept. Firing residents is not good for business. Picking good ones is. Engendering them with bitterness is not.

Think about that Talus-man,

D-bag

You don't have to put into print what is understood.
Where do you find a PGY-4 in october? You don't. You take an extra PGY-2 in July.

 

[toxic-megacolon]

By the way, what happens when you're an attending? There's no 80 hour week rule.

Not yet, but there will be. And we'll fight it. And it'll get passed anyway. And then we'll fudge our hours. And then we'll whine when an outside agency has to police our hours for us because its insulting (even though we proved we couldn't report our hours honestly).

Think about it this way. Would the average person get on an airplane if they knew the pilot had been up for 2 days without sleep? Of course not. Why is it different for your lap chole? Simulators have proven that physicians do significantly worse with extreme sleep deprivation. Are there any studies on operative mortality? Of course not, such a study would be extremely UNETHICAL. Can you imagine a double blinded RCT where patients are divided into two groups: one has surgery by a surgeon who's been up over the past 36 hours vs one who woke up this morning and doesn't have 4 days of stubble on his face.


I'm not commenting on how things should be, but just what think is going to happenin the next 10 years...

 

[Miami_med]

This is completely out of ignorance.

Why would an insurance company pay for a PA but not a resident MD? This makes no sense. After PGY-1 in most states, the MD is a lisenced physician.

 

[dawg44]

This is completely out of ignorance.

Why would an insurance company pay for a PA but not a resident MD? This makes no sense. After PGY-1 in most states, the MD is a lisenced physician.

It is called double dipping. The government pays for you so no one else can bill for your services. I know an orthopod that makes about 40,000 per year off of billing from his PA after paying her salary and benefits. That doesn't even take into account how much more efficient he is by having her there. He also doesn't have to introduce a new resident to every patient he sees. She is an extension of the practice.

 

[Miami_med]

It is called double dipping. The government pays for you so no one else can bill for your services. I know an orthopod that makes about 40,000 per year off of billing from his PA after paying her salary and benefits. That doesn't even take into account how much more efficient he is by having her there. He also doesn't have to introduce a new resident to every patient he sees. She is an extension of the practice.

Sorry, but one more question?

The government coverage is for Medicare right? I thought that this only applied as payment for the ratio of medicare patients you see. Is it still illegal to bill private insurance for patients who are not eligible for medicaid?

Thanks

 

[imalwayshungry]

The bottom line is this, all patients are the attending's patients, so anything you are allowed to do is an absolute privilege. Too many residents take that for granted. As far as their dislike for surgery, it's all a matter of perception.

check out the sister thread to this one... the i hate 80 hours one

but I see what you're saying. i found that over my third year of med school (yes i'm a measly med4), when i was working long hours on surgery, i didnt mind being there. but, when I was working short hours on something I hated, I despised being there. when I hear a resident complain about being there or having to do work (not just surgery residents but any residents), it seems to me that they simply dont like what they're doing and are miserable. i understand that the work that I did as a medical student on a surgery service was not nearly as crucial as that done by the residents; however, given the level of knowledge/skills thus far attained, the rotation constituted the most stressful weeks of med3, but they were still the best weeks of the year.

I guess that's why I dont mind working relatively long hours and I dont mind going to the ER to see a new pt - it's a hell of a lot better than being on a rotation that I hate. (and usually every thing i see is new to me given the relatively wee bit of experience i've had so far, so i almost always learn something)

oh, and have you actually had residents literally scrub out of cases to go home?!?!

 

[SLUser11]

check out the sister thread to this one... the i hate 80 hours one

What? There's another thread with the EXACT OPPOSITE title?!?

I need to check that out....thanks for the heads up.

 

[Analyzethis]

If I'm missing the point. I don't really care, because as an attending you don't have to. There is a heirarchy in medicine especially in highly sought after surgical fields and its going to continue regardless of what anyone thinks. Everyone will cross the T's and dot the I's in the paperwork. Bottomline is this though, gunners will always get ahead and gunners will always get those spots regardless of how many hours they log in a weeks time. We have about 500 american grads apply for 3 spots every year, so anyone is entirely replaceable in any residency. The sooner people in these positions realize this the better off they will be. So to keep your spot you have to keep gunning, otherwise just there are always plenty of ways to get rid of someone for any number of reasons and comply with the 80 hr work week.

*****