Longer Shifts for First-Year Residents to Start in July

[Light at end of tunnel]

Ummm.....NO.

(as someone who was a PGY-10 last year, I would prefer to not spend basically my entire prime working years in training, thank you)

10?? What field?

---

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[MediCane2006]

10?? What field?

Pediatric craniofacial surgery

 

[Goro femme]

Pediatric craniofacial surgery

Just for reference, could you please give an average number of hours worked per week during the different stages of your training since you just finished last year? Also, if your training were able to be compressed, how many years realistically do you think it would have taken you if there were no work hour restrictions?

 

[managedcarefin]

Resident pay is dictated by government while NP salary is dictated by the market. And I don't buy the argument that revenue generated + government stipend - "cost" of educating residents is a net loss for hospitals. They're businesses; the CFO wouldn't allow that to happen. Residents are most definitely exploited labor.

This is 100% a fact.

 

[MediCane2006]

Just for reference, could you please give an average number of hours worked per week during the different stages of your training since you just finished last year? Also, if your training were able to be compressed, how many years realistically do you think it would have taken you if there were no work hour restrictions?

Gen surg (5 years) was probably right around 80 (busy NE program). Research year was a lot closer to your standard issue 40. Plastics fellowship (3 years) was more like 90-100 per week because we were a small program taking a ton of ER call. Craniofacial fellowship was prob 60-70 hours per week.

I didn't feel super prepared for attending-ship but I don't think anyone does. I will say that from a technical perspective it's nice to feel some cases fall into the "muscle memory" category but as everyone always says, you can teach a monkey to operate but its learning the periop and preop judgment that's hard. I have felt the same degree of mild terror that I think most young attendings feel, but I also felt like I had gained all I was going to from training and had reached the point of "sink or swim"

I feel like my training was about right in terms of length. At the time I was going through it, I thought PGY-2 of gen surg was a giant waste of time but looking back I'm not sure. I feel the same about the second year of my plastics fellowship. Im not sure how eliminating those years would have helped me necessarily .... but I also know I'm on the more "cautious" end of the spectrum so maybe they were important for me personally in building my confidence but disposable for other folks.

 

[Crayola227]

As has been pointed out in this thread, you start to get a bit apples to oranges with some surgical fields vs less procedural fields. It depends on your goals. Everyone in this thread is conveniently applying these standards to their own situation and not considering the physicians that are very much harmed by overnights.

Let's take IM, and pretend you don't want fellowship.

IM, from what I can tell, is like the "hell on Earth" of the non-procedural residencies, and it's only 3 years.
Some might argue it would be more palatable and even learned better in a system that was less paperwork time, less hours a week, and 4 or even 5 years (an IMG IM teaching attending told me about it once).

1 year extra, alone would be 33% more training time. If you cut hours 20%, say from 80 --> 60 (I'm aware the averages are more complex than this), you'd actually come out ahead. Under this "reduced hours extended training," it would result in a total of more experience and uninterrupted sleep. If you cut paperwork with tort reform or something, it could be even better educationally.

Given that I hear being a hospitalist is like being an overglorified IM resident, only people don't graduate feeling quite experienced enough at times, really the IM resident would have nothing to lose by such an "extended length" training program. They would have more work/life balance, education, supervised training in total. 3 years of hell converted to a gentler 4 years. They wouldn't notice the difference except it would be "easier" work weeks and let's not talk money at the moment (other countries have figured this out).

In fact, I believe such extended general internal medicine tracks exist (not for the purpose of reducing hours, although frequently the schedule is more spaced out, as the additional blocks tend to be electives to supplement what is already heavy inpt training in IM). From what I hear, the extra year is worthwhile for a lot of reasons, at least from the people that opt for it.

I appreciate why someone in a 5 year surgical residency throwing each other under the bus for the next cool case and being "forced" to scrub out at 28 hours, needing to graduate with X # of Y cases just to feel comfortable, feels completely differently.

Just chew on this for the non-proceduralists out there, whose extra hours are not filled with more education via hands on. You guys probably get a lot more out of the 150th lab chole by being able to do it in your sleep, than the IM resident with the 150th LOL w/ PNA admit, and the attendant 4 hours of secretarial typing that must be done.

 

[Winged Scapula]

Ummm.....NO.

(as someone who was a PGY-10 last year, I would prefer to not spend basically my entire prime working years in training, thank you)

You've got plenty of more prime years left!

 

[sazerac]

Ummm.....NO.

(as someone who was a PGY-10 last year, I would prefer to not spend basically my entire prime working years in training, thank you)

PGY-10... wow it really is possible to finish PSLF and have no more student loans while still in residency. Amazing.

 

[mimelim]

PGY-10... wow it really is possible to finish PSLF and have no more student loans while still in residency. Amazing.

Signed my PGY-6 contract last week. Someone was trying to sell me on a PGY-8 year after I graduate. I told them to kindly **** off.

 

[SunsFun]

IMO, unfortunately this argument is about being hit on the head with a bet vs a hammer. Both suck in their own way.

Even bigger problem is with attending/residents making an assumption hours worked == learning/patient care. Starting with MS3, the culture of medicine revolves around inefficiency and minimal value added to education and patient medical care. Secretarial, social, compliance work over years have replaced much of clinically relevant tasks. Some institutions are better at dealing with it than others, but overall the balance is heavily on the inefficiently end of the spectrum.

Don't believe me? Go ahead and count how many hours in average week at each level of training have been spent acquiring skills (e.g. intern assisting in the OR) or adding value to patient MEDICAL care (e.g. time at bedside).


Sent from my iPhone using SDN mobile app

 

[ProfMD]

IMO, unfortunately this argument is about being hit on the head with a bet vs a hammer. Both suck in their own way.

Even bigger problem is with attending/residents making an assumption hours worked == learning/patient care. Starting with MS3, the culture of medicine revolves around inefficiency and minimal value added to education and patient medical care. Secretarial, social, compliance work over years have replaced much of clinically relevant tasks. Some institutions are better at dealing with it than others, but overall the balance is heavily on the inefficiently end of the spectrum.

Don't believe me? Go ahead and count how many hours in average week at each level of training have been spent acquiring skills (e.g. intern assisting in the OR) or adding value to patient MEDICAL care (e.g. time at bedside).


Sent from my iPhone using SDN mobile app

This is not a problem with training, it is a problem with modern medicine in the US. The problem I see is that residents assume that all of there time should be spent learning pathophysiology, treatment, diagnosis, surgical skill, etc. What you all call scut work, we call being a doctor.

Writing notes, putting in orders, meeting with discharge planners, calling rehab facilities, filling out reams of paperwork, dressing changes, pulling drains - these are all doctor tasks. They are things that must get done by a physician or physician extender in today's health care world. Guess what, as an attending, I still write notes, put in orders, talk to social workers, do paperwork, change dressings, pull drains. It is not all rewarding, but it is part of the job.

Now, a lot of the "scut work" does fall disproportionately on the interns. This means that as a senior resident you won't have to do as much and you can focus more of your time on the stuff you really want to be learning. You are paying it forward.

More hours worked does allow for more contact with patients, more consults, more surgeries. You also do not know when those learning opportunities will arise.

I find it interesting that the people who support rescinding the 2011 rules are the ones who have actually been there and are now attendings. The people who know what it takes to learn to do what they do.

 

[SurfingDoctor]

I only got to PGY-7... I'm so weak .

Actually, I was close to doing a PGY-8, but the wife talked me out of it. As much as it pains me to admit, she was right...

 

[schmoob]

I only got to PGY-7... I'm so weak .

Actually, I was close to doing a PGY-8, but the wife talked me out of it. As much as it pains me to admit, she was right...

Make sure you don't tell her that last part, she'll never let you forget it
Congratulations on finishing your training (whenever that was)!

 

[SurfingDoctor]

Make sure you don't tell her that last part, she'll never let you forget it
Congratulations on finishing your training (whenever that was)!

Oh, she has plenty of other things to hold over me. And training was done awhile ago... and some point one has move from Pampers to Depends .

 

[alpinism]

I personally agree with Dr. Fred and think we should do away with all work hour restrictions.

Residents nowadays don't know the meaning of hard work and sacrifice.

These are the days
The Internship Revisited
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1847908/

These are the days when interns have reason to gripe. Unless they demonstrate unflagging commitment and indisputable integrity, they risk being fired—sometimes on the spot and without warning. They have no formal contracts.

Their responsibilities are daunting and their schedule grueling. They work every day and every other night. While on duty, they rarely find time to sleep. And when off duty, they must remain in the hospital until all of their patients are in stable condition and all studies planned for the next day have been ordered. Consequently, on their post-call days, interns typically leave the hospital about 8 pm, and sometimes not until midnight.

