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IOM Duty Hours report

Discussion in 'Anesthesiology' started by Pilot Doc, Dec 2, 2008.

  1. Pilot Doc

    Pilot Doc SDN Angel
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    #1 Pilot Doc, Dec 2, 2008
    Last edited: Dec 2, 2008
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  3. Pilot Doc

    Pilot Doc SDN Angel
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    #2 Pilot Doc, Dec 2, 2008
    Last edited: Dec 2, 2008
  4. militarymd

    militarymd SDN Angel
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    :clap:...finally....a legitimate excuse to lengthen the anesthesia residency to 8 years.....thereby creating a man power shortage....so I can make more bucks in the mean time.
     
  5. militarymd

    militarymd SDN Angel
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    OR....even better.....create a whole generation of clock punchers who can't hack long hours...and will always be employees who someone will make money off of....either an AMC....or EVEN BETTER....ME
     
  6. ozzie20

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    isn't that what academic programs do with residents anyway? My office told me that even if the residents did nothing, Medicare reimbursement alone makes the hospital an extra 3 mil.
     
  7. ozzie20

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    I think what mil said may happen, but I also think what may also happen is that you'll end up with a contraction of available residencies, and the ones that remain will increase the number of spots/specialty. The smaller programs that don't have many slots and don't fill regularly will end up not being able to provide enough coverage, and the larger programs will be able to do so.


    Either way, residency is a time to learn. For me, learning comes in a variety of ways, and one way is volume, others are quality. High volume, decreased time for learning is typical of most residencies, and many people feel they learn the best there. Some have low volume low time for learning. For me, I would prefer a low volume high time for learning, just how I function, can't say that its necessarily better than a place that gives you high volume.
     
  8. racerx

    racerx ASA Member
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    I hope this report gets round-filed. I'd rather do 4 years at 100 hours / wk than 5, 6, 7 years at the pussified hours.

    (I know that it is not 100 hr/wk any more, but it was for illustrative purposes.)
     
  9. toughlife

    toughlife Resident
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    Ridiculous suggestion. We need to keep things the way they are. Is the dude who gave that speech even a physician?
     
  10. proman

    proman Member
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    He's an ENT. Former dean of Hopkins med school, left to go to Emory.

    I wonder if the 16 hours suggestion is based on the Brigham ICU study. It would be easy for most anesthesia programs to be compliant with the new rules without lengthening the residency (come in a 3pm-7a for call is 16) and any call frequency less than q4 would give the time off.
     
  11. ozzie20

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    agreed, it really wouldn't change too much for anesthesia residency.

    As for "pussified hours," I don't think you'll find many patients and their families who would want you working on them after you've been up for 29 hours straight, and really the only reason is "cause you don't wanna work pussified hours."
     
  12. militarymd

    militarymd SDN Angel
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    I guess you are a *****.
     
  13. Bertelman

    Bertelman Maverick!
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    I often wonder why you post here.

    Mostly, I think it's to reinforce your perceived superiority over legions of anesthesia residents and med students.

    Sometimes you just like to piss people off.
     
  14. ozzie20

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    thanks for the input.
     
  15. racerx

    racerx ASA Member
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    I never said I wouldn't want to work pussified hours if they were offered. I'm inherently lazy, and don't even want the temptation. I am acknowledging the opinion that to obtain the same clinical competency, I would have to be in residency that much longer under the new IOM suggestions. I'd rather get it done and over with that much quicker.

    Please reference a well designed study that definitively answers the question of whether shorter hours have translated into fewer mistakes in patient care.:luck:

    And a lesson on punctuation. . .don't use quotation marks ("") if I didn't actually type those exact words. Use ('this') to paraphrase. Sorry, just a pet peeve about quotation marks.
     
  16. ozzie20

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    Yeah, thats a good point, I'd rather get it done too in less time.
     
