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IOM Duty Hours report out today (12/2)

Discussion in 'Surgery and Surgical Subspecialties' started by Pilot Doc, Dec 2, 2008.

  1. Pilot Doc

    Pilot Doc SDN Angel
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  3. Pilot Doc

    Pilot Doc SDN Angel
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    Among the highlights of their recommendations

    - keep 80 hours week
    - keep 30 hour shift limit, but any shift over 16 hours must have a 5 hour protected sleep break that counts toward 80 hours
    - outside moonlighting to count toward 80 hour limit
    - 5 days off/month including one 48 hour block
    - 1 day off every 7 days, no averaging
    - estimated annual compliance cost $1.7 Billion

    These are just recommendations - will be very interesting to see whether they get traction in the popular press and/or backing from people with power.
     
    #2 Pilot Doc, Dec 2, 2008
    Last edited: Dec 2, 2008
  4. Pilot Doc

    Pilot Doc SDN Angel
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    Others

    - absolute limit of call to Q3 (no q2 allowed even if average is Q3.) i.e. no more Fri/Sun calls.
    - max 4 night shifts in a row with 48 hrs off after 3 or 4 consec night shifts (i.e. no more week of night float.)
    - 10 hours off after each day shift (so 14 hours is the practical limit for a day shift)
    - 12 hours off after a night shift
    - 14 hours off after a 30 hour shift and cannot come into hospital before 6am when returning

    Wow ... this is going to make designing a surgery coverage schedule really hard. Call as we know it is pretty much out b/c of the 5 hour sleep rule. And night float is hard b/c you can't work more than 4 days in a row and then get 2 days off. This is going to be really hard at hospitals (like VA's) that generally staff to keep 1 surgeon in house at night. I think you're looking at 4 people to provide 24-7 coverage.
     
    #3 Pilot Doc, Dec 2, 2008
    Last edited: Dec 2, 2008
  5. Pilot Doc

    Pilot Doc SDN Angel
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    Another interesting tidbit - all the rules can be thrown out for a "critical learning opportunity"

    But the program has to document each time it happens.
     
  6. beaverfetus

    beaverfetus poo-tee-weet?
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    you want traction with the press eh?

    http://well.blogs.nytimes.com/2008/12/02/panel-calls-for-changes-in-doctor-training/

    not bad for several hours after the release
     
  7. dr.evil

    dr.evil Senior Member
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    Life was so much better in residency and I just didn't realize it! Everything but the better paycheck.
     
  8. maxheadroom

    maxheadroom Rhinestone Cowboy
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    Wow, that looks like a HUGE administrative headache. While I appreciate efforts to make training more humane and medical care at teaching hospitals safer, the burdens seem to be getting greater and greater.
     
  9. Winged Scapula

    Winged Scapula Cougariffic!
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    I love these mandates without any funding sources.:rolleyes:
     
  10. njbmd

    njbmd Guest
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    Not to mention that the amount of work doesn't go away just the amount of time to get it done. Now some funding for an extra resident or two might make a huge difference but that never going to happen. The cutting is going to happen which means that more work, less time to get it done by the residents.

    At my institution, we already exceed these hours anyway because the teaching attendings are very aggressive about making sure that the residents get plenty of study and rest time. While I work more, the residents have a better educational experience. Since I am fairly new out of residency, I hardly notice a change from my fellowship and residency days other than the paycheck, office and lab. :D
     
  11. Celiac Plexus

    Celiac Plexus Senior Member
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    While I have never been a fan of the 80 hour business, these new recommendations seem incredibly out of touch with the current reality of surgical training.

    It may be time for surgical fields to start breaking away from the acgme, and the rrc. Maybe we need a new accreditation body that is sensitive to the training needs and funding issues germane to surgical training. These one size fits all rules/recommendations are just nuts. Oddly, in our evidence-based world that we like to say we live in, there is no evidence that any of these changes make our training environment any safer which was the original reason for going to the 80 hour work week.

    Glad I'm almost done.
     
  12. GSresident

    GSresident PGY4 on July 1, 04
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    How are level 1 trauma centers going to be plausible any more? The cost of 1.8B doesn't factor in what it will cost to pay a surgeon to stay in house for 24 hours. If those rules are adopted it will get ugly.

    How the hospitals will try to get around paying for GS/trauma coverage is they will require that you do it to have privileges. Oh I hope so much that you general surgeons out there have the balls to say 'stuff it'.

    If general surgeons magically get testosterone shots and stand up to the hospitals then state legislatures will have to act. In Kansas City, for example, there HAS TO BE A LEVEL 1 TRAUMA CENTER within so many miles of the Kansas Speed Way. The Kansas Speed way brings multi-gogilians of revenue to the state every year. Do you really think the state of Kansas is going to respect the surgeon's right to his own time when a Speedway is at stake? I suspect what will happen is state legislatures will have to tie some degree of forced servitude into medical licenses.
     
