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thedrjojo

thedrjojo

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Physician
15+ Year Member
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http://www.acgme.org/What-We-Do/Accreditation/Review-and-Comment

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Public comment til dec 19th. major change is doing away with 16hr intern shift max once and for all.
 
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sb247 said:
I'm special!

But yeah, I agree this is done. That comment period is a formality
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In the course of my training, I experience pre-80 hours rules, the 80 hour rules, and the intern 16 hour rules. I felt the 80 hour rule was a good improvement. The intern 16 hour rule didn't affect me as a fellow all that much, but it made our intern's lives horrible. Since you couldn't take more than 16 hours of call and we had two interns in our call pool, that left the weekend coverage to be split between the two interns so they never had any weekend off. Sure, there'd be a 24 hour period off during the week. For the intern on call Sunday morning, they'd actually get off until Tuesday morning. For the intern on call Sunday night, they'd leave after rounds on Monday morning at 7 or whatever, and have to be back Tuesday morning at 7. That doesn't make for a happy resident.
 
Winged Scapula said:
I wish...I was actually starting to get a little miffed today and then I realized I have doctor things to do.
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you mean like counting the mounds of cash you're getting for taking call as an attending to answer pages from nursing? 😉 😛

The indignation about having to work long hours in that thread is quite impressive. I've started multiple responses and then decided not to post because :bang:
 
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Part of it is related to the fact that medicine isn't the golden goose it used to be, and that nurses can independently staff minute clinics or whatever so why do I have to work 80 hour weeks?? So there is resentment out there about the continued personal sacrifice for what is felt to be a raw deal.

Of course, anyone in medical school now has no excuse for not realizing all of that before starting the process.
 
Goro said:
Do you think that this is a Millennial thing?
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I think that's part of it because as @meister pointed out, there isn't an excuse for med students not knowing they will have to take call and work crazy hours. They just don't seem to accept that we aren't going to tell them "it's ok, you don't have to do that if you don't want to". They look at lifestyle like it's all about the number of hours off of work per day (or more that 16 hours of work sounds less difficult than 28), whereas we look at it as the quality of the hours you have off of work. Longer shifts that allow for longer blocks of time off result in more continuous hours off to use as you see fit. How much time are you spending with your SO or kids if you're only home long enough to eat dinner and go to sleep every day? How do you feel if you never have a full weekend off to travel to a wedding or go visit family/friends for an entire year (or 5)? I was chronically miserable in residency but it was not due to overnight calls; it was due to everything, collectively, that residency involved. Golden weekends and post call days were needed to keep me sane.
 
meister said:
Part of it is related to the fact that medicine isn't the golden goose it used to be, and that nurses can independently staff minute clinics or whatever so why do I have to work 80 hour weeks?? So there is resentment out there about the continued personal sacrifice for what is felt to be a raw deal.

Of course, anyone in medical school now has no excuse for not realizing all of that before starting the process.
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I don't want dive too deeply into this argument, because among other reasons I'm extremely bias and may have a conflict of interest.

Still, I want to point out that none of this challenges the 80 hour rule, but instead allows flexibility in how you use the 80 hours.

Perhaps some grey-hairs have nostalgia for the old days, and want you to suffer just like they did....but most of us are relatively new in our careers, and saw the downsides (and upsides) of the 80 hour work week as it was developed and implemented. We don't want to make people miserable, but we clearly have experience that you don't, and we have a better understanding of what makes a competent practicing surgeon than you do.

Even though reimbursement is DOWN, the actual amount of things you need to learn in order to be competent is way UP. In surgery, most leaders are worried that 80 hours (in the current format) is not enough to produce a competent and confident surgeon.

Anyway, I could go on for quite a while about your nurse clinic comments, as it assumes you are somehow already competent in a task and being asked to perform a monotonous job, i.e. staff a clinic, which is extremely far from the actual construct of surgical residency.
 
I actually find myself doing the same thing as @Smurfette ....I find myself being motivated to type out long, eloquent responses that educate the students and give them some outside perspective....

but then, I realize that 1) I'm too busy to do that, 2) I'm too frustrated by their apparent ignorance to be neutral, and 3) my arguments would fall on deaf ears anyway....

So instead, I simply type out half the response, then delete it...then delete the importance of the situation from my brain. It's actually poetic, as students still think the resident who sends them to the library to study is the coolest one rather than the one that puts the time in to "make them miserable." The worst thing a medical teacher can do to the student is ignore them....and yet, here I am simply giving up on trying to teach them anything...
 
@SLUser11, I am not personally advocating that argument, simply stating it exists and that there is a lot of resentment/anxiety/anger out there particularly since medical school costs keep rising.

Not sure how anyone winds up in a surgical residency and thinks they'll acquire the necessary technical skills putting in regular work hours or whatever.
 
SouthernSurgeon said:
That's the part that frustrates me. The refusal to listen to those who have done it, and the insistence that 24 HR call is inhumane simply because it sounds hard or because they were tired after they did it one time during third year.

