JAMA Study: Work Hours Limits Don't Improve Rate of Readmissions and Mortality

[Winged Scapula]

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Exactly. I think it's actually worse if you're sitting and twiddling your thumbs bc you're just wasting time. There was no Facebook or Internet in wide usage back then in 1994.

Yep, it was pretty frustrating to not be on call, to have signed out, but not be allowed to leave the hospital until the Chief got out of the OR or came back in to do evening rounds.

 

[DermViser]

If you were trying to insult me, you have failed miserably.

No I think he meant as in getting to poop in your personal bathroom.

 

[Winged Scapula]

No I think he meant as in getting to poop in your personal bathroom.

Maybe I need more wine - just landing in Denver; my perception is off.

Ah…well yes, I suppose if you had BM shyness that would be a problem. I didn't like to shower in the call room - all the boys left it "icky" and smelly.

 

[DermViser]

Yep, it was pretty frustrating to not be on call, to have signed out, but not be allowed to leave the hospital until the Chief got out of the OR or came back in to do evening rounds.

WTF?!!? Then what was the point in signing out to another team?

 

[Winged Scapula]

WTF?!!? Then what was the point in signing out to another team?

Well, they could start taking calls and you could just…well hang around.

It was Chief dependent. Some would not let you sign out until you had done evening rounds, others thought they were being nice since you weren't getting called on the patients but just hanging out in the call room.

Oh and it wasn't sign out to another "team"; it would be to the in house intern or 2nd year covering the service that night. You forget surgery services don't have large teams in most places.

 

[PL198]

No.

I can guarantee you that if you're in the hospital 120-130 hours per week, you would have/we did complain about quality of life; twiddling thumbs or not, sometimes you just need to be home/do laundry/go to the bank/see your SO/pet the dog etc.

I swear I would have bet my life that you would have responded to that exact post. that discrete thought went through my head. I agree with what you're saying, I'm just saying I feel it would be easier to sit around and do that rather than run your butt off for that long

 

[Cytarabine]

If you were trying to insult me, you have failed miserably.

Lol, no. Just adding to the list of laundry etc that people start feeling the need to do after being busy in the hospital for a while

 

[DermViser]

Ah…well yes, I suppose if you had BM shyness that would be a problem. I didn't like to shower in the call room - all the boys left it "icky" and smelly.

Me too during internship. . But mainly bc I feel weird showering in a hospital and feel like I'd have to bring a lot of amenities. I resigned myself to feeling like on call you're supposed to feel like ***.

 

[DermViser]

Well, they could start taking calls and you could just…well hang around.

It was Chief dependent. Some would not let you sign out until you had done evening rounds, others thought they were being nice since you weren't getting called on the patients but just hanging out in the call room.

Oh and it wasn't sign out to another "team"; it would be to the in house intern or 2nd year covering the service that night. You forget surgery services don't have large teams in most places.

But why would you evening round after you're already signed out to someone else? It's usually before, right? I guess u could sleep.

 

[Cytarabine]

Maybe I need more wine - just landing in Denver; my perception is off.

Ah…well yes, I suppose if you had BM shyness that would be a problem. I didn't like to shower in the call room - all the boys left it "icky" and smelly.

Not shyness, but nothing compares to kicking your shoes off, getting naked, turning the shower on, and playing modern warfare on your phone while dropping a big ole number 2. It's the little things in life

 

[DermViser]

I'm just saying I feel it would be easier to sit around and do that rather than run your butt off for that long

Except there was no Internet back then. There was tv and that's it and we all have tv at home where we can watch.

 

[Winged Scapula]

I swear I would have bet my life that you would have responded to that exact post. that discrete thought went through my head. I agree with what you're saying, I'm just saying I feel it would be easier to sit around and do that rather than run your butt off for that long

I can understand that. It seems to me that running around would make the day go faster; I know it does now for me if I have a busy day in the office or OR. Others prefer a more relaxed pace.

But some (perhaps you) may feel differently. Bear in mind that this concept that we all sitting around/all the time is not valid; there were plenty of days when we ran 24/7. Remember no mid-levels to help admit/discharge etc, lots of Level 1/2 traumas interrupting your work flow. However, there were days/nights when it was quiet. You guys have the same volume of work to do that we did, just less time to get it done (given the proclivity of programs to assume that if you can't get it done in 80 hrs, there must be something wrong with you, right 😉 ).

I just like to be home/somewhere else. 😛

 

[Winged Scapula]

Lol, no. Just adding to the list of laundry etc that people start feeling the need to do after being busy in the hospital for a while

Yeah I'm sorry I misinterpreted your response; makes perfect sense now.

