"Let First-Year Residents Work Longer Shifts, ACGME Proposes"

[Statemed]

Any thoughts?

http://www.medscape.com/viewarticle/871432

"First-year residents would no longer be limited to 16-hour shifts during the 2017-2018 academic year under a controversial proposal released today by the Accreditation Council for Graduate Medical Education (ACGME).

Instead, individual residency programs could assign first-year trainees to shifts as long as 28 hours, the current limit for all other residents. The 28-hour maximum includes 4 transitional hours that's designed in part to help residents manage patient-care handoffs.

The plan to revise training requirements does not change other rules designed to protect all residents from overwork. The maximum number of hours that they can log each week remains at 80. All residents must have at least 1 day in 7 free from both clinical experience and education. And in-house call can't be more than every third night. All these limits are based on 4-week averages.

The ACGME capped the shifts of first-year residents at 16 hours in 2011 as a part of an ongoing effort to make trainee schedules more humane and avoid clinical errors caused by sleep deprivation. Some medical educators and medical societies claim, however, that this particular reform has worsened the learning experience of first-year residents as well as continuity of patient care.

ACGME CEO Thomas Nasca, MD, told Medscape Medical News that the problem arises largely from first-year residents not being on the same schedule as supervising residents and others on their "home" educational team. On a 16-hour clock, first-year residents can end up working under relative strangers, said Dr Nasca. "The lack of synchronization is very disruptive."

The solution, he said, is putting everyone on the same clock.

And it's a safe solution for residents and patients alike, according to the ACGME. The group touts a study published in the New England Journal of Medicine in February showing that longer shifts and less rest in between for surgical residents did not affect the rate of serious complications or surgical fatalities. Residents working longer shifts were no more dissatisfied with their overall well-being than those whose shifts were capped in accordance with AGME standards. They indicated that their educational experience improved, but at the expense of personal time. The study, called Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST), encompassed 117 general surgery residency programs in 151 hospitals.

"A Dangerous Step Backward"

Not everyone buys these findings and the arguments for relaxing the 16-hour rule for first-year residents. Both the American Medical Student Association and the Committee of Interns and Residents, a union representing 14,000 physicians, oppose the AGCME proposal. The consumer watchdog group Public Citizen calls it "a dangerous step backward."

"Study after study shows that sleep-deprived residents are a danger to themselves, their patients, and the public," said Michael Carome, MD, director of Public Citizen's Health Research Group, in a news release. "It's disheartening to see the ACGME cave to pressure from organized medicine and let their misguided wishes trump public health."

Public Citizen says it has public opinion on its side. A recent poll commissioned by the group showed that 86% of Americans oppose lifting the 16-hour cap on the shifts of rookie residents.

Public Citizen also looks askance at the FIRST trial, funded in part by the ACGME. It accuses the study of neglecting to obtain informed consent from trainees and patients. To Dr Carome, the study conveniently arrived at the conclusions that its authors set out to reach.

For his part, Dr Nasca said the ACGME made a good-faith effort to arrive at a consensus decision by listening to specialty societies, certifying boards, patient safety organizations, and residents. And rather than ignoring the well-being of first-year trainees, he said, the plan would step up efforts to prevent burnout and depression. It calls on residency programs, for example, to ensure that trainees can make appointments with a physician or a mental health professional, even during their working hours. And faculty and residents must be trained to identify symptoms of burnout, depression, and substance abuse.

The ACGME proposal will go to the group's board of directors for a final decision after a 45-day comment period. More information on the proposal is available for download from the ACGME."

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[Promethean]

The ACGME is accepting commentary.

http://www.acgme.org/What-We-Do/Acc...ndinstitutionalaccreditation/reviewandcomment

I think this is pretty much a done deal. Just from the way that they characterize the opposition. They say that those in favor of the changes are "uniform" in seeking the relaxation of the rule, while those who oppose it are conflicted, in that some want it kept the same while others believe that it should be extended to cover all residents, not just PGY-1.

I still logged my comment. Doing so is not a simple webform. You need to download their review and comment document and fill it in with the specific line numbers and item references that you wish to comment on, and then email that in to them. Failure to follow instructions exactly may lead to your comment being disregarded. I understand the need for a formal process, but this one seems complicated enough that it further convinces me that a public comment period is mostly just pro forma and that nothing is likely to be amended based on feedback at this point.

Possibly, if the NPR piece inspired widespread outrage among a sufficiently savvy and vocal group that the ACGME were absolutely flooded with thoughtful comments condemning 28 hour days for interns, it might not happen... do I really expect anything of the sort? Eh. Miracles happen sometimes. Like I said, I sent mine in.