My only "agenda" is trying to come up with the best call schedule I can for my co-residents. In that regard 24 HR calls were way better than the night float system we had to use after 2011.
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Yes and no. I think night float is useful during the week, because leaving your team short post call sucks. Having a dedicated person or team for nights during the week much improves that, so we never went back to pure call for our consults and floors. Over the weekend, multiple short shifts creates an atmosphere where everyone has to work every weekend essentially and thus makes it miserable. Those few 24hr shifts are much better.

Our trauma, sicu, VA, all of those are q3-4 and work much better than if there were float teams.
 
SouthernSurgeon said:
That's the part that frustrates me. The refusal to listen to those who have done it, and the insistence that 24 HR call is inhumane simply because it sounds hard or because they were tired after they did it one time during third year.

My only "agenda" is trying to come up with the best call schedule I can for my co-residents. In that regard 24 HR calls were way better than the night float system we had to use after 2011.
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As much as I hate to be one of those who complains about "those millennial kids", I do think that may be part of the issue.

This is a generation that was raised with choices and being treated like little adults. That led them to think they always get a say in daily life and that they can gain experience and knowledge simply by reading about it. The respect for others who have done it doesn't seem to exist as much anymore.

Of course young people are naturally ego centric but this generation does seem to be worse.


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thedrjojo said:
Yes and no. I think night float is useful during the week, because leaving your team short post call sucks. Having a dedicated person or team for nights during the week much improves that, so we never went back to pure call for our consults and floors. Over the weekend, multiple short shifts creates an atmosphere where everyone has to work every weekend essentially and thus makes it miserable. Those few 24hr shifts are much better.

Our trauma, sicu, VA, all of those are q3-4 and work much better than if there were float teams.
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For us the night float teams are worse because it means as a whole we are short three junior residents every month (the night floaters) instead of different services missing one postcall different says. It permanently reduces our day-team sizes instead of spreading the postcall shortage around. And on Fridays we are missing 6; the night floaters AND the three who are on call Friday night so they can't be here Friday during the day.

Can't wait for 16-hour workday to be gone.
 
LucidSplash said:
For us the night float teams are worse because it means as a whole we are short three junior residents every month (the night floaters) instead of different services missing one postcall different says. It permanently reduces our day-team sizes instead of spreading the postcall shortage around. And on Fridays we are missing 6; the night floaters AND the three who are on call Friday night so they can't be here Friday during the day.

Can't wait for 16-hour workday to be gone.
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Well, in the 16hr world, the intern was night floating 6 nights a week, so Friday wasn't an issue for us. As I said, their day off was Saturday 6am til Sunday 6pm.

We just adjusted our teams around to make up the difference. Still works better at our joint.

Not sure your math. So Pre 16hrs you had 1 junior cover what is now covered by 3 night float people? Or were 3 teams short every day with post call juniors? For us, the ability to know which team was always short (the team we pulled the resident from) and adjust the overall assignment was easier than spreading the pain. Cause spreading the pain often meant staying til 1-2pm post call despite the 24+4 rule.
 
thedrjojo said:
Well, in the 16hr world, the intern was night floating 6 nights a week, so Friday wasn't an issue for us. As I said, their day off was Saturday 6am til Sunday 6pm.

We just adjusted our teams around to make up the difference. Still works better at our joint.

Not sure your math. So Pre 16hrs you had 1 junior cover what is now covered by 3 night float people? Or were 3 teams short every day with post call juniors? For us, the ability to know which team was always short (the team we pulled the resident from) and adjust the overall assignment was easier than spreading the pain. Cause spreading the pain often meant staying til 1-2pm post call despite the 24+4 rule.
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The 16-hour world said that interns couldn't work any more than 6 nights in a row. Prior to the 2011 rules, my program did 24+6 weekend call as (Friday and Sunday) or (Saturday), for both the senior and junior call pool, on average twice a month therefore averaging two full weekends off a month. When the rules changed to 16-hours for interns and we had to go to night-float for juniors, we looked at doing 6-nights a week for night-float but ultimately decided to minimize changes to the schedule by having night-float be Sunday to Thursday night. The remaining juniors NOT on night-float split the weekend day/night until the night-floater comes back on Sunday night.

To clarify the math: pre 16-hours, we had three juniors on call each night: one for trauma, one covering acute care surgery and the chief service, and one covering vascular, general, and peds surg. This didn't include other services that either didn't have interns (critical care) or that took home call during the week. Post 16-hours we adjusted the day service complements to account for the fact there were consistently 3 juniors missing instead of rotating missing 3 juniors missing between the teams like we had before. Adjusting the overall assignments was done, but for us, having services missing juniors plus missing extras on Fridays is a lot worse than the way we had it pre 2011.

Each program is different obviously, but I think we all agree that night float sucks for surgery residents in a way it doesn't for mediciney specialties. Our juniors get fewer opportunities to get into the OR and being on night-float is socially segregating. Not to mention the continuity of care on the weekends is really tough. We are looking forward to doing away with it.
 
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