 

[Cytarabine]

I can understand that. It seems to me that running around would make the day go faster; I know it does now for me if I have a busy day in the office or OR.

But some (perhaps you) may feel differently. Bear in mind that this concept that we all sitting around/all the time is not valid; there were plenty of days when we ran 24/7. Remember no mid-levels to help admit/discharge etc, Level 1 traumas interrupting your work flow. However, there were days/nights when it was quiet. You guys have the same volume of work to do that we did, just less time to get it done (given the proclivity of programs to assume that if you can't get it done in 80 hrs, there must be something wrong with you, right 😉 ).

I just like to be home/somewhere else. 😛

Twiddling your thumbs is hell. Balls to the wall isn't great either, but still better.

 

[DermViser]

Not shyness, but nothing compares to kicking your shoes off, getting naked, turning the shower on, and playing modern warfare on your phone while dropping a big ole number 2. It's the little things in life

Exactly -- getting to do those things in your own personal bathroom like taking a bath in your own tub, and not in a hospital shower stall.

 

[Winged Scapula]

But why would you evening round after you're already signed out to someone else? It's usually before, right? I guess u could sleep.

Because the Chief was going home (unless he was in house for Trauma, and in those cases, they often just rounded with the night call intern); so he needed to round on all the patients, to be updated on the events of the day that happened while he was in the OR. That way when he'd get a call from the intern about Mrs. So and So, who'd been admitted earlier/transferred to the ICU etc. he'd know about it.

Sign out wasn't just after rounds; we signed out (if allowed) when the night call started (usually 6 pm) and then updated the intern on call after we rounded with the Chief.

 

[DermViser]

You guys have the same volume of work to do that we did, just less time to get it done (given the proclivity of programs to assume that if you can't get it done in 80 hrs, there must be something wrong with you, right 😉 ).

This is what is so stupid with all of this. The hospital volume hasn't decreased, only the time to do it in has decreased - it doesn't disappear. The volume has only stayed the the same or increased - esp. if your hospital has constructed a new building with even more inpatient beds bc it's not satisfied enough with the beds it has. But you're expected to get the same amount or more work done in less number of hours or your PD (who worked when he had more hours to do it in) calls you into his/her office.

 

[Winged Scapula]

This is what is so stupid with all of this. The hospital volume hasn't decreased, only the time to do it in has decreased - it doesn't disappear. The volume has only stayed the the same or increased - esp. if your hospital has constructed a new building with even more inpatient beds bc it's not satisfied enough with the beds it has. But you're expected to get the same amount or more work done in less number of hours or your PD (who worked when he had more hours to do it in) calls you into his/her office.

I hear ya…

my residency program kept adding attendings: 2 more Vascular guys, 2 more Surg Onc, 1 more Colorectal etc. All of whom (except one) would throw a fit if they didn't have "coverage"; more work, more patients, same residents. And they wondered why we couldn't get the work done.

I understand they finally got approved for an additional categorical a few years ago.

 

[Winged Scapula]

Yeah I thought he was saying you didn't have enough time to poop.

I thought he was telling me to stop being so "anal" and go take a poop. 😛

 

[Winged Scapula]

This is the crux of my issue with the 16 hr rule and the 2011 limits.

It took the same volume of work and further compressed it to a daytime shift. Now the day intern is expected not just to have all the work done, but to have it all done by signout at 5pm.

Having moar cases as a surgical resident is always a good thing, especially as a senior/Chief.

Its all the stuff surrounding the extra volume, including busywork/scut/what have you that's frustrating. I'm sure your attendings are the same as mine in terms of wondering why it "takes so long" to get things done. It was always implied or said out loud that if you couldn't finish it in the hours allotted, then you were weak.

I don't envy you guys with your high volume and fewer hours to accomplish things in.

 

[DermViser]

I hear ya…

my residency program kept adding attendings: 2 more Vascular guys, 2 more Surg Onc, 1 more Colorectal etc. All of whom (except one) would throw a fit if they didn't have "coverage"; more work, more patients, same residents. And they wondered why we couldn't get the work done.

I understand they finally got approved for an additional categorical a few years ago.

Yup, surgery is much worse in that regard. It's a complete ****show when it comes to the volume you have and the number of surgery residents on a team, that it almost seemed like it was purposefully set up to fail. That being said, as med students it did force us to up our game and actively contribute to speed things along bc we internally felt like our team "needed" us in order to work, bc there was just so many t's to cross, i's to dot, and loose ends to tie up that having just the interns do it would be impossible.

I seriously don't know how surgery residents keep their cool during the day without flying off the handle at everyone around them, including attendings.