 

[Foot Fetish]

28 hour shifts? That's just barbaric. One day we're going to look back on this time as the dark ages of medical education. I think all residents should be capped at 16 hours per day, not just interns.

 

[Promethean]

How we got here in the first place, and why it matters:

http://www.pennstatelawreview.org/penn-statim/the-lasting-legacy-of-a-case-that-was-lost/

 

[Promethean]

28 hour shifts? That's just barbaric. One day we're going to look back on this time as the dark ages of medical education. I think all residents should be capped at 16 hours per day, not just interns.

The dark ages were even longer. 36 hour shifts were common just a generation ago.

And 24 (plus 4 additional "if necessary") is currently the standard for PGY-2 and up. PGY-1 is currently limited to 16. Reading through the amendments in their entirety, there is some hope. They do include some clarifications of existing rules that might make things a little better, so I don't think that the whole thing is a mess.

I've worked a 36 hour stretch. I was not fit to order from a fast food menu by the end of that, let alone care for any patients. It is hard to imagine how any learning or patient care happens beyond a certain point, or how a hand off at 24 hours wouldn't be of lesser quality than the same hand off given at merely 16 hours into a shift.

 

[Ismet]

"the problem arises largely from first-year residents not being on the same schedule as supervising residents and others on their "home" educational team"

^ That's an issue with the program and not with the work hour restrictions. The program can fix things so that there's less hand-off and not necessarily more hours worked by everyone.

 

[Ismet]

28 hour shifts? That's just barbaric. One day we're going to look back on this time as the dark ages of medical education. I think all residents should be capped at 16 hours per day, not just interns.

At least at my program, the senior's 24 hour shifts are done once a week because the people that work night float need a night off. The senior on the 24 gets a fresh intern halfway through the shift. It's a long day but it's completely doable.

 

[67552931811]

The dark ages were even longer. 36 hour shifts were common just a generation ago.

And 24 (plus 4 additional "if necessary") is currently the standard for PGY-2 and up. PGY-1 is currently limited to 16. Reading through the amendments in their entirety, there is some hope. They do include some clarifications of existing rules that might make things a little better, so I don't think that the whole thing is a mess.

I've worked a 36 hour stretch. I was not fit to order from a fast food menu by the end of that, let alone care for any patients. It is hard to imagine how any learning or patient care happens beyond a certain point, or how a hand off at 24 hours wouldn't be of lesser quality than the same hand off given at merely 16 hours into a shift.

A family member of mine said he/ she once worked 72 hours straight.

 

[FindMeOnTheLinks]

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Sent from my iPhone using SDN mobile

 

[NotYou20]

I'm a M1 so I know nothing, but I'd rather take 28 hour call than have weeks on night float. Concentrate the suffering, get it over with

 

[deleted480308]

It's just forcing us to do it because the older decision makers had it forced on them. It's not good for anyone or the attending would still be doing it and they largely put an end to that crap the second they graduate in most fields

 

[chipwhitley]

I'm a M1 so I know nothing, but I'd rather take 28 hour call than have weeks on night float. Concentrate the suffering, get it over with

It sounds like it would be better, but it's not. You're a lot more exhausted by a 28 hour shift than you are by night float. I'd rather be able to get to sleep every 16 hours and deal with night float. I think that's far healthier and more humane. Not to mention in our program, the 28 hour calls that residents have to do mean that the interns are left alone to manage all the patients, including the new patients the resident admitted overnight that we know nothing about and the resident is too exhausted to help us with in the morning, after the resident goes home. That's really stressful, especially earlier on in intern year when we are still figuring out how to do basic things, having to handle double the patients every four days is really tough.

 

[PL198]

why the jump from 16 to 28?

also I'll never understand the 4 hour transition stuff. what does this refer to? sign out should take under 15 minutes, what do you need 4 hours for

"It calls on residency programs, for example, to ensure that trainees can make appointments with a physician or a mental health professional, even during their working hours. And faculty and residents must be trained to identify symptoms of burnout, depression, and substance abuse."

This is like saying, well we're going to pour 5 gallons of gas on the fire, but we're going to give you a dixie cup of water to have at your side, so it should be a net wash.

 

[PL198]

the comparison to seniors makes no sense either. not the same thing at all

 

[chipwhitley]

The continuity of patient care argument makes no sense either. What happens in hospitals without residents? Doctors aren't regularly working 28 hour shifts anywhere but residency.

