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

[Danbo1957]

Wrong. The intern is largely useless and is there to do my H/P's. The fresh intern just serves to irritate me more.

Uh-huh, tell that to your PD's face.

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[mimelim]

Fun fact, over the Thanksgiving week I was physically in the hospital 118 hours. Have fun trying to average that down to 80 hours/week. Helps to have your wife out of town with her family and having little to no downside of simply never leaving the hospital. Business is good and my op log is nice and fat .

Wrong. The intern is largely useless and is there to do my H/P's. The fresh intern just serves to irritate me more.

Your interns suck if in November they can only do your H&Ps. Obviously every program does things differently and the size of programs makes a big difference, but from day 1 the job of the intern is to learn how to run a service. It takes years to do, but after 2-3 months I expect ours to be able to do 3 things. #1 Keep the ORs moving. #2 Know when to ask for help. #3 Keep patients moving out of the hospital. They don't need to learn how to operate. They don't even really need to learn that much medicine. Fundamentally, they need to learn early because from year 2 on, they may be the only person around for hours at a time and if they can't keep the service running as a junior or senior resident, things fall apart quickly.

While my question doesn't pertain directly to the specific hours shift requirements, I can't help but wonder what the posters here think about the adverse impact that residencies, especially in surgical training create.

I know some of the attendings here are fairly progressive on most things, yet, seem to be completely ok (or at least complacent) with a system that pretty much selects for a very specific group of people. To be more specific, a female with children/parents (especially if they don't speak English) will not be able to commit so many hours a week for several years simply due to family constraints and not because of laziness or weak work ethic. So should someone like that be essentially precluded from doing orthopedics residency even if they are qualified enough to get in and want to go into that?

I know this is a matter of public policy rather than what the doctors think, but I am curious to see how individuals 'content' with a system in place justify this?


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It is hard to train surgeons. Outside of my clinical training, in the past decade I have spent more time thinking about medical/surgical education than any other academic pursuit. I can come up with 1001 different things that I would try to change. But, the reality is that in order to learn how to do the job, you need to have three things. #1 Medical knowledge, #2 Available pathology and #3 Mentors. #1 is easy to get, you simply need to read. You need to learn for your in-service exams, etc. It is flexible and while time consuming, reasonably efficient because it is pretty simple to understand. #2 and #3 are tricky. Pathology exists on the wards, in the ICU, in the OR etc. It doesn't live in the classroom, it doesn't abide by the work day. Mentors are similar. They are functioning in a clinical practice. Their schedule is somewhat their own, but they have massive constraints from their bosses, the OR staff and also their own family/social life. Because of this, it is very inefficient education, but it is essential and mandatory for training. Are there ways to make it more efficient, of course. But, everything has a cost, both time, convenience and $$$. At the end of the day, if you can't physically be there to get the education, you aren't going to get trained. Being smart /academically qualified isn't everything. Sometimes, in order to get the experience, you need to stay late, because that is when the pathology is available. Call it drive, dedication, or whatever you want. But, when we recruit for our residency, you aren't "qualified" just because you have decent scores.

 

[giantswing]

While my question doesn't pertain directly to the specific hours shift requirements, I can't help but wonder what the posters here think about the adverse impact that residencies, especially in surgical training create.

I know some of the attendings here are fairly progressive on most things, yet, seem to be completely ok (or at least complacent) with a system that pretty much selects for a very specific group of people. To be more specific, a female with children/parents (especially if they don't speak English) will not be able to commit so many hours a week for several years simply due to family constraints and not because of laziness or weak work ethic. So should someone like that be essentially precluded from doing orthopedics residency even if they are qualified enough to get in and want to go into that?

I know this is a matter of public policy rather than what the doctors think, but I am curious to see how individuals 'content' with a system in place justify this?

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Everyone sacrifices to do surgery, arguable more than non surgical residencies. Women, IMO, don't consider residencies for the very reason you mentioned, but it is do able w the right type of spouse and family support. If she's qualified, wants to go into it, and has people who can take care of her kid, it's doable, but people will tell her every step of the way that it isn't. This is a bunch of horse crap. She has to know she won't be "that" type of mother, and be okay w it.