  17. Southpaw

    Southpaw ASA Member
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    No offense, but I can envision now the results of that study posted on yahoo or google news. Then everyone, including me, could look at the news link and say "uhhhh....yeah duhhh, another stupid study with results we already knew!".

    I don't want few hours for more years of residency, but some things just don't need to be studied. You feel better, you perform better, and you're a much nicer person if you're well rested. To say that fewer mistakes are made at hour 8 vs. hour 30 is just plain common sense.
     
  18. militarymd

    militarymd SDN Angel
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    Why would I need to post here to "reinforce" that?:confused:

    I've spent enough time around residents and med students (and junior attendings and other fmg types) already to know what they're like.

    If you have really read my posts as you claim, then you would know the answer already....

    I PLAY here.
     
  19. BubbleHead

    BubbleHead Senior Member
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    :wow::eek::laugh:
     
  20. toughlife

    toughlife Resident
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    Your points are good but with the increased reliance of hospitals on the cheap labor provided by residents, you can only imagine the amount of resistance hospitals will put up if congress ever takes up this issue.
     
  21. BubbleHead

    BubbleHead Senior Member
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    Dr. MilitaryMD,

    I appreciate your sentiment, however the term "*****" is not PC. Please refer the the SOP and/or SSORM for correct and proper use of CATB... (the new and improved term to replace *****).

    v/r

    Bubblehead, MD

    CATB - [Candy Ass Titty Baby] Defined as: A newbie, non-qual-dink-puke-f*ck, overly sensitive to the ways of the working world, possibly still suckling at the teet during periods of authorized leave.
     
  22. militarymd

    militarymd SDN Angel
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    While standing at attention, facing the XO,

    MilitaryMD says, "Sir, at the time, it seemed like the right phrase to use".
     
  23. gaspasser2004

    gaspasser2004 Member Since 2004
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    When I was a CA-1 at Hopkins, we had a joint surgical-anesthesia grand rounds where two chief surgical residents debated the merits of the 80 hour work week. It was a spirited debate with each resident making very good arguments for his side. However, it was very clear that the surgical department was in a deep state of denial.

    Like the parent who says "Other kids might be (insert: drinking, smoking pot, having sex, etc.) but my kid isn't", the Hopkins surgical faculty were vigorously defending their residents' supernatural physiology. True quote: "Dr. X (one of the chiefs debating) is just as good in his 100th hour of the week as he is in his 1st hour of the week". That same surgical faculty member went on to say that basically the 80 hour work week was more applicable to "weaker" programs were the residents weren't as "strong" as the Hopkins residents. Surprisingly, one of the few senior surgical faculty to agree that the 80 hour work week might be a good idea was John Cameron, a former chairman and surgical legend.

    Its sad that people equate concern for patient safety with laziness. Its one thing if you are trying to bolt at 2pm every day (as MilMD described a partner doing in a recent thread), but it is absolutely an entirely different matter if you have been up doing cases the entire night and you don't think it is a good idea to continue working the following morning. There are people out there who think they can provide the same anesthesia post call after a hellish night as they do on a regular day after a full night's sleep - they are also the ones who think they drive better when they are drunk.

    Let's face it, medicine has done a bunch of stupid crap in the past that went unchallenged for generations before someone had the cajones to step up and change it. Like physicians going straight from the morgue to delivering babies without washing their hands - it was very controversial when Lister suggested this might be killing babies. Or blood letting - the choice of iatrogenic death for our nation's first president. In the future, I predict we will look upon 100 hour work weeks and working post call with the same disdain as we do for the other proven failures of medicine.
     
  24. usnavdoc

    usnavdoc Senior Member
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    I always think this is a funny conversation. I mean no one ever thinks about it from the patient side. Even the patients dont really question the surgeon about such things. We have a Urologist here that routinely on Friday after working all day at 1700 schedules a ilioconduit urinary diversion, cystectomy retroperitoneal LN disection which takes him between 12-18 hours to finish.

