Lawsuit May Further Limit Resident Work Hours

[southerndoc]

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American Medical News has an interesting article about a family suing a resident and Rush University Medical Center after the family's daughter was severely brain-injured following a car accident caused by the resident. The family is claiming the resident fell asleep after working a 36-hour shift at Rush.

You can read the article at: http://www.ama-assn.org/amednews/2005/03/21/prsb0321.htm

Do you think this will further limit our work hours to shifts? Between this (and possibly many more lawsuits to come from mishaps during extended shifts), and the recent studies showing increased errors with extended shifts, I think we may be seeing the days of overnight call going away and residents moving to night float systems.

Any thoughts?

 

[droliver]

I've been making the point for a few years that the liability for the work hours is going to have dramtic effects on Training Progams rules on top of the current ACGME guidelines. It's intuitive that moonlighting is eventually going to be completely prohibited during any period where you have clinical duties. The straw-man policy that these moonlighting hours don't "really" count just isn't going to pass the sniff test for the malpractice/liability carriers

 

[southerndoc]

I agree, although I think the issue raised by the lawsuit is the overnight call/continuous duty hours. Those that moonlight on days off may work excessive weekly hours, but generally do not work continuous hours.

 

[VentdependenT]

I routinely pull 30 hour shifts. I feel like my brain is coated with molases at that point and even burst out into laughter for no apparent reason.

Sucks for both the resident and the injured woman.

 

[Jeff698]

I guess the ultimate impact will depend on how the lawsuit turns out. If the hospital looses, the doors will open. I'm pretty sure this wasn't an isolated case, unfortunately.

As much as I hate to admit that anything good comes from lawsuits, this may be what it takes to get programs to pay attention to the evidence that says 36-odd hour call is bad and, as Vent said, turn your brain to molases. It isn't just car crashes that result from sleep deprivation, they're just the most obvious. I wish our profession would act without the threat of outside action but we haven't yet. It was the threat of legislation that got us the 80 hour limit, perhaps liability will get it revised.

Take care,
Jeff

 

[JAMMAN]

Of course, if they win this suit, this family will probably sue the hospital because there is no one working in the ER the next time they need help.

 

[beriberi]

Of note, 36 hours calls are now (technically) prohibited. The maximum continuous number of hours on duty are 30 (27 if you live in New York). I don't think anyone is safe in their 20th hour on duty (let alone their 30th), but the hospital should be able to clearly demonstrate that (in theory) they do not allow anyone to work 36 anymore and therefore they have already rectified the problem.

 

[E Z Daring]

Yes, the archaic system of training doctors will change eventually, but it's going to be a very slow process. It's very difficult to teach old dogs new tricks, and old dogs are always the ones in charge. With this new generation of docs (and higher proportion of women in it), things are definately going to keep changing towards better and better work environments. It's also in the patients best interest - obviously!

Medicine is so interesting from an anthopological point of view. Such a shame that culture overrides common sense. It's interesting, one of the docs I'm on rotation with kept saying that sticking under the 80hr guidelines was such a "culture shock" to her.

 

[southerndoc]

I think the newer generation of docs (the young attendings and current residents) favor life outside the hospital. Most view 24 hours of continuous duty as a disaster waiting to happen.

I am aware that 36 hours of continuous duty is no longer allowed, but 30 hours is. Even with current ACGME/RRC requirements of 30-hour limits, many programs still "allow" residents to stay past that 30-hour limit.

 

[Fantasy Sports]

Frankly, every medical school should change to a 3-year curriculum (1 year of basic science, 2 years of clinics) and then just add an extra year to residency while lowering the hours you spend there per week to something acceptable (55-60 hours).

Then again, that could just be my personal preference.