Ward rounds on the inpatients begin sharply at 7 am, 7 days a week. In attendance are the ward resident, the 2 interns, and the chief nurse. Medical students do not participate. These rounds are sacred, generally last 2 hours, and only a bona fide emergency can interrupt them. The intern on the case briefly examines the patient while the resident examines the patient's chart. Results of tests and procedures done the previous day are discussed, and, with input from the chief nurse, the resident and intern make decisions regarding additional testing or consultation, medication changes, discharge considerations, and other “housekeeping” matters. Similar rounds often take place around 6 pm that same evening.

Aided at times by medical students and the resident, interns perform and interpret all admission and follow-up blood counts, peripheral blood smears, urinalyses, stool guaiac tests, and electrocardiograms. Additionally, they start and maintain all intravenous therapy; draw all blood cultures; stain and examine microscopically all pleural, pericardial, peritoneal, spinal, and joint fluids; apply skin tests; and search for ova and parasites in stool specimens. The intern on call also draws the early morning blood samples from about 20 to 30 patients—the team's average number of patients at any given time. That job—undertaken with frustratingly blunt, nondisposable needles and ill-fitting, easily broken glass syringes—must begin by 5 am or earlier to be completed before work rounds begin. Interns also fill out the requisition slips for all laboratory tests and procedures and are responsible not only for recording the results in the patients' charts, but also for reciting the results on command.

By carrying out these seemingly menial tasks—called “scut work” in housestaff lingo—interns begin to realize the importance of accountability. They learn firsthand the subtle factors that can influence test results. They learn to appreciate other members of the healthcare team who ordinarily do such work—nurses, laboratory personnel, phlebotomists, and ward clerks. And most important, perhaps, the scut work repeatedly brings interns into physical contact with their patients, strengthening the doctor–patient bond.

Interns make daily trips to the main hospital laboratory, radiology department, microbiology unit, and other areas to obtain test results, review x-ray studies with a staff radiologist, check on the growth of various cultures, etc. This important routine requires a lot of physical effort, but it ensures timely and uninterrupted patient care.

In addition to the workload already described, interns must squeeze in time for daily chart rounds. During this ritual, the intern and resident scrutinize each inpatient record for missing data, illegible notes, disorganized inserts, and other common deficiencies. “A sloppy chart indicates a sloppy doctor,” the department chairman says. Not surprisingly, therefore, defective patient records provoke his wrath.

Interns occasionally are discussants at weekly Grand Rounds. This assignment compels them to spend long hours in the medical library searching the stacks for pertinent articles on their topic. In the process, they learn what it takes to research a subject thoroughly, how to read with discrimination, how to critically evaluate what they read, and how to give a formal presentation before a discerning audience.

They also prepare vigorously for teaching rounds, which take place at 10 AM, 4 times a week—3 with anattending physician, and 1 with the chairman. The attendings and chairman serve as consultants who simply offer opinions and make recommendations. Responsibility for managing the patient—particularly all decision-making and order-writing—rests solely with the intern and resident on the case. These teaching sessions last 1½ to 2 hours and focus on 1 patient, who is presented, examined, and discussed in detail. Interns must make certain beforehand that the patient is in bed, properly gowned, and willing to have the teaching physician come by. Interns are also expected to bring pertinent literature to the conference room and to have on hand all of the patient's past and current medical records; a microscope with which to look at relevant urine sediments, blood smears, and tissue sections; and an x-ray view box for display of relevant radiographs. The case presentation must be clear, well-organized, and free of ramblings and redundancies. Anything less is unacceptable and will earn harsh reprimands. After the case presentation, the group goes to the patient's bedside, where the attending or chairman takes over. Observing these master clinicians in action is the best part of the internship.

Once a week, the interns work a half-day in the outpatient clinic. This activity always takes place in the afternoons so that it doesn't interfere with the work rounds and teaching conferences held in the mornings. On the other afternoons of the week, the interns are busy performing work-ups of new patients, tending to patients previously admitted, and completing other assignments and duties.

These are the days when a constant bed shortage limits admissions to the very young, the very old, and the very sick. Because no Intensive or Coronary Care Units exist, interns cannot transfer their severely ill patients to a specified area for close monitoring. Instead, they must monitor the patients themselves, using the only monitors available—their own eyes, ears, nose, hands, and brain. This situation forces interns to observe their patients carefully and repeatedly, often for long periods of time. They must also attend every operation on their patients and every autopsy performed on any patient from the medical teaching service. From these various routines, interns gain competence and confidence in their clinical skills, learn the pathophysiology and natural history of disease, and understand when to treat and why.

The highlight of the workday actually occurs at night—midnight to be exact. That's when many of the house officers on duty throughout the hospital meet in the hospital cafeteria for a free meal. Although the food isn't great, the camaraderie is. Furthermore, this respite is just what it takes to recharge the interns' batteries.

These are the days when the internship ingrains discipline, stimulates a taste for continual self-education, and promotes mutual respect among all hospital personnel. Indeed, these are the days when good patient care and the education of the intern are all that matter.

What days are these? The days 53 years ago when I was a medical intern in the main teaching hospital of a state university.

Since that time, the medical internship has changed significantly, bearing almost no resemblance to the one I did. Given the ever-increasing emphasis on sophisticated technology, the shrinking of government funding for medical services, and the devastating impact of managed care,1 clinical teaching has suffered a serious blow. In addition, medical schools are so strapped for money these days that they force the clinical faculty to spend more and more time caring for paying patients and less and less time caring for medical students and house officers.

Even more disturbing to me as a medical educator is the mandate that was promulgated in 2003 by the Accreditation Council for Graduate Medical Education (ACGME), imposing work-hour limits across all training programs, regardless of specialty.2 Acting to promote patient safety, the ACGME sided with the widely held—but still disputed—notion that sleep deprivation and physical fatigue in physicians lead to harmful medical errors.3–22 As a result, interns now take call every 4th, 5th, or 6th night (but only on required rotations; the other rotations are call free). Moreover, they must leave the hospital by 1 pm on their post-call days, are not allowed to average more than 80 hours of work per week, and typically take 1 day a week off.

Thus, from its roots as a patient-centered, education-oriented year of learning, the medical internship has evolved into a laboratory-centered, algorithm-oriented, technology-driven, computer-dependent, Internet-based, “treat first, diagnose later” training program. Consequently, we are exchanging sleep-deprived healers for a cadre of wide-awake technicians23 who cannot take an adequate medical history, cannot perform a reliable physical examination, cannot critically assess information they gather, cannot create a sound management plan, have little reasoning power, and communicate poorly.24

Is this what patients want? Is this what patients need? Is this what patients deserve? I think not. I also think that unless medical education undergoes substantial reform, things will only get worse.

Meanwhile, we need to find a balance between policies of the past (which emphasized compassion, empathy, and high-touch, direct patient care) and policies of the present (which place a premium on high-tech machines and gadgets).25 But whatever the future brings, we must always view medicine as a calling, not a business, and hold fast to the patient-oriented traditions that have sustained our profession throughout its history.



Herbert L. Fred, MD, Professor
Department of Internal Medicine, The University of Texas Health Science Center at Houston

 

[Crayola227]

I personally agree with Dr. Fred and think we should do away with all work hour restrictions.

Residents nowadays don't know the meaning of hard work and sacrifice.

These are the days
The Internship Revisited
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1847908/

These are the days when interns have reason to gripe. Unless they demonstrate unflagging commitment and indisputable integrity, they risk being fired—sometimes on the spot and without warning. They have no formal contracts.

Their responsibilities are daunting and their schedule grueling. They work every day and every other night. While on duty, they rarely find time to sleep. And when off duty, they must remain in the hospital until all of their patients are in stable condition and all studies planned for the next day have been ordered. Consequently, on their post-call days, interns typically leave the hospital about 8 pm, and sometimes not until midnight.

Ward rounds on the inpatients begin sharply at 7 am, 7 days a week. In attendance are the ward resident, the 2 interns, and the chief nurse. Medical students do not participate. These rounds are sacred, generally last 2 hours, and only a bona fide emergency can interrupt them. The intern on the case briefly examines the patient while the resident examines the patient's chart. Results of tests and procedures done the previous day are discussed, and, with input from the chief nurse, the resident and intern make decisions regarding additional testing or consultation, medication changes, discharge considerations, and other “housekeeping” matters. Similar rounds often take place around 6 pm that same evening.