  13. Pilot Doc

    Pilot Doc SDN Angel
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    Where do the rules say that? The only staffing requirements I see are that interns can't be the only doc in house.
     
  14. Pilot Doc

    Pilot Doc SDN Angel
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    It's gone beyond that. Might have worked when the ACGME essentially made up the duty hour regs out of thin air. But this report was commissioned by congress. If it gets traction with the ACGME the surgery programs won't have a leg to stand on. They'll have to change or close.
     
  15. Chemdocx

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    The attending talking talking to a group of students on our surgery rotation made a sports analogy that essentially went like this...
    20-30 years ago football coaches thought it was a good idea to break athletes down every day i.e. to do things like limit water intake during practices in the hope of making the players accustomed to physiological stressful situations. Nowadays, the physical demands for gameday are perhaps not as demanding (not as many players suffer heatstroke, less practice injuries, etc. ) Players do on average perform better due to improved/efficient training and coaching methodologies bore out with trial and error. He said residency training is going through a bunch of trial and error with an eye on improving performance. maybe a stretch but I thought it was interesting
     
  16. GSresident

    GSresident PGY4 on July 1, 04
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    I could be way off on this so take this with a grain of salt. It is my recollection that there HAS to be a surgeon who can independently take a patient to the operating room IN HOUSE at all times in a level 1 trauma center. In our institution (KU Med Center) this translated into a chief resident in house 24/7. 4th years were considered chiefs in that program. If you can only be in house 16 hours at a time (5 hours being protected sleeping) someone will have to fill in the extra time. If it is another chief that will screw with the other chief's hours. They will have to be extremely clever to work that out without involving attending level surgeons.

    A personal message to pilotdoc: I am giving the most serious thought to getting a pilot license. If obama raises income taxes to ridiculous levels I will take the extra money from my practice and buy a plane. We'll see though, this is all in the dreaming about stages right now.
     
  17. GSresident

    GSresident PGY4 on July 1, 04
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    I think its a smart idea to streamline training. The problem is with the logistics of all of it. Your wonderful government has a habit of mandating things that cost money without providing the money.
     
  18. toxic-megacolon

    toxic-megacolon Toxic Member
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    Less call??? I learned a LOT filling out med rec forms, doing post-op urine output checks, calming down fussy nurses, updating the list, etc, etc, and wasting my post call day recovering from the intense learning experience. Why would I want a PA to take away from this priviledge, they are certainly not qualified!

    Jokes aside, I find that when programs cut duty hours, they cut it out of high-yield portions of the day (ie when the sun is up, cases are going in the OR, etc, etc) but need to keep night coverage which is largely scut, at least at my institution. I think 60 hours a week of being in the OR, seeing consults, rounding is MUCH more high yield than hours at night. Whether people admit it or not, call is much more a financial decision on the hospitals part.
     
  19. toxic-megacolon

    toxic-megacolon Toxic Member
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    Going from 36% to 39% on the portion of your income over 250,000 is a huge, ridiculous increase? :confused:
     
  20. opr8n

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    seriously?? 5hrs to sleep, dont think in my 3 years in residency that i have even come close to 2 hours of undisturbed sleep, good mluck implemeting that one, it would require 2 people on call every night, given that our residency covers 6 hospitals, that might be impossible or upper levels 3/4 or possibly 5 may have to take inhouse call to back up the junior for those 5 hours
     
  21. opr8n

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    i dont know about others but it is pretty common to have 12 days on, 2 off, especially if I was on over a saturday one week, the no averaging part just wont work
     
  22. opr8n

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  23. PeepshowJohnny

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    I don't understand this rule at all. You can justify the 5 hour sleep break and other stuff to improve resident's mental faculties, less mistakes, more learning. But what does forcing everyone to take a day off every week, no averaging accomplish? Sometimes it's nice to have a long week into a long weekend, since you can do some personal things like short trips only if you have two days off in a row.
     
  24. Winged Scapula

    Winged Scapula Cougariffic!
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    Really. My former program would have to restructure the call rooms...even if my pager wasn't going off I could rarely sleep as the walls were so thin you could hear the pagers go off in the next room, doors slamming, people talking in the hallway. 5 hours of sleep could easily be 30 minutes here and there in fits and starts.

    I can't imagine how these changes would be implemented without hirting more residents and/or mid levels, which further reduces the useful training.
     
  25. smq123

    smq123 John William Waterhouse
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    They openly admit that the changes will be difficult and expensive to implement.

    http://books.nap.edu/openbook.php?record_id=12508&page=268

    Gee, really?
     