 

[DermViser]

My program's OR volume has increased by over a third just since I got here, and they keep adding faculty.

No change in the residency complement though.

But I'd rather be too busy operatively than not busy enough. Too many cases is a good problem to have (from the resident perspective).

Is there an ACGME rule of having too many cases per resident in terms of operating? I'm sure you'd be a rockstar by the end though just based on volume.

 

[Cytarabine]

This is the crux of my issue with the 16 hr rule and the 2011 limits.

It took the same volume of work and further compressed it to a daytime shift. Now the day intern is expected not just to have all the work done, but to have it all done by signout at 5pm.

In my experience, at least while the interns were still on the steep part of the "improving their efficiency" learning curve, this pretty much meant just saving notes to write at home after you "got off"

 

[Armadillos]

I know for internal medicine some percentage of teaching hospitals have "non-teaching" attending only teams that take some of the less educational patients to free up the residents for better learning opportunities.

For surgery it seems like the most important and sought after experience is the actual in OR operating time and the other hospital experience is still important, but not nearly as important.I know in surgery the general idea is the surgeons who operated on a patient are caring for them throughout their stay, but in practice (atleast at my hospital) attendings are so busy that almost every day a different attending is rounding on each others patients covering for each other because of hectic schedules. With that in mind, are there models where the residents still operate on all the patients, but then a certain percent of them are sent to some "attending service" where there is a essentially a surgery hospitalist taking care of a bunch of patients w/ no residents? Obviously its not financially better for the hospital, but I assume there are plenty of programs willing to make some financial sacrifices for educational value.

 

[starstarie]

No one brought up the point that the past generation, even though women were starting to work a lot more, it was still pretty much an assumption that when need be, she would stay home with the kids for a few years. This new generation is less accepting of that idea, which is influencing the need for more lifestyle flexibility (with two full time parents). In addition, more women in surgical fields is increasing the need not only for the lifestyle flexibility, but the flexibility to be pregnant and attend to a newborn during the process (they can't all be planned just right). In my opinion, this change has been a big reason for, and need for, the change.

I had a history of medicine class where we had to interview an older doctor who trained pre-80s. He definitely attested to the fact that residents work a whole lot harder now due to level of sickness of pts, even though he was physically at the hospital for more hours.

 

[lisi326]

I know for internal medicine some percentage of teaching hospitals have "non-teaching" attending only teams that take some of the less educational patients to free up the residents for better learning opportunities.

At our hospital, "less educational" means "easier". So they're shifting the less complicated pts to the non-teaching service and giving all the interns the excessively complicated pts, which (may) be good for teaching for certainly doesn't make the residents' lives any better. Yuck

 

[DermViser]

That's definitely not universally true. At my hospital the decision for who goes to the non-teaching service is made with input by the senior medicine resident on call. They actually usually put patients who are likely to be "scut heavy" on the hospitalist's service. They also can transfer rocks to the hospitalists.

Exactly. I can't imagine a time when there were no hospitalists and you just admitted and saw everyone regardless of teaching value. In terms of for the resident/intern, they're a god send. That being said, if you trained before there were hospitalists, you'd probably have your **** down cold.

 

[June11]

I've met a few attendings in academics who actively complained against the work hour restriction. Their opinions were that the residents couldn't get adequate training while working less than 80 hours/wk and that since they went through it themselves, there's no reason that the younger generations wouldn't be able to.

It felt more like they just didn't like the current residents "having it too easy", but maybe that's just me.

 

[DermViser]

I've met a few attendings in academics who actively complained against the work hour restriction. Their opinions were that the residents couldn't get adequate training while working less than 80 hours/wk and that since they went through it themselves, there's no reason that the younger generations wouldn't be able to.

It felt more like they just didn't like the current residents "having it too easy", but maybe that's just me.

These are the academics I'm talking about.

 

[KnuxNole]

Are there times that the senior would punt the "easy cases" to the non-teaching service? I feel like with some people, they would have the tendency to do that to get few admits...

 

[jdh71]

One of the things that really stands out to me with regards to work hours and their restriction is that there really isn't a "one size fits all specialties" limit.

I think it's clear at this point that the 2011 limits were misguided. And if I were in charge of anything, and I'm not, I'd suggest going back to the 80 hours limit, while each residency comes up with their own plan on what they think is reasonable and human hours and plans to protect residents from being over-tired.

 

[DermViser]

Are there times that the senior would punt the "easy cases" to the non-teaching service? I feel like with some people, they would have the tendency to do that to get few admits...