Aided at times by medical students and the resident, interns perform and interpret all admission and follow-up blood counts, peripheral blood smears, urinalyses, stool guaiac tests, and electrocardiograms. Additionally, they start and maintain all intravenous therapy; draw all blood cultures; stain and examine microscopically all pleural, pericardial, peritoneal, spinal, and joint fluids; apply skin tests; and search for ova and parasites in stool specimens. The intern on call also draws the early morning blood samples from about 20 to 30 patients—the team's average number of patients at any given time. That job—undertaken with frustratingly blunt, nondisposable needles and ill-fitting, easily broken glass syringes—must begin by 5 am or earlier to be completed before work rounds begin. Interns also fill out the requisition slips for all laboratory tests and procedures and are responsible not only for recording the results in the patients' charts, but also for reciting the results on command.

By carrying out these seemingly menial tasks—called “scut work” in housestaff lingo—interns begin to realize the importance of accountability. They learn firsthand the subtle factors that can influence test results. They learn to appreciate other members of the healthcare team who ordinarily do such work—nurses, laboratory personnel, phlebotomists, and ward clerks. And most important, perhaps, the scut work repeatedly brings interns into physical contact with their patients, strengthening the doctor–patient bond.

Interns make daily trips to the main hospital laboratory, radiology department, microbiology unit, and other areas to obtain test results, review x-ray studies with a staff radiologist, check on the growth of various cultures, etc. This important routine requires a lot of physical effort, but it ensures timely and uninterrupted patient care.

In addition to the workload already described, interns must squeeze in time for daily chart rounds. During this ritual, the intern and resident scrutinize each inpatient record for missing data, illegible notes, disorganized inserts, and other common deficiencies. “A sloppy chart indicates a sloppy doctor,” the department chairman says. Not surprisingly, therefore, defective patient records provoke his wrath.

Interns occasionally are discussants at weekly Grand Rounds. This assignment compels them to spend long hours in the medical library searching the stacks for pertinent articles on their topic. In the process, they learn what it takes to research a subject thoroughly, how to read with discrimination, how to critically evaluate what they read, and how to give a formal presentation before a discerning audience.

They also prepare vigorously for teaching rounds, which take place at 10 AM, 4 times a week—3 with anattending physician, and 1 with the chairman. The attendings and chairman serve as consultants who simply offer opinions and make recommendations. Responsibility for managing the patient—particularly all decision-making and order-writing—rests solely with the intern and resident on the case. These teaching sessions last 1½ to 2 hours and focus on 1 patient, who is presented, examined, and discussed in detail. Interns must make certain beforehand that the patient is in bed, properly gowned, and willing to have the teaching physician come by. Interns are also expected to bring pertinent literature to the conference room and to have on hand all of the patient's past and current medical records; a microscope with which to look at relevant urine sediments, blood smears, and tissue sections; and an x-ray view box for display of relevant radiographs. The case presentation must be clear, well-organized, and free of ramblings and redundancies. Anything less is unacceptable and will earn harsh reprimands. After the case presentation, the group goes to the patient's bedside, where the attending or chairman takes over. Observing these master clinicians in action is the best part of the internship.

Once a week, the interns work a half-day in the outpatient clinic. This activity always takes place in the afternoons so that it doesn't interfere with the work rounds and teaching conferences held in the mornings. On the other afternoons of the week, the interns are busy performing work-ups of new patients, tending to patients previously admitted, and completing other assignments and duties.

These are the days when a constant bed shortage limits admissions to the very young, the very old, and the very sick. Because no Intensive or Coronary Care Units exist, interns cannot transfer their severely ill patients to a specified area for close monitoring. Instead, they must monitor the patients themselves, using the only monitors available—their own eyes, ears, nose, hands, and brain. This situation forces interns to observe their patients carefully and repeatedly, often for long periods of time. They must also attend every operation on their patients and every autopsy performed on any patient from the medical teaching service. From these various routines, interns gain competence and confidence in their clinical skills, learn the pathophysiology and natural history of disease, and understand when to treat and why.

The highlight of the workday actually occurs at night—midnight to be exact. That's when many of the house officers on duty throughout the hospital meet in the hospital cafeteria for a free meal. Although the food isn't great, the camaraderie is. Furthermore, this respite is just what it takes to recharge the interns' batteries.

These are the days when the internship ingrains discipline, stimulates a taste for continual self-education, and promotes mutual respect among all hospital personnel. Indeed, these are the days when good patient care and the education of the intern are all that matter.

What days are these? The days 53 years ago when I was a medical intern in the main teaching hospital of a state university.

Since that time, the medical internship has changed significantly, bearing almost no resemblance to the one I did. Given the ever-increasing emphasis on sophisticated technology, the shrinking of government funding for medical services, and the devastating impact of managed care,1 clinical teaching has suffered a serious blow. In addition, medical schools are so strapped for money these days that they force the clinical faculty to spend more and more time caring for paying patients and less and less time caring for medical students and house officers.

Even more disturbing to me as a medical educator is the mandate that was promulgated in 2003 by the Accreditation Council for Graduate Medical Education (ACGME), imposing work-hour limits across all training programs, regardless of specialty.2 Acting to promote patient safety, the ACGME sided with the widely held—but still disputed—notion that sleep deprivation and physical fatigue in physicians lead to harmful medical errors.3–22 As a result, interns now take call every 4th, 5th, or 6th night (but only on required rotations; the other rotations are call free). Moreover, they must leave the hospital by 1 pm on their post-call days, are not allowed to average more than 80 hours of work per week, and typically take 1 day a week off.

Thus, from its roots as a patient-centered, education-oriented year of learning, the medical internship has evolved into a laboratory-centered, algorithm-oriented, technology-driven, computer-dependent, Internet-based, “treat first, diagnose later” training program. Consequently, we are exchanging sleep-deprived healers for a cadre of wide-awake technicians23 who cannot take an adequate medical history, cannot perform a reliable physical examination, cannot critically assess information they gather, cannot create a sound management plan, have little reasoning power, and communicate poorly.24

Is this what patients want? Is this what patients need? Is this what patients deserve? I think not. I also think that unless medical education undergoes substantial reform, things will only get worse.

Meanwhile, we need to find a balance between policies of the past (which emphasized compassion, empathy, and high-touch, direct patient care) and policies of the present (which place a premium on high-tech machines and gadgets).25 But whatever the future brings, we must always view medicine as a calling, not a business, and hold fast to the patient-oriented traditions that have sustained our profession throughout its history.



Herbert L. Fred, MD, Professor
Department of Internal Medicine, The University of Texas Health Science Center at Houston

This is mostly crap.

He makes excellent points about the degradation of care and education, but the work hour restrictions isn't the main cause of those issues, or they aren't major barriers that can't be worked around.

The issue with back in his day, is that type of training is very exclusive to physicians with families and disabilities. Some disabilities are acquired in medical school, I might add.

I think there is value in a more inclusive and diverse physician work force. I don't think you need to work or train more than 80 hours a week to be an excellent physician that adds something unique and needed to the field.

 

[SunsFun]

This is not a problem with training, it is a problem with modern medicine in the US. The problem I see is that residents assume that all of there time should be spent learning pathophysiology, treatment, diagnosis, surgical skill, etc. What you all call scut work, we call being a doctor.

Writing notes, putting in orders, meeting with discharge planners, calling rehab facilities, filling out reams of paperwork, dressing changes, pulling drains - these are all doctor tasks. They are things that must get done by a physician or physician extender in today's health care world. Guess what, as an attending, I still write notes, put in orders, talk to social workers, do paperwork, change dressings, pull drains. It is not all rewarding, but it is part of the job.

Now, a lot of the "scut work" does fall disproportionately on the interns. This means that as a senior resident you won't have to do as much and you can focus more of your time on the stuff you really want to be learning. You are paying it forward.

More hours worked does allow for more contact with patients, more consults, more surgeries. You also do not know when those learning opportunities will arise.

I find it interesting that the people who support rescinding the 2011 rules are the ones who have actually been there and are now attendings. The people who know what it takes to learn to do what they do.

Training is de-facto indoctrination into the culture of medicine. Starting front the first visits to patient rooms in preclinical years many of us have been taught to not critically think about delivering value and focus more on vague processes set in place long before evidence-based medicine became a thing.

I have yet to meet a resident who thinks that they should be excused from all scut work. The issue is primarily with percentage of time spent doing work that does not have a direct educational benefit or direct value to patient medical care. Everyone does some administrative work, but it often feels like residents, even those more senior, are expected to do the administrative work as their primary responsibility and the rest comes second. I am speculating here but I would be interested to hear about concrete steps that programs take to prioritize training and actual delivery of medical care.