  26. Pilot Doc

    Pilot Doc SDN Angel
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    The 5 hour nap is a red herring. It was put in so that the recs wouldn't ban 24 hour shifts. I can't imagine any surgical program finding that solution feasible. If ACGME adopts the recs, scheduling will have to be changed wholesale. My guess is that a 3pm-7am "call" or some sort of night float are going to be the most practical ways to run a service.
     
  27. GSresident

    GSresident PGY4 on July 1, 04
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    Yes. Even that fact that my income is taxed at 36% is ridiculous, let alone taking 3% more. I've earned every freaking penny I'm making. The value to society of my services are many times more than I am paid so they are getting an amazing bargain. And, by the way, if you think you are only taxed at 36% you are dreaming.
     
  28. Winged Scapula

    Winged Scapula Cougariffic!
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    Oh I read that too. My point is that again, this is simply another set of mandates without funding or realistic options for funding. "Difficult" is putting it mildly. Look how many programs are struggling with the current recommendations.
     
  29. opr8n

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    The ACs did a cost analysis in march 08 of changing some reccs on duty hours and they figured that it would have a projected cost of 60 million dollars . . . where is that money coming from??
    That covers new resident salaries and midlevel providers
     
  30. CTS

    CTS
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    3pm-7 am is not possible - only 8 hours between shifts. 5p-7a is probably an option.
     
  31. Pilot Doc

    Pilot Doc SDN Angel
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    3p-7a would be for a call system, not a NF system. you'd have 24 hrs off after working that shift.
     
  32. jubb

    jubb Tern
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    This is just getting ridiculous. Are we trying to kill the work ethic of the next generation of doctors? I mean isn't it bad enough that we have excuses like "This isn't my patient I'm just cross covering" but now we'll have "I'm about to start my scheduled 5 hour nap find someone else." Patient ownership is a thing of the past, it'll all be shiftwork, and all as efficient as the ER.

    I believe the majority of surgery residents will blow off these rules to get the job done, but those off service interns are going to be so painful to deal with if these rules stick.
     
  33. Miami_med

    Miami_med Moving Far Away
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    It's much worse than that. This is a report to congress. It isn't like all you have to do is fool the RRC and risk probation. They will assuredly assign stiff legal and potentially criminal penalties for violating any of the recs that they adopt. When the attendings have to start working more, they will inevitably see their hours diminished by law as well. Then we'll find ourselves in a catch-22 on multiple levels. There will be a deficiency of coverage on a national scale, which will inevitably lead to some sort of ill-conceived "cure." Personally, every attending will probably be put in a position at some point where saving the patient is illegal due to work hours and not-saving the patient is illegal due to patient-abandonment laws. A beauracracy whose sole purpose is to come up with duty recs and enforce them will have to continually justify its existence with progressively more ridiculous recs. I'm thinking sort of a work hours JCAHO.

    I'm sort of hoping that this report gets lost in the greater economic situation.
     
  34. dienekes88

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    At least the doc will be well rested for his day in court... :rolleyes:

    I can only imagine the outcry about "lazy physicians" when the wait-lines in the Emergency Department go up to 20 hours, and people start dying in the waiting rooms en masse.

    What the public, i.e. the audience for the NYTimes article and the ones who will be up in arms about being put in danger, doesn't realize is that reducing the hours doesn't reduce the amount of work that has to be done. I'm sure the residents would love to sleep more. However, I'm also sure the residents would love it if patients didn't get sick at odd hours.
     
  35. dienekes88

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    This isn't limited to physicians. Wall Streeters have bemoaned the most recent crop of analysts (~last 10 years). The bright eyed college students want to come in to work late after a night out, leave early to go rock climbing and hit the organic grocery store, have time to start a family, and make Managing Director by the 3rd year. Case in point: a buddy of mine, whose work ethic is quite good - he does nothing but work, has had trouble adjusting to his "old school" boss. His boss will flat out yell at him, "****, this isn't a god damn orphanage for ******ed children." This is a guy who is definitely in the group that is the closest this generation will come to old school attitudes towards work.

    I imagine the general cushy attitude in rearing children has a lot to do with this: Everyone's a winner; every "finisher" get a prize; the kid is smart but has ADD, etc. I'm sorry, there's only one winner: the one who wins. "Finishing" is not impressive, and "finisher" medals are bullsh*t. Some people are just stupid, and there's nothing wrong with that. The second I realized that I wasn't some brilliant dude who was going to cure the world of heart disease, I got a lot happier.

    The laziness factor probably has to do with the difficulty of transitioning from being a "superstar" to being a grunt.
     