 

[SunsFun]

It is hard to train surgeons. Outside of my clinical training, in the past decade I have spent more time thinking about medical/surgical education than any other academic pursuit. I can come up with 1001 different things that I would try to change. But, the reality is that in order to learn how to do the job, you need to have three things. #1 Medical knowledge, #2 Available pathology and #3 Mentors. #1 is easy to get, you simply need to read. You need to learn for your in-service exams, etc. It is flexible and while time consuming, reasonably efficient because it is pretty simple to understand. #2 and #3 are tricky. Pathology exists on the wards, in the ICU, in the OR etc. It doesn't live in the classroom, it doesn't abide by the work day. Mentors are similar. They are functioning in a clinical practice. Their schedule is somewhat their own, but they have massive constraints from their bosses, the OR staff and also their own family/social life. Because of this, it is very inefficient education, but it is essential and mandatory for training. Are there ways to make it more efficient, of course. But, everything has a cost, both time, convenience and $$$. At the end of the day, if you can't physically be there to get the education, you aren't going to get trained. Being smart /academically qualified isn't everything. Sometimes, in order to get the experience, you need to stay late, because that is when the pathology is available. Call it drive, dedication, or whatever you want. But, when we recruit for our residency, you aren't "qualified" just because you have decent scores.

I get your point about the need to get experience and have no problem admitting that additional hours are spent on essential components of surgical training. My "beef" is with what I bolded. We are not really taking about lack of drive or dedication. The underlying assumption I am making that the person in question has plenty of both. It's simple reality of our times, however, that that people, often those who belong to more vulnerable populations, tend to have constraints that you or I may not experience. Some people have no choice but to take of a sick/non-English speaking parents, observe certain religious traditions, etc. Now, we all make big sacrifices, but personal costs and consequences can be radically different. Do you think an otherwise excellent candidate can be denied the privileges of the OR, or even medicine in general, just because training that individual is less convenient, may cost a bit more, or may require options to extend the training period?

The question is more to gauge your attitude and attitude of your department in general. Obviously, at some point we cant accommodate everyone or find a reasonable alternative. But, how far would you personally be willing to go if you were the one making those decisions?

Everyone sacrifices to do surgery, arguable more than non surgical residencies. Women, IMO, don't consider residencies for the very reason you mentioned, but it is do able w the right type of spouse and family support. If she's qualified, wants to go into it, and has people who can take care of her kid, it's doable, but people will tell her every step of the way that it isn't. This is a bunch of horse crap. She has to know she won't be "that" type of mother, and be okay w it.

What if the bolded is missing and situation mentioned in my response above is the reality? Would that still mean she is not "that" type suitable for a career in surgery?

It doesn't have to be a kid. There are million things outside of our control that can be at play here.

 

[ProfMD]

I get your point about the need to get experience and have no problem admitting that additional hours are spent on essential components of surgical training. My "beef" is with what I bolded. We are not really taking about lack of drive or dedication. The underlying assumption I am making that the person in question has plenty of both. It's simple reality of our times, however, that that people, often those who belong to more vulnerable populations, tend to have constraints that you or I may not experience. Some people have no choice but to take of a sick/non-English speaking parents, observe certain religious traditions, etc. Now, we all make big sacrifices, but personal costs and consequences can be radically different. Do you think an otherwise excellent candidate can be denied the privileges of the OR, or even medicine in general, just because training that individual is less convenient, may cost a bit more, or may require options to extend the training period?

The question is more to gauge your attitude and attitude of your department in general. Obviously, at some point we cant accommodate everyone or find a reasonable alternative. But, how far would you personally be willing to go if you were the one making those decisions?



What if the bolded is missing and situation mentioned in my response above is the reality? Would that still mean she is not "that" type suitable for a career in surgery?

It doesn't have to be a kid. There are million things outside of our control that can be at play here.

Unfortunately, those outside responsibilities you allude to all take away from time spent at the hospital. To train as a surgeon, you need to be in the hospital doing surgery. I am willing to and have made allowances for my residents to handle various situations at home that arise from time to time. However, if one has responsibilities outside of work to that are going to significantly cut into one's time in the hospital on a regular basis for the entire residency, then one should find another field.

This is for at least a couple of reasons:
1) If you can't spend the time in the hospital training, then your training will be inadequate. This makes you a danger to future patients.
2) Life as an attending is only marginally better. If you have outside responsibilities that prevent you from fully participating in the residency, then you will be miserable in your career as a surgeon.