    I would not be that patient. I would insist on being the first case of the day. I did my surgery internship prior to the duty hour rules. Say what you want to about workhours but when you have been there going on 42 hours straight and you are at the 120th hour of your week you are not the same person as you were at hour 1.
     
  25. racerx

    racerx ASA Member
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    Just to be clear, I wasn't arguing for a return to 100 h/wk. I was offering my views regarding the potential to drop below 80 h/wk at the expense of additional years of training.
     
  26. fakin' the funk

    fakin' the funk ASA Member
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    Is there an emoticon for slapping yourself in the forehead?

    Man, the IOM, the JC, et al, can go *%$# themselves in my book.
     
  27. NotAMD

    NotAMD New Member
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    are u guys ******ed?
    do u think that you really learn anything for those extra hours returning pages about tylenol after being up all day?

    i could see a lot of resistance from 2 parties: med students and attendings, med students who have no idea about actually working and attendings who want you to suffer as they did/do their work in the middle of the night.

    I think everyone who is actually in residency now knows that you dont learn anything by simply being there longer, you do mostly painful routine things and just hope you can sleep and go home, so dont resist this progressive, safe change that will make all of our lives better to give more time to study, shower, eat, be sharp, etc...and still work hard.
     
  28. Bertelman

    Bertelman Maverick!
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    I don't know about you, but I have yet to be paged for a Tylenol order on anesthesia call. Most people aren't arguing you learn more by being there longer. There are some tough types that maintain you need to be up for 24 hours because sometimes your life on a physician requires such demands, and if you can't hack it in residency, you won't be able to hack it in PP.

    More importantly, though, you need to accumulate a certain volume of experience, and by further limiting hours, the expected result would be to prolong the years of residency education.

    I actually think anesthesia has it right in this regard. I think 24 hours is a nice cutoff. I was always WAAAYYY more exhausted on IM calls when I had to remain inhouse until 1200.
     
  29. militarymd

    militarymd SDN Angel
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    Yes, those excessively long hours probably doesn't make for better training.

    You know what? that last 6 months of residency probably doesn't either.

    And to add to that list...how about those electives we all take during our 4th year in medical school....might as well nix those too.....

    EVERYONE KNOWS that 4 th year electives are a waste of time.....except for the school to make money on you with tuition....we should probably get rid of all that too.

    Why don't we just make it 2 years of class room stuff and a couple years of clinicals and call it a day....oh wait....we have another class of providers who do that already...
     
  30. coprolalia

    coprolalia Bored Certified
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    I will simply say this...

    I've pulled call before, in the unit, where I stood by the bedside of a patient all night long. It started at around 2:30 PM in the afternoon when we got the admission. It was a post-arrest patient. Well, around 6:30 PM, the guy started to crump, de-satting, hypotensive. I got a stat x-ray, and he had a hemothorax. I - yes, me - put a chest tube in him because no one else from surgery was around to do it. Promptly got 600ml of blood out of his chest wall. That was only the beginning of the night... CT surg actually came back in around 9:30 PM and put an aortic balloon pump in the guy.

    I was in and out of that guys room all night long, while trying to do other things on the unit and tend to other patients. Around, 1:30 AM, we ended-up coding him again because it looked like the balloon pump had clotted off (or... who the hell knows what happpened... I was literally by myself with a bunch of awesome ICU nurses trying to figure this guy out...). Got a rhythm back, and the balloon pump seemed to be working again. Around 4:30 AM, I'm called back in (away from another not-quite-as-sick patient) because now the guy is de-satting again. Another x-ray. Despite chest tube looking like it's in the right place, his lungs are looking whited out... I had given him blood... now I'm thinking TRALI.

    Long story short... I was there to 11:30 AM. I got the guy through it, tended to my other patients, and signed-out to the the day team after rounding. I had lined this guy, put a goddam chest tube in him (something I'd only done once before as a surgical intern), and coded him twice throughout the night. He stayed on our service for the next two weeks with all kinds of bad crap happening to him. There were several times, not just that night, that I talked with his son and daughter and told him that I've done all I could and I didn't think he was going to make it.