 

[DrBowtie]

Those who haven't done it, 16 hour days x 6 (averaged, some more some less) rinse and repeat for 9-10 months is terrible. Makes it next to impossible to get two days off in a row on wards. With 24 hour calls you can squeak out two extra half days a week.

 

[chipwhitley]

Those who haven't done it, 16 hour days x 6 (averaged, some more some less) rinse and repeat for 9-10 months is terrible. Makes it next to impossible to get two days off in a row on wards. With 24 hour calls you can squeak out two extra half days a week.

Why are those the only two options? Does working that 6th day in a week really add that much to resident education when it comes at the cost of burnout and poor quality of life? We are already working 16 hours a day after all. If the issue is the hospital can't manage without us, then isn't it more that they're exploiting our cheap labor?

 

[DrBowtie]

Why are those the only two options?

Well other options probably cost more money. You got some solutions? Send them to the ACGME

 

[deleted480308]

Why are those the only two options?

Because no one wants the slaves to work less hours. They want to run us just as hard as they did before Libby Zion

 

[chipwhitley]

Well other options probably cost more money. You got some solutions? Send them to the ACGME

The hospital could hire more staff instead of exploiting our cheap labor to profit?

 

[SouthernSurgeon]

This issue has come up a lot on the site over the years. The search function will reveal a myriad of opinions.

IMHO there are two separate arguments that tend to get conflated:
-Argument one is whether the overall duty hours (80 hrs/wk) are too strenuous
-Argument two is over the particular 16 hr limit i.e. elimination of 24 hour call

The particular debate at the ACGME level is over the 16 hour rule and the 16 hr rule only. But people tend to use it as a chance to tirade against the system as a whole.

If you're going to be sticking to the overall 80 hr limit (which I think you need to under the current paradigm for surgical specialties, but I can't speak for others), then removing the 16 hour cap is a good thing. There are a lot of us who went through this change as residents, i.e. have worked in both a 24 hr call based system and a 16 hr/night float system.

My personal opinion, which stems from experience but experience in only one program and one specialty, was that quality of life for residents under a 24 hr call system was better than it was under a night float system. These were the major problems that we dealt with:
1. Days off. When you're working on a Q4 or Q5 24 hr call system, you get to control your days off much more easily. We all got at least one if not two golden weekends (i.e. post-call Friday, off Sat, off Sun) per rotation. Compared to a night float system where you only get your 6 on/1 off schedule. Having an extended period off from work does wonders for your mental health and personal life.
2. Covering days off. Due to the 16 hr limit, covering one intern's day off requires assigning two interns (since they can't work a full 24). This again decreases days off for interns. In my program it meant having to go to DOMAs ("Day off My Ass") - i.e. using the 24 hr period where you transition from nights to days as a "day off". Another alternative in this situation is pulling senior residents who can work a 24 and making them cover the interns' days off. This decreases your available pool of seniors however and causes downstream effects (shortages for OR coverage in my program).
3. Work compression. Because you're now there only 14-16 hrs, the work you used to have 24 hours to do has to get done faster. The effect of this usually meant less time for interns to get to the OR, more staying late, and more signing stuff out that should have gotten taken care of during the day to the night team.
4. Sleep cycles. It's really hard switching back and forth from days to nights and back again. I had a really hard time coming off of nights every time. It took a lot longer to bounce back than after a regular old call. However this is specific to surgery where you end up taking a LOT of night call in that system (many programs had interns doing either 3 or 4 months out of their year on night float).

 

[chipwhitley]

Because no one wants the slaves to work less hours. They want to run us just as hard as they did before Libby Zion

Unfortunately it's probably going to take another Libby Zion to make any change.

 

[Ismet]

I'm a M1 so I know nothing, but I'd rather take 28 hour call than have weeks on night float. Concentrate the suffering, get it over with

Personal preference, but I've already done 4 weeks of night float and it's actually pretty great. As an intern, it's just you and a senior, and you learn a lot very quickly. After a couple nights I was adjusted to a new circadian rhythm, and yeah the switch back to days sucked for a couple days, but I'd rather do night float than 24's.

why the jump from 16 to 28?

also I'll never understand the 4 hour transition stuff. what does this refer to? sign out should take under 15 minutes, what do you need 4 hours for

The 16 hour limit refers to having 8 hours off between shifts. Technically if you work a 17 hour shift you're supposed to come in the next morning an hour later so you have 8 hours off. Yeah that doesn't happen.

Some programs actually require the night float people to round with the day team in the morning, I believe that's where the 28 comes from. Pretty unnecessary IMO if you give a good checkout and good documentation. I haven't run into issues yet where I wished the night team was with us on rounds in the morning...