I don't know what criteria you use to lump filling out tons of paperwork with dressing changes or pulling drains. I can't see how the first provides any comparative amount of direct medical benefit to the patient. On that note, it usually is taking a lot higher proportion of time than doing quick bedside procedures. So I don't think it's fair for you to "work in" secretarial duties under the guise of "this is what it means to be a doctor" lumping it with the rest of smaller essential job responsibilities.

Overall, my issue is with inherent flaws in a system of healthcare delivery that are bandaged with additional duty hours in training. I've recently read a good article by urology resident talking about why long hours today add little value and may not provide the same level of training as hours "back in the day".

Also, IMO, it's sad that people think EMR and just-in-time communication have made life easier for residents. This is a classic example of misuse of resources with information/communication overload paradoxically making things a lot more difficult to manage.


Sent from my iPhone using SDN mobile app

 

[SunsFun]

I personally agree with Dr. Fred and think we should do away with all work hour restrictions.

Residents nowadays don't know the meaning of hard work and sacrifice.

These are the days
The Internship Revisited
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1847908/

These are the days when interns have reason to gripe. Unless they demonstrate unflagging commitment and indisputable integrity, they risk being fired—sometimes on the spot and without warning. They have no formal contracts.

Their responsibilities are daunting and their schedule grueling. They work every day and every other night. While on duty, they rarely find time to sleep. And when off duty, they must remain in the hospital until all of their patients are in stable condition and all studies planned for the next day have been ordered. Consequently, on their post-call days, interns typically leave the hospital about 8 pm, and sometimes not until midnight.

Ward rounds on the inpatients begin sharply at 7 am, 7 days a week. In attendance are the ward resident, the 2 interns, and the chief nurse. Medical students do not participate. These rounds are sacred, generally last 2 hours, and only a bona fide emergency can interrupt them. The intern on the case briefly examines the patient while the resident examines the patient's chart. Results of tests and procedures done the previous day are discussed, and, with input from the chief nurse, the resident and intern make decisions regarding additional testing or consultation, medication changes, discharge considerations, and other “housekeeping” matters. Similar rounds often take place around 6 pm that same evening.

Aided at times by medical students and the resident, interns perform and interpret all admission and follow-up blood counts, peripheral blood smears, urinalyses, stool guaiac tests, and electrocardiograms. Additionally, they start and maintain all intravenous therapy; draw all blood cultures; stain and examine microscopically all pleural, pericardial, peritoneal, spinal, and joint fluids; apply skin tests; and search for ova and parasites in stool specimens. The intern on call also draws the early morning blood samples from about 20 to 30 patients—the team's average number of patients at any given time. That job—undertaken with frustratingly blunt, nondisposable needles and ill-fitting, easily broken glass syringes—must begin by 5 am or earlier to be completed before work rounds begin. Interns also fill out the requisition slips for all laboratory tests and procedures and are responsible not only for recording the results in the patients' charts, but also for reciting the results on command.

By carrying out these seemingly menial tasks—called “scut work” in housestaff lingo—interns begin to realize the importance of accountability. They learn firsthand the subtle factors that can influence test results. They learn to appreciate other members of the healthcare team who ordinarily do such work—nurses, laboratory personnel, phlebotomists, and ward clerks. And most important, perhaps, the scut work repeatedly brings interns into physical contact with their patients, strengthening the doctor–patient bond.

Interns make daily trips to the main hospital laboratory, radiology department, microbiology unit, and other areas to obtain test results, review x-ray studies with a staff radiologist, check on the growth of various cultures, etc. This important routine requires a lot of physical effort, but it ensures timely and uninterrupted patient care.

In addition to the workload already described, interns must squeeze in time for daily chart rounds. During this ritual, the intern and resident scrutinize each inpatient record for missing data, illegible notes, disorganized inserts, and other common deficiencies. “A sloppy chart indicates a sloppy doctor,” the department chairman says. Not surprisingly, therefore, defective patient records provoke his wrath.

Interns occasionally are discussants at weekly Grand Rounds. This assignment compels them to spend long hours in the medical library searching the stacks for pertinent articles on their topic. In the process, they learn what it takes to research a subject thoroughly, how to read with discrimination, how to critically evaluate what they read, and how to give a formal presentation before a discerning audience.

They also prepare vigorously for teaching rounds, which take place at 10 AM, 4 times a week—3 with anattending physician, and 1 with the chairman. The attendings and chairman serve as consultants who simply offer opinions and make recommendations. Responsibility for managing the patient—particularly all decision-making and order-writing—rests solely with the intern and resident on the case. These teaching sessions last 1½ to 2 hours and focus on 1 patient, who is presented, examined, and discussed in detail. Interns must make certain beforehand that the patient is in bed, properly gowned, and willing to have the teaching physician come by. Interns are also expected to bring pertinent literature to the conference room and to have on hand all of the patient's past and current medical records; a microscope with which to look at relevant urine sediments, blood smears, and tissue sections; and an x-ray view box for display of relevant radiographs. The case presentation must be clear, well-organized, and free of ramblings and redundancies. Anything less is unacceptable and will earn harsh reprimands. After the case presentation, the group goes to the patient's bedside, where the attending or chairman takes over. Observing these master clinicians in action is the best part of the internship.

Once a week, the interns work a half-day in the outpatient clinic. This activity always takes place in the afternoons so that it doesn't interfere with the work rounds and teaching conferences held in the mornings. On the other afternoons of the week, the interns are busy performing work-ups of new patients, tending to patients previously admitted, and completing other assignments and duties.

These are the days when a constant bed shortage limits admissions to the very young, the very old, and the very sick. Because no Intensive or Coronary Care Units exist, interns cannot transfer their severely ill patients to a specified area for close monitoring. Instead, they must monitor the patients themselves, using the only monitors available—their own eyes, ears, nose, hands, and brain. This situation forces interns to observe their patients carefully and repeatedly, often for long periods of time. They must also attend every operation on their patients and every autopsy performed on any patient from the medical teaching service. From these various routines, interns gain competence and confidence in their clinical skills, learn the pathophysiology and natural history of disease, and understand when to treat and why.

The highlight of the workday actually occurs at night—midnight to be exact. That's when many of the house officers on duty throughout the hospital meet in the hospital cafeteria for a free meal. Although the food isn't great, the camaraderie is. Furthermore, this respite is just what it takes to recharge the interns' batteries.

These are the days when the internship ingrains discipline, stimulates a taste for continual self-education, and promotes mutual respect among all hospital personnel. Indeed, these are the days when good patient care and the education of the intern are all that matter.

What days are these? The days 53 years ago when I was a medical intern in the main teaching hospital of a state university.

Since that time, the medical internship has changed significantly, bearing almost no resemblance to the one I did. Given the ever-increasing emphasis on sophisticated technology, the shrinking of government funding for medical services, and the devastating impact of managed care,1 clinical teaching has suffered a serious blow. In addition, medical schools are so strapped for money these days that they force the clinical faculty to spend more and more time caring for paying patients and less and less time caring for medical students and house officers.

Even more disturbing to me as a medical educator is the mandate that was promulgated in 2003 by the Accreditation Council for Graduate Medical Education (ACGME), imposing work-hour limits across all training programs, regardless of specialty.2 Acting to promote patient safety, the ACGME sided with the widely held—but still disputed—notion that sleep deprivation and physical fatigue in physicians lead to harmful medical errors.3–22 As a result, interns now take call every 4th, 5th, or 6th night (but only on required rotations; the other rotations are call free). Moreover, they must leave the hospital by 1 pm on their post-call days, are not allowed to average more than 80 hours of work per week, and typically take 1 day a week off.

Thus, from its roots as a patient-centered, education-oriented year of learning, the medical internship has evolved into a laboratory-centered, algorithm-oriented, technology-driven, computer-dependent, Internet-based, “treat first, diagnose later” training program. Consequently, we are exchanging sleep-deprived healers for a cadre of wide-awake technicians23 who cannot take an adequate medical history, cannot perform a reliable physical examination, cannot critically assess information they gather, cannot create a sound management plan, have little reasoning power, and communicate poorly.24

Is this what patients want? Is this what patients need? Is this what patients deserve? I think not. I also think that unless medical education undergoes substantial reform, things will only get worse.

Meanwhile, we need to find a balance between policies of the past (which emphasized compassion, empathy, and high-touch, direct patient care) and policies of the present (which place a premium on high-tech machines and gadgets).25 But whatever the future brings, we must always view medicine as a calling, not a business, and hold fast to the patient-oriented traditions that have sustained our profession throughout its history.