    Guess what happened? (I **** you not).

    Fast-forward a month-and-a-half later. The nurse from the unit calls me and says, "Mr. XXXXXXX is here to see you! You have to come over."

    I walk over there, see the guy. He's walked himself into the hospital. He's with his fiance. He sees me, instantly remembers me, and tells me - "thank you, doctor, for saving my life" with tears in his eyes.

    I can honestly tell you that, in that almost 30 hours straight that I worked, I learned more about practical cardiology, physiology, and resuscitation than I had before or have since. I pushed myself beyond my ability and farther into what I thought I could know or do. And, most importantly, I learned where my limits were - where the outside of that envelope is - and how to effectively navigate into and out of that area.

    I've taken plenty of brutal calls. You get to some blurry areas at 4:00 AM after you've done your tenth case, no doubt. But, what are we going to do, as providers, when some crises hits our locale? What happens if there is a plane crash or explosion - some kind of mass casualty - and you are forced to push yourself to the limit... especially if you haven't been there before?

    I'd much rather learn where my limits are in residency under the protection and indemnification of the training program than on my own. So, I gotta agree with Mil on this one. This is just more pussification of our profession, and it is creating less distinction between what we can and are willing to provide to the patient versus all the other clock-punchers.

    -copro
     
  31. toughlife

    toughlife Resident
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    :thumbup: Nice job on that. I agree with your sentiment. I came to residency to learn as much as I can. I want the biggest bang for my buck and it if means that I will have to work like a dog to be a top dog then so be it.
     
  32. pgg

    pgg Laugh at me, will they?
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    I'm absolutely with you on how great an educational experience a long, brutal night of call can be when you're taking care of a dying patient essentially on your own. And totally apart from the procedural and management learning, there's the benefit of gaining experience as THE guy who's making decisions and taking responsibility for the patient. All tremendously useful, for us.

    But that's an entirely different issue than what the hour-cutters and the public are focused on. They argue that the patients would be better off with a better rested resident. Our case numbers and the circumstances of our learning are not relevant.

    The public doesn't give a rat's ass about our education or how further hour restrictions will harm us. They can't think far enough ahead to consider the implications of a generation of physicians graduating under a 5-hour-nap with milk & cookies guideline, stepping into the role of attendings with 1/3 less experience than our predecessors.

    They just think, boy, I'm sure tired after 40 hours workin' at the mill, those dadgum doctors can't possibly be safe after 80 hours!

    I logged just under 340 hours in November, doing "12 on 12 off" ICU shifts (which really turn out to be more like 13 on 11 off) plus a handful of 24s ... this put me right up against the 80-hour limit. I was tired after the 24s, but the rest of the month I was well rested. If I hadn't taken a half-eaten piece of pizza from my son and let him pass on the bug he'd picked up from his germ-riddled friends, it would have been a fatigue-free month.

    I don't see how further hour reductions or mandatory 48-hour hospital holidays would have made be better rested last month, or done anything other than dilute my learning opportunities. We don't need more hour restrictions.
     
  33. Bertelman

    Bertelman Maverick!
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    If you aren't in over your head, how do you know how tall you are?
    T.S. Eliot
     
  34. BubbleHead

    BubbleHead Senior Member
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    My favorite medical school professor used to say... "Everybody wants to be a Doctor, but nobody wants to go the medical school or suffer through residency".
    This is exemplified by RNs that want to call themselves Doctors and practice medicine or CATBs that want to work part-time in residency after getting their MD from an online Medical School.

    Please, Stay the **** away from me!
     
  35. BubbleHead

    BubbleHead Senior Member
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    :smack:
     
  36. toughlife

    toughlife Resident
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    :thumbup: No one wants to be the sailor anymore. They all want to be captains.
     
