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Less Resident Hours = More Errors?
- Thread starter facetguy
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Don't get it.
Why don't NP's make even more mistakes when they have even less training time but nearly the same scope in some areas?
Why don't NP's make even more mistakes when they have even less training time but nearly the same scope in some areas?
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I'm skeptical of how big of a role NPs play in the care of critically ill patients, which is likely where these problems are more obvious. Making a mistake with someone who has a minor cold likely isn't as big of a deal as making a mistake with a patient that's, say, septic. Which population do you think NPs are largely going to deal with?
I think this is very true. NPs are going to have a lot of trouble breaking into high liability areas where treatment mistakes quickly result in big judgements. Primary care is very nebulous, a lot of problems develop slowly over time thus the likelihood of getting sued for a mistake is low. This is exemplified by the low malpractice rate of primary care vs something like Pulm/CC or EM. This doesn't mean they aren't making mistakes though as primary care still sees a lot of these old and very ill patients. It just makes the mistakes easy to cover up.
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Does every thread have to become a midlevel thread?
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I think people just need to give it up and realize that there are going to be some mistakes no matter what. Too many hours? Your doctor is gonna be sleep deprived. Too few hours? There's gonna be a lot of handoffs and things are going to get lost in translation (although we're actively trying to fix that). We may never find that perfect balance.
Also, from what I remember, the way they instituted these work hour restrictions actually did make residents more sleep deprived. Before what would happen is you would have fourth night call but then you'd get off for 16 (?) hours (if there are any residents happening by on here hopefully they can correct me). Now you just work 16 hours straight constantly and get 8 hours off in between theoretically to sleep but by the time you've gotten out of the hospital, gotten home, gotten up, came back to the hospital it's way less.
I may be totally messing that up but I recall people complaining about something like that.
Also, from what I remember, the way they instituted these work hour restrictions actually did make residents more sleep deprived. Before what would happen is you would have fourth night call but then you'd get off for 16 (?) hours (if there are any residents happening by on here hopefully they can correct me). Now you just work 16 hours straight constantly and get 8 hours off in between theoretically to sleep but by the time you've gotten out of the hospital, gotten home, gotten up, came back to the hospital it's way less.
I may be totally messing that up but I recall people complaining about something like that.
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These were my thoughts as well. I've experienced both (though not as a physician or medical student), and I'd much rather work 24-30 hours and have a day or two off afterwards than do 16 hour shifts five or six days in a row. With those "short" shifts every day, there's no time to decompress, and you gradually get more and more sleep deprived.
As a twenty-something guy, I can keep alert and awake for a full day without too much difficulty as long as I'm up and moving and get to repay that sleep debt the next day, and then actually do something relaxing or productive with the remainder. The current intern rules don't allow that, and it sounds miserable. I'd be happy to see it go back to 24-30 hour shifts by the time I'm starting residency.
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Prior to 2003, there were no restrictions on work hours or number of hours between scheduled duty (outside of New York state) other than it be "reasonable".
After 2003, the ACGME suggested 10 hours between scheduled duty hours but mandated 8 hours. It was never 16 hours AFAIK. This was the hardest part of the duty hour restrictions for most programs to adhere to (I know it was for mine).
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Yeah I thought I might have been way off with that number I just remembered them saying that they got longer periods of time off in between. I guess that might not have been true either since the only mandated amount was 8.
The article had nothing to do with the length and quality of training. It deals with the fact that residents are required to do the same amount of work in shorter time. Plus, there are more handoffs between doctors, which are opportunities for mistakes. As well, the residents are just as tired and don't sleep any additional hours despite the restrictions.
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Yeah, 100% agree with you.
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If anything, there's more of a push to reduce resident hours even more rather than expand them.
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Once you go ACGME, you never go back.
Those rules are here to stay, I'm sure. I agree with what was mentioned above that I much prefer to be on call and have the next day "off." I have no idea when interns can get their car fixed or see the dentist, because they work all day, every day. If you have a night float system, then you can sacrifice some sleep there and go during the day, but if you only do it a few times a year, you could go months without being available during the day on a weekday.