Good signout takes more than 15 minutes. On wards it usually takes us ~45 minutes.

 

[Psai]

The hospital could hire more staff instead of exploiting our cheap labor to profit?

Yeah that sounds like a good idea, doesn't it? Except when they hire midlevels, these guys will get the best schedules. They will work normal hours in the middle of the week during the day. Why? Because that's the cheapest thing for the hospital. Unforunately, that's when there are the most staff and the most learning gets done. The residents will get shafted to the nights and weekends as there is no overtime pay for them. So "hire more staff" would paradoxically lead to a more ****ty schedule.

This issue has come up a lot on the site over the years. The search function will reveal a myriad of opinions.

IMHO there are two separate arguments that tend to get conflated:
-Argument one is whether the overall duty hours (80 hrs/wk) are too strenuous
-Argument two is over the particular 16 hr limit i.e. elimination of 24 hour call

The particular debate at the ACGME level is over the 16 hour rule and the 16 hr rule only. But people tend to use it as a chance to tirade against the system as a whole.

If you're going to be sticking to the overall 80 hr limit (which I think you need to under the current paradigm for surgical specialties, but I can't speak for others), then removing the 16 hour cap is a good thing. There are a lot of us who went through this change as residents, i.e. have worked in both a 24 hr call based system and a 16 hr/night float system.

My personal opinion, which stems from experience but experience in only one program and one specialty, was that quality of life for residents under a 24 hr call system was better than it was under a night float system. These were the major problems that we dealt with:
1. Days off. When you're working on a Q4 or Q5 24 hr call system, you get to control your days off much more easily. We all got at least one if not two golden weekends (i.e. post-call Friday, off Sat, off Sun) per rotation. Compared to a night float system where you only get your 6 on/1 off schedule. Having an extended period off from work does wonders for your mental health and personal life.
2. Covering days off. Due to the 16 hr limit, covering one intern's day off requires assigning two interns (since they can't work a full 24). This again decreases days off for interns. In my program it meant having to go to DOMAs ("Day off My Ass") - i.e. using the 24 hr period where you transition from nights to days as a "day off". Another alternative in this situation is pulling senior residents who can work a 24 and making them cover the interns' days off. This decreases your available pool of seniors however and causes downstream effects (shortages for OR coverage in my program).
3. Work compression. Because you're now there only 14-16 hrs, the work you used to have 24 hours to do has to get done faster. The effect of this usually meant less time for interns to get to the OR, more staying late, and more signing stuff out that should have gotten taken care of during the day to the night team.
4. Sleep cycles. It's really hard switching back and forth from days to nights and back again. I had a really hard time coming off of nights every time. It took a lot longer to bounce back than after a regular old call. However this is specific to surgery where you end up taking a LOT of night call in that system (many programs had interns doing either 3 or 4 months out of their year on night float).

I agree with everything here. 16 hour days continuously suck hardcore. I'm sure it happens to me a lot less often than it happens to you but I've done it enough to know it sucks.

I've also had to switch from days to nights twice in a week. I've never been so dead in my life. It's horrible.

Also rounding with the morning team after you've been there all night is freaking torture.

 

[chipwhitley]

Yeah that sounds like a good idea, doesn't it? Except when they hire midlevels, these guys will get the best schedules. They will work normal hours in the middle of the week during the day. Why? Because that's the cheapest thing for the hospital. Unforunately, that's when there are the most staff and the most learning gets done. The residents will get shafted to the nights and weekends as there is no overtime pay for them. So "hire more staff" would paradoxically lead to a more ****ty schedule.

That's where ACGME is supposed to help us, if they're acting in our best interests.

It's funny, because they act like residents slow the hospital down with their inexperience, but then the hospital collapses if the residents work fewer hours?

 

[SouthernSurgeon]

Yeah that sounds like a good idea, doesn't it? Except when they hire midlevels, these guys will get the best schedules. They will work normal hours in the middle of the week during the day. Why? Because that's the cheapest thing for the hospital. Unforunately, that's when there are the most staff and the most learning gets done. The residents will get shafted to the nights and weekends as there is no overtime pay for them. So "hire more staff" would paradoxically lead to a more ****ty schedule.

We have "hired more staff" at my program.

They have over doubled our mid level complement, largely in response to the duty hours.

However, we live in reality. It is really hard to hire midlevels to work nights and weekends. You have to pay them a ton, turnover is high, and they don't do as good a job.

We are fortunate to be in a financially solid department, and we are trying. The residents still work a lot.