Herbert L. Fred, MD, Professor
Department of Internal Medicine, The University of Texas Health Science Center at Houston

Well, at least I am able to understand scientific literature enough to know that an opinion piece by an author who quotes his previous opinion pieces as evidence may not be a paper I would use to defend my views.


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[ProfMD]

Training is de-facto indoctrination into the culture of medicine. Starting front the first visits to patient rooms in preclinical years many of us have been taught to not critically think about delivering value and focus more on vague processes set in place long before evidence-based medicine became a thing.

I have yet to meet a resident who thinks that they should be excused from all scut work. The issue is primarily with percentage of time spent doing work that does not have a direct educational benefit or direct value to patient medical care. Everyone does some administrative work, but it often feels like residents, even those more senior, are expected to do the administrative work as their primary responsibility and the rest comes second. I am speculating here but I would be interested to hear about concrete steps that programs take to prioritize training and actual delivery of medical care.

I don't know what criteria you use to lump filling out tons of paperwork with dressing changes or pulling drains. I can't see how the first provides any comparative amount of direct medical benefit to the patient. On that note, it usually is taking a lot higher proportion of time than doing quick bedside procedures. So I don't think it's fair for you to "work in" secretarial duties under the guise of "this is what it means to be a doctor" lumping it with the rest of smaller essential job responsibilities.

Overall, my issue is with inherent flaws in a system of healthcare delivery that are bandaged with additional duty hours in training. I've recently read a good article by urology resident talking about why long hours today add little value and may not provide the same level of training as hours "back in the day".

Also, IMO, it's sad that people think EMR and just-in-time communication have made life easier for residents. This is a classic example of misuse of resources with information/communication overload paradoxically making things a lot more difficult to manage.


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I didn't say secretarial work. I said paperwork. Paperwork that needs to be done by an LIP. This would include notes, billing paperwork, etc.

And, this is not lack of critical thinking by physicians or indoctrination. Some of it is just good patient care and a lot of it (including the good patient care stuff) is required by insurance companies and/or regulating agencies.

I lump it all as "scut work" because that seems to be the attitude of increasing numbers of resident and med students. I am just pointing out that a lot of this "scut work" is just the less fun parts of doctor work.

There is stuff that we need to do as physicians that has not direct benefit to the patient but is still part of health care delivery.

 

[SunsFun]

I can probably safely erase 90%+ of information in chart with 0 impact on patient care. How is creating it not a waste of time? I can't really make your argument work without pretty much equating good patient care with insurance documentation and regulation requirements.


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[VA Hopeful Dr]

I can probably safely erase 90%+ of information in chart with 0 impact on patient care. How is creating it not a waste of time? I can't really make your argument work without pretty much equating good patient care with insurance documentation and regulation requirements.


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You didn't read his second paragraph did you?

 

[ProfMD]

I can probably safely erase 90%+ of information in chart with 0 impact on patient care. How is creating it not a waste of time? I can't really make your argument work without pretty much equating good patient care with insurance documentation and regulation requirements.


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Like I did not say it was secretarial work, I also did not say that it was not a waste of time. Trust me, there is plenty of wasted time doing stuff. This is still stuff that doctors need to do. Resident = doctor = you get to do this stuff too.

If you think everything we need to do as doctors has direct value to patient care, you are in for a nasty surprise.

 

[SunsFun]

Like I did not say it was secretarial work, I also did not say that it was not a waste of time. Trust me, there is plenty of wasted time doing stuff. This is still stuff that doctors need to do. Resident = doctor = you get to do this stuff too.

If you think everything we need to do as doctors has direct value to patient care, you are in for a nasty surprise.

And this was my point all along. You acknowledge the problem of waste yet you say "this is still stuff that doctors need to do".

Understanding that some inefficiency is unavoidable doesn't prevent me from wanting to see it's minimization as a goal rather than seeing it as an unchangeable byproduct.


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[ProfMD]

And this was my point all along. You acknowledge the problem of waste yet you say "this is still stuff that doctors need to do".

Understanding that some inefficiency is unavoidable doesn't prevent me from wanting to see it's minimization as a goal rather than seeing it as an unchangeable byproduct.


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That's fine. I agree. Good luck getting the regulatory agencies, government, insurance agencies, etc to change though.

Until the requirements change, this is still stuff that all doctors, e.g. residents, need to do (as opposed to secretarial staff).

This is not stuff that can or should be removed as resident responsibilities. Therefore, until the requirements change, your argument that this stuff does not contribute to education or direct patient care is not a valid argument for limiting work hours further.

 

[SunsFun]

That's fine. I agree. Good luck getting the regulatory agencies, government, insurance agencies, etc to change though.

Until the requirements change, this is still stuff that all doctors, e.g. residents, need to do (as opposed to secretarial staff).

This is not stuff that can or should be removed as resident responsibilities. Therefore, until the requirements change, your argument that this stuff does not contribute to education or direct patient care is not a valid argument for limiting work hours further.

I appreciate your willingness, as an attending, to consider my arguments. I hope more people in our field decide to step back and think critically about what they are doing and what their role in the entire system is. Without widespread support any notion of change is doomed from the start.


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[educ8r]

I have a different experience of 24+4 vs 16 than some of the posters in this thread. I found 24+4 to be much more taxing overall. Increased time commitment also came with lots more responsibility as I made the transition from PGY1 to PGY2. There's nothing magical about becoming PGY2 that makes you able to deal with the increased requirements. Luckily I had 24s in medical school, so I kind of knew what to expect. I don't think that PGY2 should be the first time a resident sees 24 hour shifts.

 

[Ismet]

I don't think that PGY2 should be the first time a resident sees 24 hour shifts.

Agreed. I hate that my first 24 will be as a senior.

 

[WingedOx]

Bipolar physicians & others.

BPAD is prevalent in up to 2-10% of the population depending on what study and how you define the spectrum.

I could speculate prevalence in physicians, and my reasons for thinking it's similar or even higher than gen pop. My argument: we're not talking about an insignificant # of physicians. I could argue that these physicians represent special diversity in medicine that's worth trying to include.

"But 2nd yr there's overnights...." the rationale of not allowing interns vs seniors to do overnight shifts was for experience level affecting ability to cope and practice safely. Overnights can be hard on anyone with BPAD, but I would argue that all else equal it's likely harder on them as an intern owing to stress levels.

Yes, many docs with BPAD suck it up for years and manage. Doesn't mean I think that more years of such a sleep schedule is better overall and means they all can. I could get into some of the science about cumulative effects of stressors and how it affects BPAD long term. 3 years vs 2 years call I think can be significant. When's the breaking point?

Yes, many suck it up & manage, but some lose it, it's hard to predict, & no, I don't think that supports this change.

That "normal" people are arguing for weekends of all things, over the sanity of a not insubstantial # of physicians, I don't find compelling.

Anyone going into medicine is embracing a lot of work. A fair number of people go into medicine fairly healthy, and it's training itself in school or beyond that pushes them to the physiological limits where they even attain diagnoses of BPAD, narcolepsy, seizures disorders, migraines, etc. So it's also not enough to me that we just demand that people with such dx just don't apply to med school, or that when they get diagnosed we don't think of better ways to treat and include them. Sometimes that means the healthier among us take a hit. That's training. Just as when someone has a baby, etc.

Stress is a reality we embrace as well. I don't argue that if the stress exacerbates conditions and then people can't practice with reasonable accommodations, that we change essential functions of the job.

For most specialties, being able to work longer than 24 hours at a time is not an essential job function. In residency it's a convenience to employers and scheduling and typically not an essential element of education, which is why specialty boards and courts have allowed for shorter shifts in many fields.

Also, the frequency of such call makes a difference. Someone with BPAD might be OK with the frequency of 24 hr call out in practice, at once a week, with few actual calls, vs q3. At my program, nightfloat was 1 month, and 1 month of such a schedule is less disrupting to circadian rhythms
Seniors taking call only had one overnight per week.

We've proven that 16 hour intern shifts can be done. "Stress level" intrinsic to performance of the job while you're at work is a bit different than how long a shift is. One we might be able to change to positively increase the the diversity and inclusiveness of our workforce, another we might argue we have less control over.

As far as "reasonable" accommodations BPAD and other physicians who have conditions that are affected by overnights, there's a thread in psych forum now. I have seen discrimination for more than one doc dealing with a psych or med dx. Don't kid yourselves justice is done by our affected colleagues.

Yes. I appreciate it's hard to qualify the positive impact on health of more weekends vs what we KNOW is physiologically a strain, one that can even be deadly to a not insignificant number of us, 24 hr shifts.

In general, if I have to work 6x16s and enable, say, 10% of physicians with certain conditions to be included in the workforce, and sacrifice my weekends for it for a few years, I would rather that sacrifice than them.