  37. coprolalia

    coprolalia Bored Certified
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    Or... everyone wants to be a chief and not just another indian.

    I think that hours restrictions breed a culture of clock-watching. I'm not necessarily saying that this is an inherently bad thing, because some people truly don't know their limits. I remember falling asleep, post-call, when I was a PGY-2 while entering orders into the computer. My attending tapped me on the shoulder and said, "Go home." I did. But, the restrictions we already have in place are good enough.

    But, this is like training to run a marathon. I don't know how, but your body adapts to such extreme alterations in the normal diurnal cycle. I can easily pull a 24-hour call now, whereas before I started medical school I would've been devastated if you'd asked me to stay up for 24-hours straight. There's no way I could've done it.

    What worries me are two things: (1) loss of continuity of care (I already gave an example of this) and (2) inability of future providers to really invest themselves in what they do.

    The "continuity of care" thing has alwas been argued, and I believe it's valid. But, I think the second point is more important. I can tell you that I've learned the primary difference between a nurse and a physician over the past four years. Hear me out...

    Nurses (generally) are more concerned with process than they are outcome... and this is a direct result of their training. If the patient dies, they may be sad, emotionally upset, or disappointed, but they don't necessarily feel any professional responsibility provided that they followed nursing protocol. I think - in no small part - this is part of the "clock-watching" phenomenon. They show up from 7:00 AM - 3:00 PM, they follow the rules, and they go home at 3:00 no matter whether or not the patient is getting ready to code. They sign out, and it's not their problem anymore. There's no real investment in the outcome. They did their job for eight hours and, provided that they followed the hospital rules and JCAHO-gestapo-don't-think-just-follow-the-formula mandates, now it's time to go home. And, the majority of nurses I know will begin to bitch vociferously if they are asked to stay an extra hour past their shift... I can only imagine if you told them they wouldn't be getting any overtime.

    I would admonish us - as a profession -not to let this kind of thinking creep into our practice. It is already happening in our expectation that our "shift" will end at 3:00 PM when the night float person comes to get us out. It is already happening in our Emergency Medicine colleagues "shift" mentality. It's a bad trend, and I think these restrictions are creeping broadly into medicine... because the public doesn't really understand what we do, and thinks that they can mandate a solution for us based on the opinions of a few of our ivory-tower colleagues who think they know what's best.

    Not too long ago, I had a case where there was a complication intra-op, and I wasn't sure if the result of the surgery was going to be okay when the patient woke-up. I was pre-call that day. At about 4:30 PM, one of my junior resident colleagues came into my room to get me out for the day. I told him what happened and said "no thanks, I'm staying to finish this one myself." We finished the case around 7:30 PM, and I stayed until almost 9:00 PM making sure that there was nothing else that needed to be done. Ultimately, the patient did fine... but I was fully prepared to go back to the OR and stay there all night, if necessary, to help this patient.

    We adopt the "clock-watching shift mentality" as a profession, and I think we lose that. When someone says absolutely, "you have to go home now because it's the rules" we lose all distinction in what separates us from other healthcare providers. And that, my friends, will be a truly unfortunate day.

    -copro
     
    #37 coprolalia, Dec 9, 2008
    Last edited: Dec 9, 2008
  38. fakin' the funk

    fakin' the funk ASA Member
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    It doesn't matter to me whether you learn a helluva lot more between the 65th and 80th hour of the week (averaged over 4 weeks :D ). Maybe you do, maybe you don't.

    I do feel strongly that the period of medical training, as expensive, grueling, and long as it already is, should NOT be extended by self-appointed commissions for marginal, if any, benefit.

    I.e., shortening the workweek from 80 to 65 hours is a MARGINAL, if even nonzero, improvement in patient safety and resident health, with a SUBSTANTIAL cost to the individual resident.
     