Our medicine teams always cap on call. So non-teaching cases (i.e. sickle cell crisis for the 85th time, social work/disposition largesse, etc. when to the non-teaching service. It's more just moving patients to certain services, since the ER never sleeps. It's kind of not true to real life bc when you're the attending you have to see patients whether they have education value or not.

 

[PL198]

One of the things that really stands out to me with regards to work hours and their restriction is that there really isn't a "one size fits all specialties" limit.

I think it's clear at this point that the 2011 limits were misguided. And if I were in charge of anything, and I'm not, I'd suggest going back to the 80 hours limit, while each residency comes up with their own plan on what they think is reasonable and human hours and plans to protect residents from being over-tired.

continuing on that, what would you suggest for each service? when I think about that issue I'm confronted by the following dilemma: Do services like surgery that might be more sensitive to error require more training time, to familiarize trainees with the material, or less to ensure that the trainees are functioning at a high enough level, even from a physical dexterity standpoint? I understand surgerons have to have tons of experience to be able to respond adequately and promptly when an issue arises ,but it seems foolish for them to have the most hours worked during residency, when they need to be so precise.

 

[DermViser]

continuing on that, what would you suggest for each service? when I think about that issue I'm confronted by the following dilemma: Do services like surgery that might be more sensitive to error require more training time, to familiarize trainees with the material, or less to ensure that the trainees are functioning at a high enough level, even from a physical dexterity standpoint? I understand surgerons have to have tons of experience to be able to respond adequately and promptly when an issue arises ,but it seems foolish for them to have the most hours worked during residency, when they need to be so precise.

Are you talking about in terms of exhaustion and resident fatigue? The hours of General Surgery is inherent to that specialty.

 

[jdh71]

continuing on that, what would you suggest for each service? when I think about that issue I'm confronted by the following dilemma: Do services like surgery that might be more sensitive to error require more training time, to familiarize trainees with the material, or less to ensure that the trainees are functioning at a high enough level, even from a physical dexterity standpoint? I understand surgerons have to have tons of experience to be able to respond adequately and promptly when an issue arises ,but it seems foolish for them to have the most hours worked during residency, when they need to be so precise.

I can't make a recomendation for a surgical residency, or a PM&R residency, or whatever because that's no what I do.

It's not like surgeons are a bunch of reckless dicks. They aren't going to be dangerous, but if they think they can push out beyond 80 hours for legitimate reasons then they should be able to define what they think is appropriate for their training and in which situations.

 

[PL198]

Are you talking about in terms of exhaustion and resident fatigue? The hours of General Surgery is inherent to that specialty.

yeah it seems like a lot of surgery residency is like one upping how overworked you are and how tired you are.
"Dude I was just so tired my scalpel was 2 tenths of an inch from cutting off the dude's SMA"
" Dude I was just so tired I nicked the dude's LAD but it didn't go through, so all good. Only two more surgeries to go tonight!"

 

[KnuxNole]

I usually don't say those statements to brag, I vent about that due to my frustrations about always hurting patients at night....

 

[DermViser]

yeah it seems like a lot of surgery residency is like one upping how overworked you are and how tired you are.
"Dude I was just so tired my scalpel was 2 tenths of an inch from cutting off the dude's SMA"
" Dude I was just so tired I nicked the dude's LAD but it didn't go through, so all good. Only two more surgeries to go tonight!"

I have never heard Gen Surgery residents say that. They're exhausted for a reason bc physiology kicks in. They usually don't brag about it.

 

[PL198]

I understand they're exhausted but I'm saying it's also seen as a badge of honor for surgeons. When you think of some of the mentalities held by them, it's not like it's surprising. I'm just saying working 100 hours is cool, but at some point there are tangible declines in physical functioning, and I'd wager that currently, those declines are being reached very frequently.

 

[DermViser]

I understand they're exhausted but I'm saying it's also seen as a badge of honor for surgeons. When you think of some of the mentalities held by them, it's not like it's surprising. I'm just saying working 100 hours is cool, but at some point there are tangible declines in physical functioning, and I'd wager that currently, those declines are being reached very frequently.

Of course it's a badge of honor for them. Their job is harder than most residents.

 

[LabMonster]

alright so tell me one more profession. you throw around buzzwords aimed at eliciting this sort of mystical ambiguity about medicine, so I'd like to hear about a similar profession. just because a job isn't average, doesn't mean you have to give a poor amount of effort. I don't get what you're saying, you're speaking from both sides of the aisle. We shouldn't care what people think about us, yet we're supposed to be mother theresa and have some superior representation of commitment towards our customers? It's one or the other.

Yeah I don't get what you're saying either.

 

[LabMonster]

Except most EM residencies are in academic medical centers in urban areas, not rural areas.

And you can choose your residency, we are not without choice.