16 vs 24 hr shifts is more stressing physiologically, and that's just fact. As someone said, continuing to insist that we must physically abuse physicians to provide quality care, sounds ridiculous to me.

The fact a study finds most residents can suck it up either way to protect patients, as has been pointed out, doesn't do much to look at how residents cope.

If you can show this is the ONLY way to make patients safer (I doubt it), that there's no way to structure residencies to better respect physiological needs, I'll find the "but my weekends!" " but hospitals hiring more people, $!" "Patient handoff!" arguments more compelling.

Tldr
Not convinced there's no better way
These hours are bad for HUMANS
There must be a way to protect pts
The tradeoff shouldn't be inhumane hrs vs inhumane lack of weekends
This is not essential for educational experience, per courts, other countries, specialty boards, stop pretending Osler meant this sort of thing
Don't pretend the ADA & employers will protect docs that have a hard time with this, or that even attempting to exclude such docs is possible, reasonable, and won't cost us

Sigh...

As a former psych chief resident who had actually resident go manic after a couple weeks of night float, I felt like responding to this. And my response is ....meh.

Look, if someone's bipolar disorder is uncontrolled to the point that a 24 hour shift is going to throw them into something serious, they need to step away for a while and come back when it's better controlled. Simple as that. That's you putting the patients at risk in that situation, not the work hours. Sleepless nights happen.

And severe mood/psychotic disorders are far from the only mental health concern that residents need to face, and as I'm sure plenty of posters have pointed out here, my own mental health was a hell of a lot better when I had a god damn golden weekend once in a while.

/hi guys, long time no see.

 

[radsisrad]

I personally agree with Dr. Fred and think we should do away with all work hour restrictions.

Residents nowadays don't know the meaning of hard work and sacrifice.

These are the days
The Internship Revisited
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1847908/

These are the days when interns have reason to gripe. Unless they demonstrate unflagging commitment and indisputable integrity, they risk being fired—sometimes on the spot and without warning. They have no formal contracts.

Their responsibilities are daunting and their schedule grueling. They work every day and every other night. While on duty, they rarely find time to sleep. And when off duty, they must remain in the hospital until all of their patients are in stable condition and all studies planned for the next day have been ordered. Consequently, on their post-call days, interns typically leave the hospital about 8 pm, and sometimes not until midnight.

Ward rounds on the inpatients begin sharply at 7 am, 7 days a week. In attendance are the ward resident, the 2 interns, and the chief nurse. Medical students do not participate. These rounds are sacred, generally last 2 hours, and only a bona fide emergency can interrupt them. The intern on the case briefly examines the patient while the resident examines the patient's chart. Results of tests and procedures done the previous day are discussed, and, with input from the chief nurse, the resident and intern make decisions regarding additional testing or consultation, medication changes, discharge considerations, and other “housekeeping” matters. Similar rounds often take place around 6 pm that same evening.

Aided at times by medical students and the resident, interns perform and interpret all admission and follow-up blood counts, peripheral blood smears, urinalyses, stool guaiac tests, and electrocardiograms. Additionally, they start and maintain all intravenous therapy; draw all blood cultures; stain and examine microscopically all pleural, pericardial, peritoneal, spinal, and joint fluids; apply skin tests; and search for ova and parasites in stool specimens. The intern on call also draws the early morning blood samples from about 20 to 30 patients—the team's average number of patients at any given time. That job—undertaken with frustratingly blunt, nondisposable needles and ill-fitting, easily broken glass syringes—must begin by 5 am or earlier to be completed before work rounds begin. Interns also fill out the requisition slips for all laboratory tests and procedures and are responsible not only for recording the results in the patients' charts, but also for reciting the results on command.

By carrying out these seemingly menial tasks—called “scut work” in housestaff lingo—interns begin to realize the importance of accountability. They learn firsthand the subtle factors that can influence test results. They learn to appreciate other members of the healthcare team who ordinarily do such work—nurses, laboratory personnel, phlebotomists, and ward clerks. And most important, perhaps, the scut work repeatedly brings interns into physical contact with their patients, strengthening the doctor–patient bond.

Interns make daily trips to the main hospital laboratory, radiology department, microbiology unit, and other areas to obtain test results, review x-ray studies with a staff radiologist, check on the growth of various cultures, etc. This important routine requires a lot of physical effort, but it ensures timely and uninterrupted patient care.

In addition to the workload already described, interns must squeeze in time for daily chart rounds. During this ritual, the intern and resident scrutinize each inpatient record for missing data, illegible notes, disorganized inserts, and other common deficiencies. “A sloppy chart indicates a sloppy doctor,” the department chairman says. Not surprisingly, therefore, defective patient records provoke his wrath.

Interns occasionally are discussants at weekly Grand Rounds. This assignment compels them to spend long hours in the medical library searching the stacks for pertinent articles on their topic. In the process, they learn what it takes to research a subject thoroughly, how to read with discrimination, how to critically evaluate what they read, and how to give a formal presentation before a discerning audience.

They also prepare vigorously for teaching rounds, which take place at 10 AM, 4 times a week—3 with anattending physician, and 1 with the chairman. The attendings and chairman serve as consultants who simply offer opinions and make recommendations. Responsibility for managing the patient—particularly all decision-making and order-writing—rests solely with the intern and resident on the case. These teaching sessions last 1½ to 2 hours and focus on 1 patient, who is presented, examined, and discussed in detail. Interns must make certain beforehand that the patient is in bed, properly gowned, and willing to have the teaching physician come by. Interns are also expected to bring pertinent literature to the conference room and to have on hand all of the patient's past and current medical records; a microscope with which to look at relevant urine sediments, blood smears, and tissue sections; and an x-ray view box for display of relevant radiographs. The case presentation must be clear, well-organized, and free of ramblings and redundancies. Anything less is unacceptable and will earn harsh reprimands. After the case presentation, the group goes to the patient's bedside, where the attending or chairman takes over. Observing these master clinicians in action is the best part of the internship.

Once a week, the interns work a half-day in the outpatient clinic. This activity always takes place in the afternoons so that it doesn't interfere with the work rounds and teaching conferences held in the mornings. On the other afternoons of the week, the interns are busy performing work-ups of new patients, tending to patients previously admitted, and completing other assignments and duties.

These are the days when a constant bed shortage limits admissions to the very young, the very old, and the very sick. Because no Intensive or Coronary Care Units exist, interns cannot transfer their severely ill patients to a specified area for close monitoring. Instead, they must monitor the patients themselves, using the only monitors available—their own eyes, ears, nose, hands, and brain. This situation forces interns to observe their patients carefully and repeatedly, often for long periods of time. They must also attend every operation on their patients and every autopsy performed on any patient from the medical teaching service. From these various routines, interns gain competence and confidence in their clinical skills, learn the pathophysiology and natural history of disease, and understand when to treat and why.

The highlight of the workday actually occurs at night—midnight to be exact. That's when many of the house officers on duty throughout the hospital meet in the hospital cafeteria for a free meal. Although the food isn't great, the camaraderie is. Furthermore, this respite is just what it takes to recharge the interns' batteries.

These are the days when the internship ingrains discipline, stimulates a taste for continual self-education, and promotes mutual respect among all hospital personnel. Indeed, these are the days when good patient care and the education of the intern are all that matter.

What days are these? The days 53 years ago when I was a medical intern in the main teaching hospital of a state university.

Since that time, the medical internship has changed significantly, bearing almost no resemblance to the one I did. Given the ever-increasing emphasis on sophisticated technology, the shrinking of government funding for medical services, and the devastating impact of managed care,1 clinical teaching has suffered a serious blow. In addition, medical schools are so strapped for money these days that they force the clinical faculty to spend more and more time caring for paying patients and less and less time caring for medical students and house officers.

Even more disturbing to me as a medical educator is the mandate that was promulgated in 2003 by the Accreditation Council for Graduate Medical Education (ACGME), imposing work-hour limits across all training programs, regardless of specialty.2 Acting to promote patient safety, the ACGME sided with the widely held—but still disputed—notion that sleep deprivation and physical fatigue in physicians lead to harmful medical errors.3–22 As a result, interns now take call every 4th, 5th, or 6th night (but only on required rotations; the other rotations are call free). Moreover, they must leave the hospital by 1 pm on their post-call days, are not allowed to average more than 80 hours of work per week, and typically take 1 day a week off.