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Back in 1986, I was on call every day for a straight month. I have no idea what happened in the world between September 13 and October 12 as I never left the hospital grounds. Residencies will get there; we have grouped an entire staff working on adapting to the new hours, identifying that which works and that which doesn't. Nothing is residency is perfect, nothing has been, nor will be.
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Good god.
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The doctors in my family had similar experience. One trained about 50 years ago, the other 25 years ago. The younger one remembers multiple occasions of not sleeping for 72 hours straight due to back to back to back complex surgical cases (he is an ENT specialist). As far as I know, he never made any grossly negligent mistakes in his training. He and his father both are adamant that the new hour restrictions don't allow doctors to learn to the fullest extent possible. He talks about the general criticisms (hand-offs, lack of exposure to complex cases, etc).
Do you feel that you miss out on certain cases, don't get to see your patients through to the full length of time in the hospital or that you are missing out on important learning by the 16 hour shift cap? I feel like surgery residents would lose the most education wise by shift caps (although I am completely naive on the subject).
As a med student it's easy to imagine endless hours and continuous patient care. In reality, the 8-10 hrs between shifts on a call day when I go home have absolutely little or no effect on patient care/outcome. On the general med/cardio services it's not like an ICU where something is changing by the minute. You pick a plan and go with it, then wait to see what happens. My handoffs for patients getting admitted for anything from CHF exac to eval for transplant with SBP after a 16hr shift are usually (followup K+, culture if spikes, fluids and ICU if hypotensive). What about if you take 30hr call and then you are absent for 24hrs on your post-call day? What happened to your patient/continuity then? Especially considering not all medicine/acute problems occur right at admission. You can argue this either way. The 16hr rule is only for interns, and the 80hr rule is probably one of the most important things for your own health and safety of your patients. Try working a real 80hr week where you have real responsibility and this becomes pretty obvious. Don't worry, if you go to a legit residency they will work you hard no matter what.
Meant to add that on a call day (q4), which is when I admit new patients, I hand off my list to nightfloat and pick it up from the same person in the morning. And I generally have the same intern taking care of my patients overnight 6 days a week for at least 2 weeks at a time so they get to know them well.
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I went 5 straight months without a weekday off. While on Trauma they would give us our days off during the week because the weekends were complete **** shows.
The intern rules are idiotic. The only thing they do is hurt resident education. Handoffs, while they can always be improved are always going to be problematic. Half of the time I just tell whoever is covering to call/text me if there is an issue with a complicated patient and I will help them out. I don't know how anyone can justify this system. We are going to produce inferior physicians compared to before.
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I did my intern year in 2010, so I was the last class not to be affected by the new rules. I'm not jealous of the two classes that have followed me. Most of our non-elective admissions, bounce-backs, traumas, and intra-abdominal catastrophes happen at night, so the interns don't get nearly the exposure to the work-up of these things. They also never have the chance to work something up on their own. When I get a call for something happening on the floor at night, I can work it up as I see fit, and when the studies are back (labs, x-rays, EKG, etc), I can either decide that it's a non-issue, or I can start the appropriate interventions. The new ACGME guidelines talk about direct/indirect supervision, and the result is that our interns are rarely given the chance to do anything without someone else knowing. And since they're never on call, they don't get to "play around" with a problem. Obviously, when someone is sick/going down the drain, I would always get the senior resident involved pretty quickly, but the lesser stuff is good to work through on your own.
When I'm on call, I've been there for a regular day, work most/all night, then round again with my team (filling them in on any issues as we go), stick around for a few hours and leave. The entire team has now been back to see all of their patients before I ever leave. It's not just a hand-off, because I am still there, seeing all of the patients again. A hand-off rarely (if ever) implies walking around to examine every patient and review labs/vitals/etc. the way we do on rounds.
Now, something else could happen, but usually the decisions made on rounds in the morning are the plan for the rest of the day.
Exactly. Miserable. I usually had at least every 4th day "off" when I was post-call (which went until noon with the 30 hour rule). As a PGY-2, I had even more call and was often Q3, and we got out at 10am ish. I'd rather do that than the "all day, every day" scheme.