 

[NinerNiner999]

So the worst case scenario is that the hospital is sued - and loses. Then another hospital is sued, this time involving the ACGME who actually condones working 80 hours a week (A risky legal move in itself to publicly give good grace to an unfavorable workload to most of America). The ACGME, in response to impending litigation and settlement decides to reform its already reformed work hour rule and shorten residency work hours even more. Residencies, who already feel as though the training in their programs is taking a hit will appeal to the federal government for more medicare funding so they expand the length of their residencies to make up for the lost training time resulting from the reduced hours. A medicine residency that takes 3 years to complete will increase to 5 years. A surgery residency that takes 7 years now will have to be lengthened to 12 years to make up for lost time. Those already in their residency, who are effected by the work hour reform mid-training will have to stay for more years than they expected to "complete" their training, leaving a gap in attending coverage of at least 2-3 years because there is shortage of residency graduates. Applications to medical school will decline because the thought of spending 20 years in training and starting a career at age 42 sounds ridiculous (not to mention over a decade of student loan interest before a salary exists to start chipping away at the debt). The United States, suffering a major shortage of health care professionals opens its doors to foreign doctors eligible for work to fill the gap and the residencies, now suffering a record high attrition rate, struggle to replace the jobs once filled by experienced, well trained attendings. Physician reimbursement drops across the board because foreign doctors are willing to work at a reduced rate and medicare - already being reduced to cover the expanded residency programs - will reduce its physician reimbursement even more. All of this potentially within the next 20 years.

🙂

 

[Ross434]

So the worst case scenario is that the hospital is sued - and loses. Then another hospital is sued, this time involving the ACGME who actually condones working 80 hours a week (A risky legal move in itself to publicly give good grace to an unfavorable workload to most of America). The ACGME, in response to impending litigation and settlement decides to reform its already reformed work hour rule and shorten residency work hours even more. Residencies, who already feel as though the training in their programs is taking a hit will appeal to the federal government for more medicare funding so they expand the length of their residencies to make up for the lost training time resulting from the reduced hours. A medicine residency that takes 3 years to complete will increase to 5 years. A surgery residency that takes 7 years now will have to be lengthened to 12 years to make up for lost time. Those already in their residency, who are effected by the work hour reform mid-training will have to stay for more years than they expected to "complete" their training, leaving a gap in attending coverage of at least 2-3 years because there is shortage of residency graduates. Applications to medical school will decline because the thought of spending 20 years in training and starting a career at age 42 sounds ridiculous (not to mention over a decade of student loan interest before a salary exists to start chipping away at the debt). The United States, suffering a major shortage of health care professionals opens its doors to foreign doctors eligible for work to fill the gap and the residencies, now suffering a record high attrition rate, struggle to replace the jobs once filled by experienced, well trained attendings. Physician reimbursement drops across the board because foreign doctors are willing to work at a reduced rate and medicare - already being reduced to cover the expanded residency programs - will reduce its physician reimbursement even more. All of this potentially within the next 20 years.

🙂

Im fed up with naysaying. First of all. Hard as it sounds, residencies are surviving the 80 hour work week. Second, the lawsuits that have been mentioned probably wont do much to decrease the total hours worked - rather, they could *possibly* eliminate 36 hours shifts, which wouldnt really impact quality or quantity of training whatsoever. Residents might just have to work more weekends. Next. Lets say that through some great legal battle, there is a 65 hour work week - a reasonable reduction. This is still only a 22% loss in time. A 7 year residency would not become a 12 year residency. It would become an 8.5 year residency. And a 3 year residency would become a 3.5 year residency. Not to mention that hardly any surgical residencies are 7 years. Finally, even if the number of applications to med school got cut in half (unlikely), there would still be enough qualified applicants to not require any additional foreign doctors (beyond what we use now).

 

[NinerNiner999]

Im fed up with naysaying. First of all. Hard as it sounds, residencies are surviving the 80 hour work week. Second, the lawsuits that have been mentioned probably wont do much to decrease the total hours worked - rather, they could *possibly* eliminate 36 hours shifts, which wouldnt really impact quality or quantity of training whatsoever. Residents might just have to work more weekends. Next. Lets say that through some great legal battle, there is a 65 hour work week - a reasonable reduction. This is still only a 22% loss in time. A 7 year residency would not become a 12 year residency. It would become an 8.5 year residency. And a 3 year residency would become a 3.5 year residency. Not to mention that hardly any surgical residencies are 7 years. Finally, even if the number of applications to med school got cut in half (unlikely), there would still be enough qualified applicants to not require any additional foreign doctors (beyond what we use now).