 

[deleted480308]

That's where ACGME is supposed to help us, if they're acting in our best interests.

of course they aren't. The decisions are made by a bunch of older established docs who were abused by this enough to think everyone deserves their turn that also happen to be secure enough in their careers that it's been forever since anyone could threaten their entire career for not working like this. It's a total, "let them eat cake" thing

 

[chipwhitley]

We have "hired more staff" at my program.

They have over doubled our mid level complement, largely in response to the duty hours.

However, we live in reality. It is really hard to hire midlevels to work nights and weekends. You have to pay them a ton, turnover is high, and they don't do as good a job.

We are fortunate to be in a financially solid department, and we are trying. The residents still work a lot.

If the only way to have a financially solid department is to rely on trainees to work very long hours, then there's a serious issue with the system.

 

[deleted480308]

We have "hired more staff" at my program.

They have over doubled our mid level complement, largely in response to the duty hours.

However, we live in reality. It is really hard to hire midlevels to work nights and weekends. You have to pay them a ton, turnover is high, and they don't do as good a job.

We are fortunate to be in a financially solid department, and we are trying. The residents still work a lot.

Which is the real reason this is happening. Residents/interns are cheap and incapable of leaving en masse....it's like a pre-civil war plantation owner that didn't have enough people to work the field come harvest time. Does he pay a ton of money for his neighbors to help out? Nope. Just tell the slaves they are sleeping less.

 

[SouthernSurgeon]

Which is the real reason this is happening. Residents/interns are cheap and incapable of leaving en masse....it's like a pre-civil war plantation owner that didn't have enough people to work the field come harvest time. Does he pay a ton of money for his neighbors to help out? Nope. Just tell the slaves they are sleeping less.

I think the fundamental disconnect that comes up in these discussions is that I'm actually quite professionally satisfied. Certainly not a "slave".

My program has asked a lot of me. Intern year was one of the hardest and most transformative years of my life. But it was also one of the best and my program has given me a lot back in return. I've achieved a net gain out of the exchange.

 

[deleted480308]

I think the fundamental disconnect that comes up in these discussions is that I'm actually quite professionally satisfied. Certainly not a "slave".

My program has asked a lot of me. Intern year was one of the hardest and most transformative years of my life. But it was also one of the best and my program has given me a lot back in return. I've achieved a net gain out of the exchange.

I totally get that. I know what my premedicine life was like and if my PD told me I had to work 120s, I would do it in a heart beat. I'd be tired and I'd internally hate not seeing my family. But I'd be there in a minute because of the ROI. I'm with you on that 100%. I'd do anything to get through this including take a punch or wear full drag. Just get me to graduation.

But to be frank. It's not really optional. And most places/fields aren't asking anyone but residents to do this kind of stuff. When you have to pay overtime to all the ancillary staff and ^$200/hr to attendings who don't need your money anyway it's easy to tell the resident who presents no additional cost that "education" is the reason they now have to pull ridiculous shifts or add 50% to their work hours (I'm looking at you FIRST trial ) The question isn't really if it's "worth it" over the lifetime of the resident. The question is, "is it ok?". Are we abandoning the principle of, "do no harm" with our trainees?

 

[Promethean]

At least at my program, the senior's 24 hour shifts are done once a week because the people that work night float need a night off. The senior on the 24 gets a fresh intern halfway through the shift. It's a long day but it's completely doable.

24 is doable, in the right situations. That fresh intern is key. The intern is the one who generally gets most of the pages, has to do a lot of the running to preview situations before sending the ones that actually require attention up the chain.

The ideal on a 24 hours shift is that if there is a chance to nap, the doctor will take it, so that a 24 hour shift might actually involve a critical hour or two of rest somewhere within it. On certain services at the right facilities, it might mean getting almost a full night's sleep in a call room, with maybe just an interruption or two. So a 24 hour shift is doable in those situations. Heck, 36 or 48 becomes doable if there are genuinely enough rest periods within them.

So, that is the issue with extending 24 hours to intern year. They are taking the person who is almost certainly guaranteed not to get a minute of rest, and whose clinical judgment is least developed to begin with, and making sure that they are maximally fatigued. This will make intern year more hell than it needs to be, and will harm patients. As you say above, there are ways to resolve the problems with 16 hour shifts other than expanding them to 24 (plus 4 extra.)

I hope everyone who cares about this takes a moment to provide their commentary to the ACGME.

 

[sleepcrash]

Here's a link with instructions on how you can speak out against this, including a pre-filled form to submit comments to the ACGME: https://goo.gl/3YysDF - Please share with your class/your residents.