Thus, from its roots as a patient-centered, education-oriented year of learning, the medical internship has evolved into a laboratory-centered, algorithm-oriented, technology-driven, computer-dependent, Internet-based, “treat first, diagnose later” training program. Consequently, we are exchanging sleep-deprived healers for a cadre of wide-awake technicians23 who cannot take an adequate medical history, cannot perform a reliable physical examination, cannot critically assess information they gather, cannot create a sound management plan, have little reasoning power, and communicate poorly.24

Is this what patients want? Is this what patients need? Is this what patients deserve? I think not. I also think that unless medical education undergoes substantial reform, things will only get worse.

Meanwhile, we need to find a balance between policies of the past (which emphasized compassion, empathy, and high-touch, direct patient care) and policies of the present (which place a premium on high-tech machines and gadgets).25 But whatever the future brings, we must always view medicine as a calling, not a business, and hold fast to the patient-oriented traditions that have sustained our profession throughout its history.



Herbert L. Fred, MD, Professor
Department of Internal Medicine, The University of Texas Health Science Center at Houston

Sucked to be him.

I've never learned anything useful from drawing labs or cultures.

 

[Bobblehead]

We haven't heard yet how this will be implemented for us. I expect that the average intern on our ICU rotation will add between 6-12 hours per week (1-2 hours for 6 days per week) as a result of this. Due to work hours interns were sent home at 9am, now I expect they will be staying until all of the new patients are presented in a less rushed fashion. Think standard resident level sign out vs attending level sign out. We normally stay well below 80 hours due to a dedicated night team structure although that has created other continuity issues.

 

[Light at end of tunnel]

We haven't heard yet how this will be implemented for us. I expect that the average intern on our ICU rotation will add between 6-12 hours per week (1-2 hours for 6 days per week) as a result of this. Due to work hours interns were sent home at 9am, now I expect they will be staying until all of the new patients are presented in a less rushed fashion. Think standard resident level sign out vs attending level sign out. We normally stay well below 80 hours due to a dedicated night team structure although that has created other continuity issues.

Sounds kind of aweful.

 

[kjamess]

Also, important to note. The increase workload for 1st year Residents will truly add to patient continuity of care. With modern technology, that is clearly the only possible way. Not to mention the cost savings to hospitals overworking underpaid 1st year Residents, rather than paying other medical staff (PA's, NP's). No, sleep deprivation is clearly the best way to become a better physician. Will all newly admitted patients in July be notified of this wonderful increase in care taking?

 

[kjamess]

looking back at my time in residency, I preferred having the 28 hr shifts. I wasn't strapped for time during the shift, got a chance to sneak some sleep in, and I got 2 days off afterwards. I was much happier with this schedule, as opposed to constant ~12-16 hr shifts 6 days a week as in intern. man, the latter really wears you down

 

[Crayola227]

Sigh...

As a former psych chief resident who had actually resident go manic after a couple weeks of night float, I felt like responding to this. And my response is ....meh.

Look, if someone's bipolar disorder is uncontrolled to the point that a 24 hour shift is going to throw them into something serious, they need to step away for a while and come back when it's better controlled. Simple as that. That's you putting the patients at risk in that situation, not the work hours. Sleepless nights happen.

And severe mood/psychotic disorders are far from the only mental health concern that residents need to face, and as I'm sure plenty of posters have pointed out here, my own mental health was a hell of a lot better when I had a god damn golden weekend once in a while.

/hi guys, long time no see.

Well, it might have been a different thread, but I mentioned at my program, interns didn't do overnights, and whatever they did for nightfloat meant that the seniors only had to be one overnight 1 day a week.

I agree that I don't think it would be terribly common for well-controlled BPAD on meds to be thrown into total disarray with 1 all nighter per week, although the risk is there. But q3 or q4 call? I don't think it's outrageous to say that's a different story and I think I don't see why we need to subject any trainee to it.

I would hope with medication that a BPAD suffering could transition to a one month nightfloat. My friend at a different program does nightfloat as 1 week every 4. That just sounds brutal. As they put it, they spend half the time just adjusting, as most people take about a week to switch to nights not being a total suck, and then maybe a week to turn around to days feeling good after getting their brains on the night program and then back. Jet lag.

Also in another thread I brought up people with epilepsy and migraines. There are other conditions that can stand a bit of sleepless nights, and turn around to a month of nightfloat, but the more 24 shifts in a short time frame you add, the worse off some will be.

I agree weekends are a good thing. You can make 6 figures and have weekends as a resident in Australia, where they clearly train subpar doctors.

I never said I was against the occasional sleepless night, but there's no way to convince me that chronic sleep deprivation is well tolerated or necessary for training, the work hours in general are unhealthy. They're just not healthy. It has nothing to do with lazy. We just know we hurt people as we jack up the hours. Why defend it when there's other ways to do this?

 

[deleted716403]

It is sad that we have been exploited too much by the system that we don't even stand up for ourselves, or don't realize, when we are about to be further exploited. The dangerous thing about this is that we have been made accustomed to thinking that our health - even our lives - aren't a priority!

The "patient safety" argument is hypocritical and false. When people make policy for others, they tend to forget the voices of the people that the policy is going to impact. Junior doctors have the least experience (lowest on the totem pole) but represent cheap labor. That's why. Why don't hospitals make NP/PAs work nearly as much? It's because they have organizations to stand up for them.

The "educational experience" is also false. There are numerous studies that prove cognitive decline in long hours.

Those of you who compare it to 16-hour 6-day work week: you only compare because you don't realize that your human right is being violated. Neither option is acceptable.

Depression, suicide, CVS diseases, etc. can all be the result of sleep deprivation & exhaustion. Doctors' and patients' wellbeing is the reason that Europe has 48-hour work week LAW.

 

[VA Hopeful Dr]

It is sad that we have been exploited too much by the system that we don't even stand up for ourselves, or don't realize, when we are about to be further exploited. The dangerous thing about this is that we have been made accustomed to thinking that our health - even our lives - aren't a priority!

The "patient safety" argument is hypocritical and false. When people make policy for others, they tend to forget the voices of the people that the policy is going to impact. Junior doctors have the least experience (lowest on the totem pole) but represent cheap labor. That's why. Why don't hospitals make NP/PAs work nearly as much? It's because they have organizations to stand up for them.

The "educational experience" is also false. There are numerous studies that prove cognitive decline in long hours.

Those of you who compare it to 16-hour 6-day work week: you only compare because you don't realize that your human right is being violated. Neither option is acceptable.

Depression, suicide, CVS diseases, etc. can all be the result of sleep deprivation & exhaustion. Doctors' and patients' wellbeing is the reason that Europe has 48-hour work week LAW.

Nope, not a human rights violation but nice try.

 

[ProfMD]

It is sad that we have been exploited too much by the system that we don't even stand up for ourselves, or don't realize, when we are about to be further exploited. The dangerous thing about this is that we have been made accustomed to thinking that our health - even our lives - aren't a priority!

The "patient safety" argument is hypocritical and false. When people make policy for others, they tend to forget the voices of the people that the policy is going to impact. Junior doctors have the least experience (lowest on the totem pole) but represent cheap labor. That's why. Why don't hospitals make NP/PAs work nearly as much? It's because they have organizations to stand up for them.

The "educational experience" is also false. There are numerous studies that prove cognitive decline in long hours.

Those of you who compare it to 16-hour 6-day work week: you only compare because you don't realize that your human right is being violated. Neither option is acceptable.

Depression, suicide, CVS diseases, etc. can all be the result of sleep deprivation & exhaustion. Doctors' and patients' wellbeing is the reason that Europe has 48-hour work week LAW.

The "interns working 24 hour shifts is the end of civilization" side needs new arguments.

 

[Zywie]

It is sad that we have been exploited too much by the system that we don't even stand up for ourselves, or don't realize, when we are about to be further exploited. The dangerous thing about this is that we have been made accustomed to thinking that our health - even our lives - aren't a priority!

The "patient safety" argument is hypocritical and false. When people make policy for others, they tend to forget the voices of the people that the policy is going to impact. Junior doctors have the least experience (lowest on the totem pole) but represent cheap labor. That's why. Why don't hospitals make NP/PAs work nearly as much? It's because they have organizations to stand up for them.

The "educational experience" is also false. There are numerous studies that prove cognitive decline in long hours.

Those of you who compare it to 16-hour 6-day work week: you only compare because you don't realize that your human right is being violated. Neither option is acceptable.

Depression, suicide, CVS diseases, etc. can all be the result of sleep deprivation & exhaustion. Doctors' and patients' wellbeing is the reason that Europe has 48-hour work week LAW.