1) I mentioned above as a "Worst Case Scenario" and 2) when you factor in a drop from 130hours/wk (prior to 80 hour restriction) to 80hrs/wk, then drop that to 65 hrs, that is a 50% drop in hours, resulting in a net doubling of time lost for those specialties (surgery especially). Further, in order to compensate for time lost due to research, more and more surgical residencies are becoming 7 years. The 80-hour rule is only two years in effect and many attendings (if not maybe most) are considering an expansion in residency length now to compensate for the reduction. 65 hours/week would only make this closer to reality. I hate naysayers too, but I would only hope that those who say American medicine is an institution and will never fall will wipe the fog from their eyes and wake up - it's already crumbling...

 

[southerndoc]

There are more than a handful 7-year surgical residencies. The surgery residency at the hospital where I am training is a 7-year program. They require 2 years of research plus 5 years of training.

This lawsuit is not likely to limit total work hours during a week, but rather continuous work hours. If you work 16 hour shifts 7 days per week it's still safer than working 30 hours continuously.

 

[Ross434]

1) I hate naysayers too, but I would only hope that those who say American medicine is an institution and will never fall will wipe the fog from their eyes and wake up - it's already crumbling...

Yeah, the old institution kind of sucked. Wouldnt you rather have a longer residency if you worked less hours? It kind of scares me that a lot of doctors trained during 130 hour work weeks. How much extra information do you actually process and usefully store during those last 50 hours.

 

[southerndoc]

Keep in mind that a lot of those doctors that trained during 130-hour workweeks also had less diagnostic tests, less patients, and often weren't up all night.

 

[Furrball]

Yeah, the old institution kind of sucked. Wouldnt you rather have a longer residency if you worked less hours? It kind of scares me that a lot of doctors trained during 130 hour work weeks. How much extra information do you actually process and usefully store during those last 50 hours.

Not really, 60 to 80 hours qweek is about what I worked in graduate school and I regularly worked 50 to 60 as a biochemist. My wife is a PhD post-doc and has been on a stint over the last month of 100 to 110 hour weeks. I wouldn't know what to do with all of the extra time, maybe more research?

 

[NinerNiner999]

Yeah, the old institution kind of sucked. Wouldnt you rather have a longer residency if you worked less hours? It kind of scares me that a lot of doctors trained during 130 hour work weeks. How much extra information do you actually process and usefully store during those last 50 hours.

Perhaps only half of my point is being taken. It is the prospect of a longer residency that I am opposed to - especially after I have taken out loans, started a family, and focused on a pre-defined time limit for my current path.

I also see Southerndoc's point that the workload was not nearly what it is now and that the 130 hour weeks allowed for perhaps a greater amount of sleep. Now, our workload has increased, partially due to the expanding number of diagnostic tests we can order and partially due to an already inefficient transfer of care between day shift, night shift, float, weekends, skeleton, and whatever other coverage scheme we have adopted to maintain our 80-hour rule. Plus, every individual involved in patient care has their own contibution to management, prolonging hospital stay and eventually making more work. Instead of one doctor, one assessment, and one plan, there are four, making everything more time consuming.

I believe the solution to work hours lies between the 130 hour workweek and and the current system. I also think that ultimately it is dependent on the legal canon of the time, which now, is not a favorable environment for a simple solution...

 

[Winged Scapula]

Keep in mind that a lot of those doctors that trained during 130-hour workweeks also had less diagnostic tests, less patients, and often weren't up all night.

And the patients weren't as ill. With the change in insurance and MediCare reimbursement, patients are no longer allowed to be admitted the night before surgery for bowel prep, lab work-up, to linger around after surgery or childbirth, etc. The current patients tend to be sicker than they were in the old days.

 

[hello23]

less hour = good!