  36. dilated

    dilated Fought Law; Law Won
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    So the guy works really hard and does his job well but it's a giant problem that he doesn't like being insulted and yelled at? The horrors of our generation. It would be such a better world if his self worth was so low that upon being called a ******ed child he immediately accepted it as being what he deserved rather than the deluded rantings of a bitter geezer.

    I'm not used to getting SCREAM SCREAM SCREAMed at for being less than perfect either, mostly because nobody outside the 19th century mentality of medicine still does that (except Tom Coughlin). But you get used to it after a while and stop caring when the attending goes on a rant about what an idiot you are. Still wouldn't call it a positive thing though.
     
  37. surgicalskills

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    Completely agree. I've already scrubbed in on up to 40 lap choles during my residency. I'm a third year. If I was given enough instructions, taken through the cases by caring, understanding attendings through even half of these cases, I could be way ahead. Instead, the majority of them were about holding the camera or retracting. Not very optimal learning and a good example of how inefficient our training is. We don't need to be doing call Q3 to be surgeons. That's just old school thinking to keep us in line. Quality over quantitiy, that's always been proven right in just about any endeavor.
     
  38. dienekes88

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    He messed up. When he messes up, the fund can lose millions.

    Thicker skin. Maybe his boss shouldn't have called him ******ed, but he wasn't being berated without reason.

    Hahaha. Or it would be better if his self-worth didn't depend on external sources as is generally the case for our generation. :idea: In his case, it doesn't. He hears that and just works harder, because he knows he's doing a good job the rest of the time. He's just more careful now.
     
  39. SLUser11

    SLUser11 CRS
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    I think students planning on doing residency in New York should read this post 3-4 times, and then read this post as well.
     
  40. surgicalskills

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    why do you say that?
     
  41. dienekes88

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    Probably 'cause they're informative posts regarding New York City surgical residencies.

    SLUser11 is warning people to stay away from NYC for GS based on the information you've provided.
     
  42. surgicalskills

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    I understand. Well, I hate to be painting such a negative impression but that is what I have experienced and many like myself say the same thing. But, I don't regret coming here. As new yorkers say, "it is what it is"
     
  43. GSresident

    GSresident PGY4 on July 1, 04
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    Ahh the glory of idiocy that is the self-esteem-second-hander. The problem is that back in the early 90's the school system and our liberal moron politicians set out to destroy the idea of accomplishment and earned wealth. One way to do that is to divorce the idea of achievement from self-esteem. When everyone is a super genius, why should anyone be paid any more than anyone else? Why should a neurosurgeon get paid more for an hour of delicate surgery than a podiatrist spending an hour clipping toenails? If achievements lose their meaning, then why should the inventor of a new gadget be paid any more than someone who shlubs his way through life?

    Sure the gadget makes the lives of millions of people easier, and saves them time every day which can be spent on being more productive or leisure. But that certainly isn't anything special. If it weren't for Joe Schlub Mr. Inventor wouldn't seem all that special. Mr. Inventor is only great by comparison to Mr. Schlub, so he owes a portion of his self esteem and the products of his labor to Mr. Schlub. You get the idea.
     
  44. butterfly0660

    butterfly0660 Junior Member
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    Seriously???? I am halfway through my second year, and have done over 40 lap choles, start to finish!
     
  45. Anka

    Anka Senior Member
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    Could anyone in the NYC programs comment on whether abuse is directed at everyone, or are there "special people" who are protected by the program and actually trained (e.g., a person or two each year who are clearly favorites)?

    Anka
     
  46. jubb

    jubb Tern
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    EVERYBODY'S A WINNER!!!! YAY US!

    I'm so sick of this mentality and the sense of entitlement it is brewing. There are winners and losers, there is right and wrong.

    I think one of the fundamental characteristics of a good surgeon is that the buck stops with him/her. They have to make definitive decisions and get the patient what they need regardless of what is going on around them. I think making the new age surgeon think that it's not their problem unless they've slept an uninterrupted 5 hours is incredibly dangerous to the profession. Sure we could more efficiently teach a resident to do lap chole's by a well calculated and planned out method. We could cut all inefficiency so the resident went from room to room only working on the parts of a surgery that he/she needed to "work on"/learn and having someone else help set up the room and close the port holes at the end of the case and do all the other tedious stuff. Aside from the self centered notion that the surgical world should revolve around training residents this mindset is wrong. We aren't training someone to be able to just technically do the procedures we are training them to be a surgeon. That means training them to be a professional. Training someone who will operate all night after a long day if that is what is required for patient care. Training someone who will put the patients needs above their own.

    Becoming a surgeon is so much more than just Knowledge and Technical Skill.
     
  47. surgicalskills

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    You did the case with the attending assisting or the other way around? If the former, then, that's is awesome and I envy you. What state are you in?
     

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