I've also pasted the instructions below:

• ACGME is accepting comments for the next 45 days using a rather convoluted form. To make it easier, I’ve pre-filled the form. All you have to do is download it, fill in your name and organization in the appropriate boxes, tweak the language of the comments as you see fit, and email it to [email protected]. Note that there is a section on the form where you can opt out of the publication of your comments if you’d like.
• AMSA, the American Medical Student Association, is organizing in opposition to these changes. After you’ve emailed the above form to ACGME, fill out AMSA’s petition here (Need proof that this is a legitimate petition? Read AMSA's statement.)
• Share the link to these instructions with your classmates and friends at other medical schools, and encourage them to do the same: https://goo.gl/3YysDF

 

[chipwhitley]

I totally get that. I know what my premedicine life was like and if my PD told me I had to work 120s, I would do it in a heart beat. I'd be tired and I'd internally hate not seeing my family. But I'd be there in a minute because of the ROI. I'm with you on that 100%. I'd do anything to get through this including take a punch or wear full drag. Just get me to graduation.

But to be frank. It's not really optional. And most places/fields aren't asking anyone but residents to do this kind of stuff. When you have to pay overtime to all the ancillary staff and ^$200/hr to attendings who don't need your money anyway it's easy to tell the resident who presents no additional cost that "education" is the reason they now have to pull ridiculous shifts or add 50% to their work hours (I'm looking at you FIRST trial ) The question isn't really if it's "worth it" over the lifetime of the resident. The question is, "is it ok?". Are we abandoning the principle of, "do no harm" with our trainees?

I have an idea - why not make it optional? It seems like many people in this thread, including the person you responded to, are getting a lot out of it and would be happy to do it. The rest of us can have a more humane schedule.

 

[Ismet]

24 is doable, in the right situations. That fresh intern is key. The intern is the one who generally gets most of the pages, has to do a lot of the running to preview situations before sending the ones that actually require attention up the chain.

The ideal on a 24 hours shift is that if there is a chance to nap, the doctor will take it, so that a 24 hour shift might actually involve a critical hour or two of rest somewhere within it. On certain services at the right facilities, it might mean getting almost a full night's sleep in a call room, with maybe just an interruption or two. So a 24 hour shift is doable in those situations. Heck, 36 or 48 becomes doable if there are genuinely enough rest periods within them.

So, that is the issue with extending 24 hours to intern year. They are taking the person who is almost certainly guaranteed not to get a minute of rest, and whose clinical judgment is least developed to begin with, and making sure that they are maximally fatigued. This will make intern year more hell than it needs to be, and will harm patients. As you say above, there are ways to resolve the problems with 16 hour shifts other than expanding them to 24 (plus 4 extra.)

I hope everyone who cares about this takes a moment to provide their commentary to the ACGME.

Absolutely. I think the way my program does it is excellent. We have minimal handoffs, the night team stays the same except for 1 night off per week in which a senior does a 24 and gets a fresh intern for the night shift. There's never a time when no one knows the patients or when you're working with a "stranger" who's not on the inpatient service.

 

[Promethean]

Those who haven't done it, 16 hour days x 6 (averaged, some more some less) rinse and repeat for 9-10 months is terrible. Makes it next to impossible to get two days off in a row on wards. With 24 hour calls you can squeak out two extra half days a week.

16 x 6 exceeds work hour requirements.

16 x 5 = 80. Scheduled right, there should be enough room in that for ample time off. If someone was squeezing an extra 16 in on you on the regular, they weren't in compliance.

24s do mean working fewer days. Why not do 3 24s a week (72 hours + 8 hours of discretionary time where you can stay late for signouts, rounds) and get 4 days a week off? That is a rhetorical question, because I think that the limitations of such a system become apparent quickly with a little thought.

Btw, one good thing about the revision is that it makes it clear that those 80 hours are supposed to be all inclusive, including lectures and other training opportunities. And suggests scheduling for less than 80 so that residents have some discretion about staying for a particular case, patient, etc.

 

[deleted480308]

I have an idea - why not make it optional? It seems like many people in this thread, including the person you responded to, are getting a lot out of it and would be happy to do it. The rest of us can have a more humane schedule.

I'd be all for that...if you want to trust it would stay optional. I already know residents in 4 states who are consistently pressured to work hours off the clock and not report. And, I'm not a particularly well connected student

 

[Promethean]

I have an idea - why not make it optional? It seems like many people in this thread, including the person you responded to, are getting a lot out of it and would be happy to do it. The rest of us can have a more humane schedule.