 

[Justin4563]

fantasy has it correct.. changing the medical school curriculum to 3 years because everybody knows that the 4th year is not terribly critical. just get rid of vacations do 18 month straight basic science month off and 12-18 months of clinicals and then go to residency.. THe problem is that there are WAY too many bureacrats running the system and this would never fly. not to mention the 20-25K per person in tuition the school would miss out on. SO this commonsense is just preposterous. The basic premise in American medicine is exploitation. SOmeone is always exploiting someone and it continues as you go up the food chain.. Really nauseating

 

[MD'05]

Frankly, every medical school should change to a 3-year curriculum (1 year of basic science, 2 years of clinics) and then just add an extra year to residency while lowering the hours you spend there per week to something acceptable (55-60 hours).

Then again, that could just be my personal preference.

When do you apply for residency? In third year? That is madness. I didn't have enough time as it was to get everything done.

 

[juddson]

Of note, 36 hours calls are now (technically) prohibited. The maximum continuous number of hours on duty are 30 (27 if you live in New York). I don't think anyone is safe in their 20th hour on duty (let alone their 30th), but the hospital should be able to clearly demonstrate that (in theory) they do not allow anyone to work 36 anymore and therefore they have already rectified the problem.

On the contrary, this showing will be the final nail in the coffin. If the plaintiff's attorney can show (1) that the hospital violated the law, or (2) violated its own internal regulations regarding work hours, liability on thier behalf will be assured.

The courts have rules that where a party violates some law or regulation, and some injury results which would be the sort of injury the law was reasonably designed to prevent, there is going to be "negligence per se", and the hospital is going to be liable without the plaintiff having to show anything else. It is my understanding that the work hours regulations already in effect limit hours to 30. If the hospital either required or even permitted the resident to work for 36 hours, I think they are toast. Moreover, the reasons these regulations are in effect is to prevent the injuries that flow out of residents who are too tired to behave non-hazardously. If the court determines that the traffic accident occured because of fatigue, it is exactly the sort of injury the regulation was deisgned to prevent - ie., injuries flowing from the fatigue of overworked employees.

Even if the work hours are not regulated by legal statute, a mere showing that such hours violate the hospital's own internal regulations will be enough to show liability. Why? Because an internal regulation suggests (1) that the hospital knew such hours should be regulated and (2) understood the importance of those regulations yet failed to enforce them despite the above. That's also quite enough to suggest clear liability.

Personally, I support the suit against the hospital, particularly if they violated the law (a law that exists to prevent precisely this sort of injury) or thier own internal regulations.

Judd

 

[MichiMO]

1) I mentioned above as a "Worst Case Scenario" and 2) when you factor in a drop from 130hours/wk (prior to 80 hour restriction) to 80hrs/wk, then drop that to 65 hrs, that is a 50% drop in hours, resulting in a net doubling of time lost for those specialties (surgery especially). Further, in order to compensate for time lost due to research, more and more surgical residencies are becoming 7 years. The 80-hour rule is only two years in effect and many attendings (if not maybe most) are considering an expansion in residency length now to compensate for the reduction. 65 hours/week would only make this closer to reality. I hate naysayers too, but I would only hope that those who say American medicine is an institution and will never fall will wipe the fog from their eyes and wake up - it's already crumbling...

I am sorry, I just don't get this whole argument of "if they shorten work hours, they will have to lengthen residencies." How much "learning" is going on after you have been working for over 24hrs? At that point, you are just cheap labor, plain and simple. It is not about education. That is just a ridiculous argument that perpetuates the system.

 

[NinerNiner999]

I am sorry, I just don't get this whole argument of "if they shorten work hours, they will have to lengthen residencies." How much "learning" is going on after you have been working for over 24hrs? At that point, you are just cheap labor, plain and simple. It is not about education. That is just a ridiculous argument that perpetuates the system.