 

[giantswing]

What if the bolded is missing and situation mentioned my response above is the reality? Would that still mean she is not "that" type suitable for a career in surgery?

It doesn't have to be a kid. There are million things outside of our control that can be at play here.

No, it means maybe her husband/partner/nanny will have to stay home w the kids, may have a larger role in child care/house keeping. It's still uncommon but more and more men are doing this. The same is true for men, pregnancy aside; doctor couples often pay $$$ in child care.

As a woman, you can be various combinations and amounts of breadwinner, child bearer, and child raiser. If you want to be the Primary Child Raiser, there's all sorts of careers that probably aren't for you, least of all surgery.

A friend of mine who is a full time general surgeon while her husband stays at home said this best (paraphrasing): "I know I'm supposed to cry, ache, and pine for my children and feel guilty about being at work as much as I am. I do not. I am the breadwinner. This is my job. Also, my job keeps me sane, and staying at home with my kids all day would make me crazy."

 

[SouthernSurgeon]

Of note - in the same issue of JACS, they looked at gender differences in perception of duty hours. Female residents expressed significantly more dissatisfaction with the hours than men as well as were more likely to have concern for the impact of prolonged duty hours on patient safety.

 

[HooliganSnail]

You basically just agreed with me, you just didn't realize it.

Based on your response, your interns are there just to do your paperwork too! You do the surgery, and they do the discharge summary...

Medicine isn't surgery. Our training is fundamentally different. Expecting interns to come in from day 1 and "learn how to run a service" just is NOT going to happen in the ICU. They are being trained to run the ICU, slowly, methodically. Just like your interns are slowly being trained to actually do surgery. ICU patients are...well...critically ill. When an intern is "managing"them, it is with a heavy look over the shoulder. Everyone starts out with a real tight leash, that is slowly elongated over the course of the training depending on their individual ability (there are senior residents with very short leashes).

Here is the kick. It really bugs the hell out of me when I am on a 28hr call, and the intern leaves in the middle, and is replaced by another one....they never know what is going on, and they are behind the ball. Me I'm just trying to keep everyone alive(ish) till sign out, and the new intern in the evenings is just not that useful outside of pushing paper. Cynical I know, but maybe I'm just beaten down a little.

The frustrating part is that I agree fundamentally with what you are saying, the intern should be learning to do this job on their own. I think when they leave in the middle of the day they miss out on learning a lot of critical things, and I think the idea of night float just doesn't hold up when it comes to getting high quality clinical experience. It's not just my opinion either, because since our interns have switched to block nights to meet ACGME standards, they are struggling to get signed off on procedures, which is a critical part of being the on-call resident running the ICU in the middle of the night.

 

[SunsFun]

Fun fact, over the Thanksgiving week I was physically in the hospital 118 hours. Have fun trying to average that down to 80 hours/week. Helps to have your wife out of town with her family and having little to no downside of simply never leaving the hospital. Business is good and my op log is nice and fat .



Your interns suck if in November they can only do your H&Ps. Obviously every program does things differently and the size of programs makes a big difference, but from day 1 the job of the intern is to learn how to run a service. It takes years to do, but after 2-3 months I expect ours to be able to do 3 things. #1 Keep the ORs moving. #2 Know when to ask for help. #3 Keep patients moving out of the hospital. They don't need to learn how to operate. They don't even really need to learn that much medicine. Fundamentally, they need to learn early because from year 2 on, they may be the only person around for hours at a time and if they can't keep the service running as a junior or senior resident, things fall apart quickly.