The problem with making it optional is that interns and residents have little to no recourse if we are forced to do optional things. Once we enter the medical education system, we lose a lot of power to defend ourselves. since, especially in clinical years, we are being evaluated based on subjective assessments. Taking any real stand for our own rights can easily alienate those whom we depend upon for our training and the evaluations that open the way for the next stage of our training. Any interruption in our clinical training due to a conflict with a superior has the potential to be career ending.

So, we pretty much have to put up and shut up. And if an attending makes it clear that they prefer that their residents do "optional" 24 hour shifts, those residents no longer have a real option.

Having restrictive guidelines is the only protection we have, and even those are encroached upon at many programs.

 

[DrBowtie]

16 x 6 exceeds work hour requirements.

16 x 5 = 80. Scheduled right, there should be enough room in that for ample time off. If someone was squeezing an extra 16 in on you on the regular, they weren't in compliance.

24s do mean working fewer days. Why not do 3 24s a week (72 hours + 8 hours of discretionary time where you can stay late for signouts, rounds) and get 4 days a week off? That is a rhetorical question, because I think that the limitations of such a system become apparent quickly with a little thought.

Btw, one good thing about the revision is that it makes it clear that those 80 hours are supposed to be all inclusive, including lectures and other training opportunities. And suggests scheduling for less than 80 so that residents have some discretion about staying for a particular case, patient, etc.

Brain fart. Ive already blocked out the misery of intern year. We were basically 13 hours x 6 average with a 16 hour long call and shorter post long call day to even out. I'm not sure I've seen or heard of any places doing 16 hours x 5 days because that would require more bodies.

 

[Ismet]

16 x 6 exceeds work hour requirements.

16 x 5 = 80. Scheduled right, there should be enough room in that for ample time off. If someone was squeezing an extra 16 in on you on the regular, they weren't in compliance.

24s do mean working fewer days. Why not do 3 24s a week (72 hours + 8 hours of discretionary time where you can stay late for signouts, rounds) and get 4 days a week off? That is a rhetorical question, because I think that the limitations of such a system become apparent quickly with a little thought.

Btw, one good thing about the revision is that it makes it clear that those 80 hours are supposed to be all inclusive, including lectures and other training opportunities. And suggests scheduling for less than 80 so that residents have some discretion about staying for a particular case, patient, etc.

We do 13-14 hours x 6 days per week on inpatient services. You get 1 day off per week averaged over 4 weeks. So technically you can work 24 straight days and then get 4 days off in a row and still be in compliance with duty hours.

 

[DrBowtie]

We do 13-14 hours x 6 days per week on inpatient services. You get 1 day off per week averaged over 4 weeks. So technically you can work 24 straight days and then get 4 days off in a row and still be in compliance with duty hours.

During my intern year, Q4 long call days were not day off eligible so it further limited options.

 

[Mad Jack]

As inhumane as they sound, I'd rather have a few 28 hour shifts peppered in my schedule than to do 16s constantly- more days off keep you saneish.

 

[ProfMD]

What we should be worried about is balancing two issues:
1) Patient safety.
2) Resident education.

So far, there is no good evidence that limiting work hours has improved patient safety. There are serious concerns, particularly among surgical specialties, that residents are not getting appropriate training under the new rules.

 

[Promethean]

Brain fart. Ive already blocked out the misery of intern year. We were basically 13 hours x 6 average with a 16 hour long call and shorter post long call day to even out. I'm not sure I've seen or heard of any places doing 16 hours x 5 days because that would require more bodies.

So, 16 X 5 is totally doable and might even be a relatively humane schedule. Set it up so that several days of the same "shift" are grouped together whenever possible. So, either 7a-11p or 7p-11a. Gives 4 hours of overlap on either end, resolving the issues with hand off. You'd also potentially have twice as many hands for both the 7-11a and 7-11p hours, which are both busy times of day. Your attendings could keep a 9-5 schedule if they wanted and still be able to see all the interns every day.

Doing the same shift several days in a row minimizes the pain of switching back and forth between days and nights and gives the potential for real time off every week, maybe even a rare 3 or 4 day stretch if the stars aligned just right. (What? I know, right?)

The problem, as you notice, is that this would require more interns. Yup. But not a lot more. The minimum that such a system could work with would be 4, assuming no absences, vacations, etc. But it could work seamlessly at any program with 5+ interns, or a willingness to use nonresident night float to cover some of the shifts.

 

[SouthernSurgeon]

What we should be worried about is balancing two issues:
1) Patient safety.
2) Resident education.