Agreed - not much "learning" takes place while working past 24 hours. However, instead of looking at this situation logically, look at the system as a whole. The US training system is led and perpetuated by attendings and faculty who worked in a system without work hours and who may not have even been paid. They are the least likely to see a benefit from reducing hours and more likely to be proponents for longer programs when hours are shortened. They are also apt to argue that it takes far more than 80 hours per week of patient care to learn as much as they did. They make the rules.

 

[ptolemy]

Agreed - not much "learning" takes place while working past 24 hours. However, instead of looking at this situation logically, look at the system as a whole. The US training system is led and perpetuated by attendings and faculty who worked in a system without work hours and who may not have even been paid. They are the least likely to see a benefit from reducing hours and more likely to be proponents for longer programs when hours are shortened. They are also apt to argue that it takes far more than 80 hours per week of patient care to learn as much as they did. They make the rules.

heh sorry, just laughing at the fact that this quote came from someone at Hopkins.. Didn't the medicine dept say they wanted to work hard?

__________________
Emergency Medicine Intern
Johns Hopkins Hospital
Baltimore, Maryland

I know, not everyone is like that and Hopkins is a GREAT institution, but in light of the thing a few years ago, I had to laugh. wasn't he an ER intern too?

 

[deltamed]

Agreed - not much "learning" takes place while working past 24 hours. However, instead of looking at this situation logically, look at the system as a whole. The US training system is led and perpetuated by attendings and faculty who worked in a system without work hours and who may not have even been paid. They are the least likely to see a benefit from reducing hours and more likely to be proponents for longer programs when hours are shortened. They are also apt to argue that it takes far more than 80 hours per week of patient care to learn as much as they did. They make the rules.

They will get the point when they are sued for supervising an overworked resident who kills someone. Also, I've heard some enlightened attendings saying they want to actually SHORTEN some long residency and cut out all the crap you don't need. Who needs 5 years of general surgery if they are going to be doing all thoracic or laproscopic or vascular?

 

[Fantasy Sports]

When do you apply for residency? In third year? That is madness. I didn't have enough time as it was to get everything done.

Yes you would apply in your third year. Consider it the Duke curriculum, except you move the clinical years up and convert their research year into the intern year of residency.

So you would apply to residency sometime late in 2nd year or early 3rd year theoretically.

Just an idea, the details can be worked out by beaurocrats.

 

[Lefty]

This is an interesting thread. Without meaning to hijack it I would like to change the direction of the thread a little. You have all focused on the effects of accidents and lawsuits on residency hours, training length, and regulations. What about your medical licenses or criminal record?

No one has yet mentioned "Maggie's Law"--a new law enacted in 2003 in New Jersey. As I understand it those people involved in traffic accidents following extended shifts can be charged with and prosecuted for vehicular homocide. I understood the law to specify an extended shift as "longer than 24 hours". How often do we have to work >24 hrs? That is pretty serious. State licensure may vary from state to state but in our medical jurisprudence class we were taught that if charged with a felony in CA we are at risk of losing our license. I'm sure its not too different in most other states.

So, in the O.P.'s post if the resident driving would have been in NJ he could have been charged with vehicular homicide and possibly lost his license. You can imagine that if many states began to adopt "Maggie's law", or similar laws, something would have to change. It wouldn't look good for a hospital to have it's residents going to jail for vehicular homicide.

I did not look at any residency programs in NJ specifically for this reason.

Here are some links to articles explaining Maggie's law:

http://www.drivers.com/article/643/

http://www.insurancejournal.com/news/national/2003/08/12/31404.htm

http://www.mrtraffic.com/jerseydrowsy.htm

Lefty

 

[tofurious]

heh sorry, just laughing at the fact that this quote came from someone at Hopkins.. Didn't the medicine dept say they wanted to work hard?

Those good ol' Osler's marines...

On a separate note, did anyone else's residency program make them watch a sleep deprivation module that first acknowledged the level of intoxication of residents staying awake > 24 hours and then recommended consuming 300 mg of caffeine q6hr (1 can of soda per hour equivalent) to stay awake?

 

[ortho2003]

less hour = good!

