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

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LabMonster said:
Shift work seems cute and cuddly, but if you work in a fairly rural hospital - the ER is the primary care office, and so you do follow patients and you do worry about certain patients because they my be, hmm - generally more unhealthy than others. So I do not think EROAD is applicable to all facets of EM.

I completed my residency and passed my boards, so I have perspective and you do not. Residency is hell, I get it, but embrace what you are doing - learning on the job when you are primarily responsible for making decisions is much harder. Prepare for it.
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ED at rural is still shift for a lot of people. Yes, you may follow up, but most would be like "go see your pcp for f/u and lab results, bye Felicia!".

I think this job is average, but I know I'm the huge minority in that. It's something me and others will always disagree with
 
southernIM said:
I don't think that's true of any individual provider.

For the society of physicians as a whole, yes. But we (for the most part) have people willing to provide needed care in safety net hospitals, the VA, etc. They also still get paid, as it turns out.
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Yes, we know they get paid. The question is whether they are reimbursed to recover their costs.
 
Promethean said:
Oh, look! My point!

This is just one of many ways that the profession is supported which may not be entirely obvious to someone who only considers their own COA and time investment. Not to say that what we put into upholding our end of the social contract is in any way trivial. It is enormous sacrifice, but it is not made in a void.
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The AMA receives 72 million dollars from the govt. for their CPT code book. Physicians don't get jack **** of that.
 
southernIM said:
Because we live in an evidence based profession, where everyone demands data.

Then, when they get results they don't want to hear, they just dismiss it and say you can use statistics to say whatever you want.
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You actually think academics would put out journal articles saying that resident work hour restrictions has made patient care better?
 
southernIM said:
Not the point.
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It is when you're going to say like Promethean did, that the profession as a whole, is somehow supported because of it, and that all of our medical school tuition and fees are subsidized. Those who go to public medical schools -- yes they are subsidized. Not people who go to private medical schools.
 
southernIM said:
It was just an example of the ways that a social contract exists - the way our profession and society are intertwined, in this case financially. It wasn't a value statement about how that money was being spent.

Another example would be the 15 billion spent annually to subsidize GME training.
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Yes, the 15 billion spent in GME is probably a better example. Whether a physician "owes" his country in terms of training without which he cannot practice is probably debatable. That door then opens up funding GME positions by pharma and/or industry, to where that person definitely would not owe the country anything then.
 
southernIM said:
Who are these "academics". Nasca is an "academic" and he is most certainly in favor of the duty hour restrictions. He would love to publish a study that shows they improve outcomes.

I think Vollp's group at Penn would love to be able to publish a positive finding.
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You're telling me physicians at academic medical centers fully embraced resident work hour restrictions when they were implemented in 2003? Nasca believes residents in Derm, Ortho, and Radiology should pay tuition for their training and those previously funded positions be rerouted to primary care.
 
southernIM said:
I am saying that there is a wide diversity of beliefs regarding the duty hours, with Nasca probably falling at one extreme of the spectrum. There were actually surgeons on the original duty hours committee in 2003.

Alleging that there is a widespread conspiracy, uniformly held, by all academic physicians to publish false or distorted data to support their personal beliefs is well, about as reasonable as thinking we do the same when it comes to vaccinations and autism.
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It's not a conspiracy. I never said it was. I never said they would publish false data either.
 
why would academics be behind the duty hours. they are the ones that benefit from having hordes of slaves that they can pay 1/4th of the person they operate on the level at. that makes absolutely no sense.
 
PL198 said:
why would academics be behind the duty hours. they are the ones that benefit from having hordes of slaves that they can pay 1/4th of the person they operate on the level at. that makes absolutely no sense.
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Exactly my point. Hospitals lose when work hour restrictions are there bc it's less of a deal financially. They have to hire PAs and NPs who get paid much more than 40 K.
 
PL198 said:
Seriously. what is the rational explanation behind " medicine is a calling," ? Why isn't law a calling, people's legal status is just as important as their health status in terms of their overall well-being. What about their accountants or financial managers? Obviously your financial status is very important towards well-being.

Also it's pretty clear to me there is a significant difference between the actual work done by a resident in a 100 hour week in 1990 than in 2014. The whole " I did it, you can too" crap doesn't make any sense.