So move to Europe with their 48 hour work weeks, sputtering economies and complete disarray. It amazes me how medical students romanticize the European systems withe no knowledge about whats actually going on there. The NHS works there junior doctors well over the 48 hours, pays them half of what they make here, taxes them higher and then doesn't even guarantee at the end of training you will even become a consultant. In the UK if a consultant spot doesn't open up you're stuck as a registrar with registrar pay until one does. Sure training for 5 years post med school to be a GP in the middle of nowhere to make 60K a year and get taxed at a higher rate than we do here or better yet try living in London working 55-60 hours a week on 60k.... That's worse than trying to live in NYC on a residents salary. Ohh not to mention in order to save the hospital trusts and emergency departments in the UK money the NHS is contemplating forcing GPs offices to be open to patients 7 days a week. The grass is always greener, especially when you live on a 5 acres of land and can't even see your neighbors lawn. Most medical students here have no idea how well we actually have it in the states. Nobody is saying our system is perfect but it trains the most technically superior doctors in the world.

You signed up for medical school knowing what you were getting yourself into. Please stop with the "exploitation" and "human rights violation" nonsense. You willingly signed up to be a doctor knowing what it entailed. Nobody put a gun to your head and forced you into working. You're not a migrant worker in Qatar being literally worked to death in 100+ degree heat to build a new soccer stadium or being forced into a labor camp in North Korea.

 

[WingedOx]

I would hope with medication that a BPAD suffering could transition to a one month nightfloat. My friend at a different program does nightfloat as 1 week every 4. That just sounds brutal. As they put it, they spend half the time just adjusting, as most people take about a week to switch to nights not being a total suck, and then maybe a week to turn around to days feeling good after getting their brains on the night program and then back. Jet lag.

\

I mean, if someone is working that many nights then it's because those nights need to be covered. No real way around that.

The "interns working 24 hour shifts is the end of civilization" side needs new arguments.

Seriously. It's not like it really made a huge difference in how fatigued I was covering a weeknight/Friday night shift after a normal work day compared to a Saturday night weekend shift from 8PM to 8AM when I spent Saturday morning and afternoon doing normal weekend things.

 

[WingedOx]

It is sad that we have been exploited too much by the system that we don't even stand up for ourselves, or don't realize, when we are about to be further exploited. The dangerous thing about this is that we have been made accustomed to thinking that our health - even our lives - aren't a priority!

who on here is actually saying this?

The "patient safety" argument is hypocritical and false. When people make policy for others, they tend to forget the voices of the people that the policy is going to impact. Junior doctors have the least experience (lowest on the totem pole) but represent cheap labor. That's why. Why don't hospitals make NP/PAs work nearly as much? It's because they have organizations to stand up for them.

The "educational experience" is also false. There are numerous studies that prove cognitive decline in long hours. Those of you who compare it to 16-hour 6-day work week: you only compare because you don't realize that your human right is being violated. Neither option is acceptable.

Someone who has never actually taken any call apparently knows more than the people who have. Medicine is ultimately a job of decision-making, and the only way you learn to be "the decider" is by being the one in the hospital who's job it is to call the shots. That's where you learn autonomy, and ultimately where you learn when you need to ask for help too...a skill that's necessary no matter how experienced you are. Regular resident rotations built my knowledge base for sure, but those nights and weekends where it's just me and the pager taught me how to be a physician.

But the other thing you'll need to learn is that unlike med school rotations, residency isn't just an "educational experience." You're there because there's a job to be done. If you're not there in the middle of the night, another one of your co-residents will need to be. And I'm not sure where this magical fantasy land where you can find NPs and PAs willing to work perpetual nocturnal shifts happens to exist.

Depression, suicide, CVS diseases, etc. can all be the result of sleep deprivation & exhaustion. Doctors' and patients' wellbeing is the reason that Europe has 48-hour work week LAW.

I see that little has changed after stepping away from SDN for a while. The Allo board is still loaded with posters who aren't taking responsibility for their own mental health maintenance.

Look, given my occasional role as SDN's official in-house Bleeding Heart Libtard SJW (TM), you aren't going to get me to disagree that there are a lot of problems with the culture of medical training, but the simple fact is that the repeal of the 16 hour intern rule isn't one of them.

 

[WingedOx]

I missed you

I was disappointed not to show up in the "poster graveyard" thread... glad someone did.

 

[KnuxNole]

The thing is....call isn't always meant to be educational. Usually I'm too tired to remember the patients or what happened anyway, and fixing errors after getting nursing calls for sleepy mistakes I've put in(1000 U regular insulin, lol). After intern year, you have to work 24 hour calls in most programs anyway, starting early doesn't hurt and like others said, makes call schedules a little easier.

I know people argue handoffs, but those were a joke in our program anyway, might as well not have them. Hell, some residents skipped it due to how bad some were at it...

 

[Azete]

So move to Europe with their 48 hour work weeks, sputtering economies and complete disarray. It amazes me how medical students romanticize the European systems withe no knowledge about whats actually going on there. The NHS works there junior doctors well over the 48 hours, pays them half of what they make here, taxes them higher and then doesn't even guarantee at the end of training you will even become a consultant. In the UK if a consultant spot doesn't open up you're stuck as a registrar with registrar pay until one does. Sure training for 5 years post med school to be a GP in the middle of nowhere to make 60K a year and get taxed at a higher rate than we do here or better yet try living in London working 55-60 hours a week on 60k.... That's worse than trying to live in NYC on a residents salary. Ohh not to mention in order to save the hospital trusts and emergency departments in the UK money the NHS is contemplating forcing GPs offices to be open to patients 7 days a week. The grass is always greener, especially when you live on a 5 acres of land and can't even see your neighbors lawn. Most medical students here have no idea how well we actually have it in the states. Nobody is saying our system is perfect but it trains the most technically superior doctors in the world.

You signed up for medical school knowing what you were getting yourself into. Please stop with the "exploitation" and "human rights violation" nonsense. You willingly signed up to be a doctor knowing what it entailed. Nobody put a gun to your head and forced you into working. You're not a migrant worker in Qatar being literally worked to death in 100+ degree heat to build a new soccer stadium or being forced into a labor camp in North Korea.

I agree with your overall sentiment, but it's obvious you are even more clueless about the UK healthcare system than the person you quoted. Please, nobody take this literally.

 

[Zywie]

I agree with your overall sentiment, but it's obvious you are even more clueless about the UK healthcare system than the person you quoted. Please, nobody take this literally.

Oh really, please explain what is so clueless? To become a GP consists of F1 and F2 + 3 years of registrar training, although you get your registration with the medical council after F1 (similar to how you can technically practice here after intern year but good luck trying that). starting pay for a junior doctor in the UK is 22k GBP, and takes til year 4 to finally get over 40k. It's not like the purchasing power of the pound is much greater than the dollar 40k GBP doesn't get you much father in the UK than $40k in America. Try living in NYC on 40k, it's not happening. The starting salary for a an NHS employed GP is 55k GBP max salary for an NHS employed GP is 85kGBP. Becoming a specialist consultant takes at least 8 years post graduation. F1 and F2 + a minimum 6 years as a specialty registrar. While the trainees there don't work 80 hour weeks, they're pushing 60+ and getting paid less for a lot longer. I have friends and family who are in medicine in the UK, most of my friends in school there are looking to leave as soon as they can and go to either Aus, USA or Canada.

 

[bannie22]

I take pity on the residents having to slave 24-28 hour shifts, under the disguise of patient care.
In no other occupation would this ever be allowed, and patients definitely would not allow themselves to be cared for by some human being performing at a level equivalent to a drunk if they had the option.

 

[WingedOx]

Do people who post stuff like this, like, actually read the thread?

I take pity on the residents having to slave 24-28 hour shifts, under the disguise of patient care.
In no other occupation would this ever be allowed, and patients definitely would not allow themselves to be cared for by some human being performing at a level equivalent to a drunk if they had the option.

 

[VA Hopeful Dr]

I take pity on the residents having to slave 24-28 hour shifts, under the disguise of patient care.
In no other occupation would this ever be allowed, and patients definitely would not allow themselves to be cared for by some human being performing at a level equivalent to a drunk if they had the option.

Right, cause the military never does anything that.

Or first responders.

 

[VA Hopeful Dr]

Do people who post stuff like this, like, actually read the thread?

Reading is for sociopathic attendings who only want residents to work 28 hours because we had to

 

[ProfMD]

Reading is for sociopathic attendings who only want residents to work 28 hours because we had to

Fortunately, now that all my interns will be able to work 28 hours, I'll have all kinds to time to read SDN. That is, when I'm not driving around in my Lambo or sailing on my yacht.

 

[Matthew9Thirtyfive]

Right, cause the military never does anything that.

Or first responders.

I'm doing it right now! I do it 1-2 times per week.