I am probably one of the few who disagree, but I am struggling enough to get cases in with an 80 hour work week. I don't need someone coming along and telling me that I am going ot lose another 15 or 20 hours of time in the hospital, especially if it is in exchange for another year of my life at a resident's salary. Giving up 150-250K for a little better life-style in residency is not worth it to me.

 

[CJMPre-Med]

There are MANY people in this country who put in over 80 hours/week with overtime (truckers, construction workers, I-bankers, lawyers etc.)-- why isn't the government then simply outlawing ALL work above and beyond 80 hours/week (or 70 hours or whatever the new # will be)? After all, they're citing the dangers to society, so it should hold across the board.


Yes, I'm aware that hospitals receive funding from the gov't for residents and hence the gov't has a say in working conditions, but, again, they're citing safety concerns (e.g., car accidents after work due to fatigue), which should hold regardless of profession.

 

[kas23]

There are MANY people in this country who put in over 80 hours/week with overtime (truckers, construction workers, I-bankers, lawyers etc.)-- why isn't the government then simply outlawing ALL work above and beyond 80 hours/week (or 70 hours or whatever the new # will be)?

It's about liability and patient care. A resident who has worked over 80 hours per week may lead to the death of a patient. With the exclusion of truckers and construction workers from your list above, an I-banker or lawyer working over 80 hours per week will hardly lead to the death of a human being.

 

[southerndoc]

There are MANY people in this country who put in over 80 hours/week with overtime (truckers, construction workers, I-bankers, lawyers etc.)-- why isn't the government then simply outlawing ALL work above and beyond 80 hours/week (or 70 hours or whatever the new # will be)? After all, they're citing the dangers to society, so it should hold across the board.


Yes, I'm aware that hospitals receive funding from the gov't for residents and hence the gov't has a say in working conditions, but, again, they're citing safety concerns (e.g., car accidents after work due to fatigue), which should hold regardless of profession.

It's not really the 80 hours/week that's the problem. Instead, it's the extended shifts (like 30 hour calls).

For your information, the workhours of truckers are limited by the Department of Transportation. The DOT strictly enforces their workhours. Truckers must keep logs of how many hours they have been driving. They are limited to 8-10 hours of driving continuously (depending on whether they are hauling hazardous materials) and are required to have so many hours of rest between driving episodes and so many hours of rest per day (I think it's 10 hours of rest daily). It's been a while since I saw the rules, but when I was in high school, I worked part-time for a trucking company entering in this information into their computer system. The DOT actually fined the company I worked for several hundred thousand dollars for violating this.

 

[Lefty]

There are MANY people in this country who put in over 80 hours/week with overtime (truckers, construction workers, I-bankers, lawyers etc.)-- why isn't the government then simply outlawing ALL work above and beyond 80 hours/week (or 70 hours or whatever the new # will be)? After all, they're citing the dangers to society, so it should hold across the board.

If you read about Maggie's law in NJ you'll see that their law does not differentiate b/w the professions. It only says that if you are "working" over 24 hrs and cause an accident on the way home then you can be charged with vehicular homicide. The original case, after which the law was made, did not even involve medical personnel.

It's about liability and patient care. A resident who has worked over 80 hours per week may lead to the death of a patient. With the exclusion of truckers and construction workers from your list above, an I-banker or lawyer working over 80 hours per week will hardly lead to the death of a human being.

It is not only about medical liability and patient care. After working those long hours and then driving home you are putting yourself and anyone else on the road at risk (as is anyone--I-bankers, lawyers, etc who drives home in an exhausted physical state). Furthermore, if you are charged with vehicular homicide b/c of a state law then you will also face the issue of losing your license.

With laws like Maggie's law the issue is no longer limited to liability and patient care. Any residents or physicians (I don't know how the prosecution might view a med student's shifts) working extended hours will have to worry about a lot more than their own medical liability and patient care if they are involved in an auto accident on the way home afterwards.