Seriously. when were physicians brainwashed into this thinking that they owed it to their patients ?
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How is 1990 different from 2014 in terms of patients?
 
southernIM said:
You presume a degree of interest alignment between individuals and institutions that does not exist.
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Pretty sure academic physicians are one of the last people to take the side of making things easier for residents.
 
southernIM said:
But I also don't see this roaring crowd trying to repeal the 2003 standards. Even in surgery the vast, vast majority agree they were a good thing.
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The main reason you don't see a roaring crowd trying to repeal the 2003 standards is bc everyone knows that ship has long sailed and is never coming back. The govt. expects medicine to police its own profession. When they don't and a major event happens, then control comes from the outside thru govt. involvement - i.e. the Libby Zion case (which in the end wasn't even due to resident fatigue). The only reason the ACGME agreed to do the 80 hr. work week restriction is bc Congress was ready and prepared to pass legislation addressing the issue which could have been much worse in terms of training.

Residency PDs aren't going to come out in front of their residents and say, "I so wish we could go back to the days before work hour restrictions".
 
DermViser said:
How is 1990 different from 2014 in terms of patients?
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I'm sure I couldn't even imagine the stuff they could get away with back then. Having your SO come in on call, stuff like that.
 
southernIM said:
Or it is because they agree that it's a good thing.
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My point is the work hour restriction was a reactive response, not a proactive response. If they really thought it was a good thing for residents, it would have happened a lot earlier than 2003.
 
southernIM said:
Now this I would agree with. work standards should not be made easier if it compromises patient care.

I would hope that's a pretty universally agreeable standard, but apparently not.
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I put the caveat of "think" for a reason.
 
PL198 said:
I'm sure I couldn't even imagine the stuff they could get away with back then. Having your SO come in on call, stuff like that.
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I'm sure your SO can come to your call room now. I don't think that has changed.
 
DermViser said:
I'm sure your SO can come to your call room now. I don't think that has changed.
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ok you understand what I'm hinting at. sleeping with another resident, nurse, insert random person here. I am 100 % certain they got away with things that would be on the front page of the local newspaper if you did them today.
 
PL198 said:
ok you understand what I'm hinting at. sleeping with another resident, nurse, insert random person here. I am 100 % certain they got away with things that would be on the front page of the local newspaper if you did them today.
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Um, dude, that still happens. It's not banned, for goodness sakes.
 
southernIM said:
His point was that you could get away with a lot more in the past than you could today, and it's absolutely true. There is way more scrutiny, both publicly and by the hospital administration.

I heard a story on the interview trail that a decade or so ago at one program (can't remember which, and I'm sure it's an apocryphal anecdote anyways) - a resident punched an anesthesia attending in the face. When called to the chairman's office - the chair had only one question: "Well did you at least knock him out, son?"
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Oh yes, definitely. It's now the same, if not worse, stress level, and god forbid, if you raise your voice at a nurse over the phone, your PD automatically calls you into his office and throws you under the bus. At least before, the stress as a surgery resident was probably more manageable knowing your program had your back.
 
southernIM said:
And my point is that views are not static.

There was a lot of wailing and gnashing of teeth in 2003. A decade later, and the medical training world has not fallen apart. Many of the same people who were vocally complaining that this would ruin training have now come around and said the work hours are a good thing, precisely because the have the benefit of retrospection.

I think a lot of these people have also realized that the loss of autonomy is a far bigger threat to training quality than the hours are, which is reflected in the shifting of the education literature and meetings to this topic.

Yes, some people still complain. For the most part it is old fogeys who like to complain and would complain about the quality of today's graduates regardless of whether the work hours have changed.
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To be fair, we've pretty much lost autonomy already. I don't know if there is much more to lose.
 
Its always amusing to see the general surgeons squabble over this stuff. Maybe if general surgery had a better work/life balance they could attract the best medstudents who would learn faster than the current crowd of gen surg residents.
 
Armadillos said:
Its always amusing to see the general surgeons squabble over this stuff. Maybe if general surgery had a better work/life balance they could attract the best medstudents who would learn faster than the current crowd of gen surg residents.
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As much grief as I can give general surgery sometimes, general surgeons aren't really squabbling here. All accredited general surgery programs fall under the ACGME. The ACGME has said that residents in all specialties must work 80 hrs or less per week (averaged in a month). Even the stupidest medical student knows that this doesn't make any sense since each specialty is just so very different in terms of the filter they have for accepting and rejecting admissions/consults, procedures they do, etc.

General Surgery/Neurosurgery/Orthopedics/Urology/Plastics is nothing like the non-surgical based specialties and thus the hours affect them much more greatly bc it affects the amount of time they'd be in the operating room.

Edit: Oops, realized you were making the point that if General Surgery emphasized work-life-balance more they'd get better candidates. Realize first, the emphasis on lifestyle is a millenial med student generation characteristic. It isn't too far back where people chose a specialty based on intellectual interest not on lifestyle. At that time General Surgery and Internal Medicine were both at the top of the pack. Also most surgery residents subspecialize anyways and don't practice General Surgery - so in the end they're a physician who won't be overtaken by midlevels, whose skills aren't easily replaceable without recruiting someone else, and who pretty much call the shots in terms of bringing in revenue to the entire hospital - that's a pretty good position to be in. Oh and Neurosurgery, Ortho, Urology, and Plastics don't really have a good work-life balance during residency.
 