So far, there is no good evidence that limiting work hours has improved patient safety. There are serious concerns, particularly among surgical specialties, that residents are not getting appropriate training under the new rules.

I agree with you with the caveat that we should be balancing three issues:

1. Patient safety
2. Resident education
3. Resident quality of life

And my points above are that the new rules have potential negative impact on both 2 and 3

 

[deleted480308]

What we should be worried about is balancing two issues:
1) Patient safety.
2) Resident education.

So far, there is no good evidence that limiting work hours has improved patient safety. There are serious concerns, particularly among surgical specialties, that residents are not getting appropriate training under the new rules.

You missed resident safety on your list. Driving accidents, needlesticks, mental health all get worse with worse hours

 

[deleted480308]

So, 16 X 5 is totally doable and might even be a relatively humane schedule. Set it up so that several days of the same "shift" are grouped together whenever possible. So, either 7a-11p or 7p-11a. Gives 4 hours of overlap on either end, resolving the issues with hand off. You'd also potentially have twice as many hands for both the 7-11a and 7-11p hours, which are both busy times of day. Your attendings could keep a 9-5 schedule if they wanted and still be able to see all the interns every day.

Doing the same shift several days in a row minimizes the pain of switching back and forth between days and nights and gives the potential for real time off every week, maybe even a rare 3 or 4 day stretch if the stars aligned just right. (What? I know, right?)

The problem, as you notice, is that this would require more interns. Yup. But not a lot more. The minimum that such a system could work with would be 4, assuming no absences, vacations, etc. But it could work seamlessly at any program with 5+ interns, or a willingness to use nonresident night float to cover some of the shifts.

+1. Nothing requires a resident and only a resident. Attendings are also capable of doing all these crazy hours. But they don't because it's miserable and ridiculous. I'm not interested in a hospital saying, "but you need to work 28hrs straight because we haven't hired enough other people". Too bad. The system can't just drop everything on residents

 

[DrBowtie]

So, 16 X 5 is totally doable and might even be a relatively humane schedule. Set it up so that several days of the same "shift" are grouped together whenever possible. So, either 7a-11p or 7p-11a. Gives 4 hours of overlap on either end, resolving the issues with hand off. You'd also potentially have twice as many hands for both the 7-11a and 7-11p hours, which are both busy times of day. Your attendings could keep a 9-5 schedule if they wanted and still be able to see all the interns every day.

Doing the same shift several days in a row minimizes the pain of switching back and forth between days and nights and gives the potential for real time off every week, maybe even a rare 3 or 4 day stretch if the stars aligned just right. (What? I know, right?)

The problem, as you notice, is that this would require more interns. Yup. But not a lot more. The minimum that such a system could work with would be 4, assuming no absences, vacations, etc. But it could work seamlessly at any program with 5+ interns, or a willingness to use nonresident night float to cover some of the shifts.

Problem is that only works for a single service and not across multiple sites and teams. Internal Medicine also has patient caps which complicate things further.

 

[Promethean]

What we should be worried about is balancing two issues:
1) Patient safety.
2) Resident education.

So far, there is no good evidence that limiting work hours has improved patient safety. There are serious concerns, particularly among surgical specialties, that residents are not getting appropriate training under the new rules.

3) and often forgotten - Resident physical and mental health

Well trained doctors are no good to anyone if they are dead or so damaged that they must exit the profession. Well being of the trainees has to be taken into account. too.

 

[Psai]

So, 16 X 5 is totally doable and might even be a relatively humane schedule. Set it up so that several days of the same "shift" are grouped together whenever possible. So, either 7a-11p or 7p-11a. Gives 4 hours of overlap on either end, resolving the issues with hand off. You'd also potentially have twice as many hands for both the 7-11a and 7-11p hours, which are both busy times of day. Your attendings could keep a 9-5 schedule if they wanted and still be able to see all the interns every day.

Doing the same shift several days in a row minimizes the pain of switching back and forth between days and nights and gives the potential for real time off every week, maybe even a rare 3 or 4 day stretch if the stars aligned just right. (What? I know, right?)

The problem, as you notice, is that this would require more interns. Yup. But not a lot more. The minimum that such a system could work with would be 4, assuming no absences, vacations, etc. But it could work seamlessly at any program with 5+ interns, or a willingness to use nonresident night float to cover some of the shifts.

The thing you're missing is that your patients don't respect work hours. Sometimes you finish early, sometimes you finish late. Having set hours is stupid. Also leaving the hospital at 11 pm sounds horrible.