 

[WilcoWorld]

How about the errors introduced by multiple hand-offs? When patients get signed-out to night float the covering resident rarely comes anywhere close to fully understanding the case, is prone to mixing up facts, and does not do his/her own assessment. These and multiple other things introduce error. The more resrictions on hours the more sign-outs are required, the more sign-outs the more error introduced. At some point the error introduced by reducing work hours will exceed the amount that is eliminated by reducing work hours.

 

[Seaglass]

How about the errors introduced by multiple hand-offs? When patients get signed-out to night float the covering resident rarely comes anywhere close to fully understanding the case, is prone to mixing up facts, and does not do his/her own assessment. These and multiple other things introduce error. The more resrictions on hours the more sign-outs are required, the more sign-outs the more error introduced. At some point the error introduced by reducing work hours will exceed the amount that is eliminated by reducing work hours.

So patient hand-offs to tired residents and a different one every 2-3 days is better than hand-offs to the same well rested resident every day?

This is a ridiculous excuse that I hear over and over again. In all of the hospitals I have been involved in the on-call signout is AT LEAST as bad as nightfloat signout, and usually worse. Think about it - with the traditional system patients are usually only being taken care of by their own resident every 3-4th night. THe other nights they are being taken care of by tired residents who may/may not be familiar with their case. At night those residents are trying to sleep and aren't going to see patients except for codes/unstable situations. With nightfloat there is usually at least an organized signout time and procedure, and that resident is there to WORK at night, not sleep. In my experience they (and I) went to see a lot more patients at night for calls than when "on-call." Also nightfloat tends to be 1 or 2 residents on for several nights in a row - plenty of time to become familiar with patients and educated about their hospital course.

 

[kas23]

There is very little excuse for a poor sign-out. First, the sign-out should tell you ANY possible complications that may arise during the night or during the day. You should also know this patient anyways from the day before (assuming you are not doing a guest call, which truly is scary). This is just a matter of good communication, not medical knowledge.

The only excuse I can come up with for a poor sign-out is if the resident has already been on service for 30 hours. This resident is going to be fatigued and will not likely convey all pertinent medical information in an efficient manner. The only solution to this is to keep that resident on service past 30 hours and to not have him/her sign-out to anyone, but just keep working. This is a ridiculous solution. So, there has to be a sign-out at some point and I would rather give it/receive it if I have been on service the least amount of time.

 

[oldbearprofessor]

Frankly, every medical school should change to a 3-year curriculum (1 year of basic science, 2 years of clinics) and then just add an extra year to residency while lowering the hours you spend there per week to something acceptable (55-60 hours).

Then again, that could just be my personal preference.

I have no desire to get into the middle of this whole debate, but I did notice this post and a response to it and wanted to add a historical note. In the 1970's a perceived shortage of physicicans led to a number of medical schools changing to a 3 year curriculum, including mine. I started in July and we did 13 consecutive months preclinically, had two weeks off and then did the clinics for about 20 months with one month vacation allowed. By the early 1980's virtually all medical schools eliminated this for various reasons, the most substantial one being that the students felt they were being rushed and did not like it. I do not think that medical school finances were the principal reason for the change in either direction.

I am aware of some schools currently with shortened preclinical time of 1 yr or 1.5 yrs and they seem to do fine. However, I would be extremely surprised to see the 3 yr medical school concept return. I loved it, the majority of my classmates hated it and asked to have it go back to 4 yrs.

Regards

OBP

 

[Fantasy Sports]

I am aware of some schools currently with shortened preclinical time of 1 yr or 1.5 yrs and they seem to do fine. However, I would be extremely surprised to see the 3 yr medical school concept return. I loved it, the majority of my classmates hated it and asked to have it go back to 4 yrs.

As always, speaking from experience (like you are) should be considered more heavily than speaking from theory (like I am). That said, I wonder, if the residency hours were reduced to say, 60 hours a week, and then we adopted a system in which we have 1 year preclinical + 2 years clinical + 1 bonus year of internship/residency to make up for loss of residency work hours-- would people still be burned out as much?

I defer to your knowledge of past and current history in this matter OBP, but it would seem logical that while students may become burned out in medical school, that in the long-run, once you factor in residency burnout, that students might actually do better and feel better.