Psych isn't the issue here, its obviously the most bottom feeding specialty out there as far as average applicant, I would never dispute that. I also don't dispute that surgeons probably have the most to learn of almost any specialty due to the breadth and depth of the field.

The issue is medstudents like me are more commonly doing things like rad onc/rads/derm/anesthesia/EM/Uro/ENT and not even considering gen surgery. So if you have one the the specialties requiring the most knowledge and its finding it can't attract the best medstudents then eventually there is going to be a breaking point. I've talked to plenty of academic surgeons who have said that surgery applicants are not the rockstars they used to be, its not like Im the first person to say this.

As Dermviser pointed out, med-students are looking at life more holistically now than ever before, some specialties are going to have to adapt to that if they want to attract those medstudents who have free choice in their career.
 
True, the surgeons have more to gripe vs. me who work hours is a non-issue, since we don't reach 80 hours, and we WANT light call.
 
DermViser said:
As much grief as I can give general surgery sometimes, general surgeons aren't really squabbling here. All accredited general surgery programs fall under the ACGME. The ACGME has said that residents in all specialties must work 80 hrs or less per week (averaged in a month). Even the stupidest medical student knows that this doesn't make any sense since each specialty is just so very different in terms of the filter they have for accepting and rejecting admissions/consults, procedures they do, etc.

General Surgery/Neurosurgery/Orthopedics/Urology/Plastics is nothing like the non-surgical based specialties and thus the hours affect them much more greatly bc it affects the amount of time they'd be in the operating room.

Edit: Oops, realized you were making the point that if General Surgery emphasized work-life-balance more they'd get better candidates. Realize first, the emphasis on lifestyle is a millenial med student generation characteristic. It isn't too far back where people chose a specialty based on intellectual interest not on lifestyle. At that time General Surgery and Internal Medicine were both at the top of the pack. Also most surgery residents subspecialize anyways and don't practice General Surgery - so in the end they're a physician who won't be overtaken by midlevels, whose skills aren't easily replaceable without recruiting someone else, and who pretty much call the shots in terms of bringing in revenue to the entire hospital - that's a pretty good position to be in. Oh and Neurosurgery, Ortho, Urology, and Plastics don't really have a good work-life balance during residency.
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Personally, no specialty or profession is interesting enough that I would want to do it for more than 80 hrs per week, every week. I don't think this is a millennial characteristic, since I myself am not a millennial. It's just that this generation is well educated enough to have plenty of other options in the work place. Sacrificing yourself on the altar of medicine becomes much less attractive. Helping people is fantastic, but not if you have to sacrifice your own life to do it. There's plenty of capacity to hire more physicians if need be. Just takes few more bucks for residency spots.
 
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Deleted so as to not derail thread further
 
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southernIM said:
And a lot of people in medical education (non-surgeons) have argued that the duty hours limits actually made surgery more attractive since it took a lot of the concerns about abuse in training out of the picture by leveling the playing field with the limits.
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But work hour restrictions just changes the hours, not the people. The abuse stereotypically associated with General Surgery isn't the hours (that probably just compounds it) but the stereotypical malignant personalities of General Surgeons.
 
Anyhow, Ill stop derailing the thread as the work hours are not really an issue for my specialty. And honestly I'm more in line with the surgeon line of thinking than people would expect. In my opinion, so long as the programs are completely transparent and honest with applicants ahead of time, they should be able to do pretty much whatever they want hours wise and applicants can go wherever matches their personal goals for training. It doesn't make sense to try to fit all specialties into one mold.
 
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FIREitUP said:
just keep in mind the limitations of this study, guys. it was an observational study on patient outcomes in medicare patients ONLY. i honestly would like information about younger demographics and the incidence of medical errors. telling us that old people haven't really died any faster doesn't tell me that much.
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Who cares if there are 1000 times as many errors if it doesn't change outcomes. The only outcomes that matter are the hard outcomes. It doesn't get much harder than death.
 
DermViser said:
As much grief as I can give general surgery sometimes, general surgeons aren't really squabbling here. All accredited general surgery programs fall under the ACGME. The ACGME has said that residents in all specialties must work 80 hrs or less per week (averaged in a month). Even the stupidest medical student knows that this doesn't make any sense since each specialty is just so very different in terms of the filter they have for accepting and rejecting admissions/consults, procedures they do, etc.