  39. geogil

    geogil Still training.
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    What I find fascinating about this whole debate is what medical students say versus what the residents and attendings say. Every blog and forum (check out the allo board here) frequented by medical students hails the IOM recommendation as a boon to them. By and large the residents (at least from waht I see here) are against the new recommendation. I don't know if that difference is born out of the few years difference in age, or if it's experience talking. It reminds me of something a friend told me a while ago, that "education is the only industry where people want less for their dollar". Obviously you don't pay to do a residency, but I think the idea is the same. I see in my classmates at times a tendancy to do as little as possible to minimize their effort (and consequently their return). For me, I would rather pass through the fire of a tougher residency and have a more solid foundation for when I was the one making the final call.
    -g
     
  40. NotAMD

    NotAMD New Member
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    Completely agree. I would rather work 80hrs weekly than extend residency. I dont think that is what they are saying though, I think they are keeping the same timeframe just with more sensible hours.
     
  41. NotAMD

    NotAMD New Member
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    I find this thread interesting so Im inclined to reply and discuss even though I agree with most of what you have said.

    Especially about nurses clock watching, and only doing more if they got overtime, etc.. totally agree. They do not have invested what MDs have, time, money, etc... So they have little to lose and therefore dont take it as seriously.. totally understand this..they have no idea..i feel your frustration

    But take the new guidlines into consideration, even under this scenario what nurse is working these hours? 1 weekend off per month and probably a ton of 16 hour shifts, looking at 70-80 hour weeks potentially.. i mean maybe they pull 5 12s a week at most...my point is we will still outwork most everyone in the hospital, and still have these touchy feely midnight moments where we went the extra mile under the new guidlines.

    Also, id just like to point out that TIME is not what separates us from nurses. Its the QUALITY OF OUR OVERALL EDUCATION.
    The extra radiology elective I took or the extra overnight shift I pulled on a quiet night dose NOT make the difference between doctor and nurse, or I would certainly hope not. Its not even that MDs "suffered" through school/residency, its not a mentality or anything that is intangible..

    in my mind its tests that separate us..the endgame of the education. nurses never passed the usmle! they have nothing but on the job training! they dont even know what they dont know... so dont feel the need to rationalize your superiority over someone who essentially shadows you and does whatever you do..then faults you for deviating from that algorithm for reasons they dont understand.... you are a doctor, you passed the tests, you took the mcat passed, usmle passed, path, gross, whatever exams and passed.. did they? no they did the quiz at the end of the chapter and turned it in for a check plus.. come on..
     
    #41 NotAMD, Dec 9, 2008
    Last edited: Dec 9, 2008
  42. SaintFrances

    SaintFrances Senior Member
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    Excellent point of view. Too often, it is the length of training that is focused upon rather than educational benchmarks to which physicians are held. When people compare different mid-level providers to physicians - they always focus upon how many "years" of training each has received.
     
  43. CambieMD

    CambieMD cambiemd
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    Residencies would have to be lengthened if we keep reducing work hours. Physicians will not be as well trained. We already know that the hand-offs that take place now are dangerous for patients. More hand-offs will just reduce patient safety even more.

    Physicians will increasingly feel like shift workers. This will add to cost.
    This is another bad idea.

    Pt care is so fractured that sometimes no one really knows the pt. I am amazed at how little residents know about their patients. I ask what I think is a reasonable question and get a blank stare .

    I just finished reading a book called Outliers. The author emphasizes the importance of spending a certain amount of time with an activity if you really want to become proficient @ it. His magic number was 10,000 hours. To get to 10,000 hours we would have to be in practice for years. If residents hours are reduced it will take them loner to reach the 10,000 hour mark. I think that physicians reach this number post residency.

    Cambie
     
    #43 CambieMD, Dec 10, 2008
    Last edited: Dec 10, 2008
  44. huktonfonix

    huktonfonix board certified!
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    they must be going to cush residencies. If you average 60 hours a week at 48 weeks a year for a 4 year residency, the average physician is averaging well over 10000 hours of experience by the time they finish residency.
     

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