It is hard to train surgeons. Outside of my clinical training, in the past decade I have spent more time thinking about medical/surgical education than any other academic pursuit. I can come up with 1001 different things that I would try to change. But, the reality is that in order to learn how to do the job, you need to have three things. #1 Medical knowledge, #2 Available pathology and #3 Mentors. #1 is easy to get, you simply need to read. You need to learn for your in-service exams, etc. It is flexible and while time consuming, reasonably efficient because it is pretty simple to understand. #2 and #3 are tricky. Pathology exists on the wards, in the ICU, in the OR etc. It doesn't live in the classroom, it doesn't abide by the work day. Mentors are similar. They are functioning in a clinical practice. Their schedule is somewhat their own, but they have massive constraints from their bosses, the OR staff and also their own family/social life. Because of this, it is very inefficient education, but it is essential and mandatory for training. Are there ways to make it more efficient, of course. But, everything has a cost, both time, convenience and $$$. At the end of the day, if you can't physically be there to get the education, you aren't going to get trained. Being smart /academically qualified isn't everything. Sometimes, in order to get the experience, you need to stay late, because that is when the pathology is available. Call it drive, dedication, or whatever you want. But, when we recruit for our residency, you aren't "qualified" just because you have decent scores.

In light of your most recent comments on DNP/PA role in healthcare, do you still feel the same about stringent and grueling for surgery residents?

Also, relevant to this discussion:

http://www.kevinmd.com/blog/2016/12...rs-per-week-still-poorly-trained-surgeon.html


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[mimelim]

In light of your most recent comments on DNP/PA role in healthcare, do you still feel the same about stringent and grueling for surgery residents?

Also, relevant to this discussion:

http://www.kevinmd.com/blog/2016/12...rs-per-week-still-poorly-trained-surgeon.html


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Yes.

 

[deleted393595]

Yes.

Can we pls also get paid more than a burger flipper at McDonalds?

I mean, CMS pays out $150k/resident/hospital. Where does that money disappear?

Also, Congress says that residency is "educational" (for anti-trust purposes), yet Social Security and Medicare are cut out of resident paychecks since the IRS considers it to be "work". Why doesn't the AMA and the ACGME stand up for us on this?

 

[IlDestriero]

Just wait until congress makes it classified as not work and can't get credit for the residency/fellowship years for your loan repayment plans. That's the lowest hanging fruit of all.


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Il Destriero

 

[TooMuchResearch]

Just wait until congress makes it classified as not work and can't get credit for the residency/fellowship years for your loan repayment plans. That's the lowest hanging fruit of all.


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Il Destriero

At least then they also wouldn't count as creditable years towards social security. Nope, that makes it worse. Anyway, I refinanced my loans.

 

[cbrons]

Wrong. The intern is largely useless and is there to do my H/P's. The fresh intern just serves to irritate me more.

Which specialty?

 

[ProfMD]

Can we pls also get paid more than a burger flipper at McDonalds?

I mean, CMS pays out $150k/resident/hospital. Where does that money disappear?

Also, Congress says that residency is "educational" (for anti-trust purposes), yet Social Security and Medicare are cut out of resident paychecks since the IRS considers it to be "work". Why doesn't the AMA and the ACGME stand up for us on this?

$150000 is probably an overestimation. Truth is, it varies by hospital. The link below suggests it is closer to $75000.

Thank money goes toward you salary, benefits, malpractice insurance, book/travel funds, pay residency coordinators, and to cover costs of inefficiencies associated with having residents.

Hospitals are not making a profit off of residents.

http://www.acgme.org/Portals/0/PDFs/2015 AEC/Presentations/PC001/PC001g_Financial.pdf

 

[IlDestriero]

Even if the hospital is shelling out $75,000 of their own money, isn't that a steal of a deal for a full time resident employee?

Definitely not.


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Il Destriero

 

[meister]

Some will say residents are a net loss. They may be right, if you count all the interns and juniors.

However I assure you that my attendings, who get to sleep through the night while I read every study for the hospital from 8PM to 8AM, are getting their money's worth. What's the price for a full night's sleep?

 

[ProfMD]

Even if the hospital is shelling out $75,000 of their own money, isn't that a steal of a deal for a full time resident employee?

No. The alternative is either more physicians or mid-levels - all of whom can bill and offset the costs of their salaries.

 

[ProfMD]

Some will say residents are a net loss. They may be right, if you count all the interns and juniors.

However I assure you that my attendings, who get to sleep through the night while I read every study for the hospital from 8PM to 8AM, are getting their money's worth. What's the price for a full night's sleep?

The people I know in non-academic practices either have nocturnists (hospitals who work at night) or midlevels taking care of the simple stuff. As an academic surgeon, I get less sleep on call than my private practice colleagues.

 

[meister]

Surgery is not radiology, but you are probably right about the true value of almost all but the most senior surgical residents.