General Surgery/Neurosurgery/Orthopedics/Urology/Plastics is nothing like the non-surgical based specialties and thus the hours affect them much more greatly bc it affects the amount of time they'd be in the operating room.

Edit: Oops, realized you were making the point that if General Surgery emphasized work-life-balance more they'd get better candidates. Realize first, the emphasis on lifestyle is a millenial med student generation characteristic. It isn't too far back where people chose a specialty based on intellectual interest not on lifestyle. At that time General Surgery and Internal Medicine were both at the top of the pack. Also most surgery residents subspecialize anyways and don't practice General Surgery - so in the end they're a physician who won't be overtaken by midlevels, whose skills aren't easily replaceable without recruiting someone else, and who pretty much call the shots in terms of bringing in revenue to the entire hospital - that's a pretty good position to be in. Oh and Neurosurgery, Ortho, Urology, and Plastics don't really have a good work-life balance during residency.
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I'd argue that lifestyle is only a factor now because it's getting to the point where people's lifestyles are truly being disrupted. Millenials aren't magically more lazy than their predecessors, it's just that the exploitation continues to increase. Residents of 20 years ago did significantly less work and thus lifestyle wasn't nearly as much of a concern. If you're twiddling your thumbs half the time you're in the hospital "learning" it's a lot easier to not complain about the quality of your life, then if you're going balls to the wall 24/7 when you're in there.
 
Instatewaiter said:
Who cares if there are 1000 times as many errors if it doesn't change outcomes. The only outcomes that matter are the hard outcomes. It doesn't get much harder than death.
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Bc some outcomes that aren't death can be bad also.
 
PL198 said:
I'd argue that lifestyle is only a factor now because it's getting to the point where people's lifestyles are truly being disrupted. Millenials aren't magically more lazy than their predecessors, it's just that the exploitation continues to increase. Residents of 20 years ago did significantly less work and thus lifestyle wasn't nearly as much of a concern. If you're twiddling your thumbs half the time you're in the hospital "learning" it's a lot easier to not complain about the quality of your life, then if you're going balls to the wall 24/7 when you're in there.
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People were also MUCH less sicker back then. You basically admitted someone with malignant hypertension to the ICU. That doesn't happen anymore. People didn't have and 8 point problem list like you have now: HTN, DM2, Hypothyroidism, CRF, CHF, PVD, etc. etc.
 
PL198 said:
I'd argue that lifestyle is only a factor now because it's getting to the point where people's lifestyles are truly being disrupted. Millenials aren't magically more lazy than their predecessors, it's just that the exploitation continues to increase. Residents of 20 years ago did significantly less work and thus lifestyle wasn't nearly as much of a concern. If you're twiddling your thumbs half the time you're in the hospital "learning" it's a lot easier to not complain about the quality of your life, then if you're going balls to the wall 24/7 when you're in there.
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True, half the time in the hospital setting, I am basically sitting around....there are times the hospital is jumping, jumping...and others that it's so quiet haha.
 
KnuxNole said:
True, half the time in the hospital setting, I am basically sitting around....there are times the hospital is jumping, jumping...and others that it's so quiet haha.
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I meant that as in 20 years ago they were less busy compared to now, but I guess you could also compare different services today
 
KnuxNole said:
True, half the time in the hospital setting, I am basically sitting around....there are times the hospital is jumping, jumping...and others that it's so quiet haha.
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Depends on the hospital you're at and where you're doing residency.
 
PL198 said:
I'd argue that lifestyle is only a factor now because it's getting to the point where people's lifestyles are truly being disrupted. Millenials aren't magically more lazy than their predecessors, it's just that the exploitation continues to increase. Residents of 20 years ago did significantly less work and thus lifestyle wasn't nearly as much of a concern. If you're twiddling your thumbs half the time you're in the hospital "learning" it's a lot easier to not complain about the quality of your life, then if you're going balls to the wall 24/7 when you're in there.
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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.
 
PL198 said:
I meant that as in 20 years ago they were less busy compared to now, but I guess you could also compare different services today
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20 years ago, the population was a lot less. The obesity epidemic wasn't anything like it is now. Back then you had one heart attack and it took you out or a bout of pneumonia and it took you out. Medicine has advanced so much that people are dying of much more severe and complicated reasons.
 
Winged Scapula said:
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.
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take a poop
 
DermViser said:
People were also MUCH less sicker back then. You basically admitted someone with malignant hypertension to the ICU. That doesn't happen anymore. People didn't have and 8 point problem list like you have now: HTN, DM2, Hypothyroidism, CRF, CHF, PVD, etc. etc.
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20 years ago? No…its was the same.

Anything 30 or more years ago (most people draw the line at the mid 80s as to when things changed).
 
Winged Scapula said:
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.
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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.
 
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