Again, this is just an idea, and perhaps a radical one at that. But I am just making a suggestion as to 1) avoid lengthening already long residencies in some fields 2) eliminate sloppiness during the 30th hour on call and 3) perhaps students will learn more in the long-run by training at a rate at which they are not simply doing the motions of work, but learning more since they are fresh.

Of course, since based on your posts you seem to be an academic OBP, I think your take on this idea is very important. Thanks.

 

[oldbearprofessor]

As always, speaking from experience (like you are) should be considered more heavily than speaking from theory (like I am). That said, I wonder, if the residency hours were reduced to say, 60 hours a week, and then we adopted a system in which we have 1 year preclinical + 2 years clinical + 1 bonus year of internship/residency to make up for loss of residency work hours-- would people still be burned out as much?

I defer to your knowledge of past and current history in this matter OBP, but it would seem logical that while students may become burned out in medical school, that in the long-run, once you factor in residency burnout, that students might actually do better and feel better.

Again, this is just an idea, and perhaps a radical one at that. But I am just making a suggestion as to 1) avoid lengthening already long residencies in some fields 2) eliminate sloppiness during the 30th hour on call and 3) perhaps students will learn more in the long-run by training at a rate at which they are not simply doing the motions of work, but learning more since they are fresh.

Of course, since based on your posts you seem to be an academic OBP, I think your take on this idea is very important. Thanks.

Hmmm, flattery will get you everywhere, even getting me into a debate I don't want to get into.

First off, I claim some right of knowledge of this based on the fact that I still work 30 hour shifts at times with very little or no sleep. One of my colleagues who was on call last night just left after 36 hrs straight working quite hard in the hospital. He is over 60 yrs old but there is no 30 hr rule or 80 hr week for attendings. Now, in fairness, we do this much, much less than residents, but still, I have no trouble relating to the fatigue of long shifts.

I really don't know the solution. I strongly supported the new work-hour rules. It will be difficult to greatly get the number of hours down much more, however, especially in critical care rotations. I think much of the solution is in relatively small work-place changes that can decrease the hours a bit and more importantly, limit the pressures of residency life. For example, after night call, usually there is no reason that the post-call resident cannot finish rounds one-one with a senior or a faculty and move to sign out well before the 30th hour. However, to send the resident home from an intensive care unit rotation at exactly 24 hours (e.g. at 7 AM) before "next day"rounds is a problem from a patient care and resident education perspective. Again, here, common sense can help in limiting the post-call work to that which is absolutely necessary and focusing on getting the resident home. The post-call resident needs to be relieved of as much scut as possible as well as responsibility for procedures whenever possible.

Also, many consult service, ER, and general ward rotations in pediatrics (what I know about) could be done with fewer 24-30 hour shifts and more cross-coverage. If a 36 month residency or fellowship could limit itself to perhaps 8-10 of the "hard" months of 80 hour weeks, it would make the overall life much more tolerable. In my day, this meant limiting the q3 night-call to 8-10 months/3 yrs (those were 100+ hr weeks). Now, it might mean limiting the q4 or q5 months similarly.

The main point I'm trying to make is that I think that resident life HAS gotten better in the last 20 years and that continued incremental improvements can make a difference and perhaps get the AVERAGE number of hours close to the 60 hour goal. I don't think this means a need to lengthen residency or shorten med school.

My surgical colleagues, of course, may disagree 🙄

Regards

OBP

 

[CJMPre-Med]

It's about liability and patient care. A resident who has worked over 80 hours per week may lead to the death of a patient. With the exclusion of truckers and construction workers from your list above, an I-banker or lawyer working over 80 hours per week will hardly lead to the death of a human being.

Yes, I'm aware of the patient care issues that may arise. However, that's the reason the # of hours was reduced to 80/week. In this case, the matter is being pressed due to something entirely unrelated to patient care (i.e., a car death), so I fail to see why it should not hold across the board, for every profession/occupation.


Some of the other posts subsequent to yours were helpful in explaining things, though. 🙂