My CNN.com article on resident work hours

[gettheleadout]

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Without increasing the size of the patient set, which I think is what you're suggesting, I'd wager there aren't enough doctors to go around.

Then overlap shifts like circulus suggested.

 

[dmf2682]

Then overlap shifts like circulus suggested.

Any significant overlap and you run out of doctors. If you shorten the overlaps you get the current system. Postcall residents round with the rest of the team before going home.

 

[gettheleadout]

Any significant overlap and you run out of doctors. If you shorten the overlaps you get the current system. Postcall residents round with the rest of the team before going home.

Then that represents an inadequacy with the underlying system of undergraduate medical education and residency position availability. It doesn't mean that this solution wouldn't be better, just that the current system is ill-equipped to actually fix its problems.

 

[dmf2682]

One thing I'd like to point out is that according to resident input here, the current "new" system doesn't actually reduce sleep deprivation in residents, meaning that the observed lack of improvement in patient care quality is to be expected. I think it is reasonable to assume that actual reduction of resident sleep deprivation would improve patient care (going back to still immediate cognitive and physical impairment effects of sleep deprivation while working.)

Not disputing that lack of sleep causes errors. The question is whether or not they're outweighed by increase in signout errors . I said what I did in response to what go2guy suggested.

 

[dmf2682]

Then that represents an inadequacy with the underlying system of undergraduate medical education and residency position availability. It doesn't mean that this solution wouldn't be better, just that the current system is ill-equipped to actually fix its problems.

I think we agree on this point.

 

[KnuxNole]

Most people are at their peak physical health/beauty.

And when most people seem very carefree and seem to travel every other week. On FB, I see people going to bars, out to the city, vacation spots 5-6x a week, and wonder how cush being a 20-something person is.

I'm sure life as a 40 something is sweet too 🙂

 

[Instatewaiter]

wondering if you would get in trouble for simply underreporting at the behest of your superiors. It's understandable though that if the program is "convicted" of breaking hour restrictions then you're screwed regardless.

don't know the answer

Would additional years compensate for the lost education or training time?

If you mean would additional years of training get you to the same level of competency... probably yes.

The problem is that these years add up. To be a cardiologist it takes at minimum 6 years. With interventional it takes an additional year and many cards programs are 4 years.

So to be an interventional cardiologist it takes 7-8 years. Add extra years onto IM and extra years onto cards and you are looking at over a decade until you are an attending. Those extra years are going to piss you off when you realize you could have started your real life 2 years earlier (you know, when you're 35 instead of almost 40).

How long is a resident awake at any given point during the week? Do you disagree with the information Dr. Youn cited that 24 continuous sleepless hours significantly impairs cognitive and motor function?

Indirect measures are worthless. By 2pm my cognition and motor function are diminished compared to 10am. Should I stop seeing patients at 2?

The question should be whether 24 hours awake impairs patient care. Anything else is a useless metric.

Why do you think reduced working hours would make the training system less humane?

Things are less humane now because with the new work hours, interns never leave the hospital at a decent hour. Before, you would have 1 bad day/night, a rest day, and then 2 days where you got out of the hospital at a reasonable hour. Now you never have days where you leave at a reasonable time.

 

[Instatewaiter]

As for the argument about increasing residency and how "I would like it when the time comes", you know what? I'd much rather do a year or two extra of residency and not make the crazy $$, but at least I'll still have a more or less normal personal life, and my family will still be by my side. Who knows, maybe I'll even be home for a few extra holidays during my extended years...

Being one of the only people on this board who have actually worked the hours, I can tell you, they aren't really that bad. With this knowledge, when you get there, you wont want the extra years. What if they made you do an extra 2 years of college so that you could sleep a bit more? What about medical school? Those weren't that bad right? Well residency isn't that bad either.

When you're an attending, you don't have the option of just having someone else do the work for you. The buck falls on you. So when you are on call the entire weekend, and it was a busy weekend, you have to suck it up and work on Monday. And during that Sunday, you have to have the brain power to make the right decisions despite having to work most of the night.

Aren't handoffs unavoidable regardless if you spend 8 hours, or 20 in the hospital? Hence doctors leave as detailed notes as possible... To say that someone must be in a hospital for 36 hours to minimize hand offs..when the handoffs still occur regardless, is a very ridiculous reason to cause damage to the resident's personal life. You guys are not robots. **** happens all the time. You go in there, you do your best, and then you're supposed to leave (within a reasonable amount of time). YOURE NOT supposed to be bullied by other residents, attendings, and administrators...and intimidated to lie on your work log. Wtf???? Yeah, looks like we'll keep taking it up the ass. Hospitals will continue to be "more effecient and cost effective", and patient outcomes will remain as positive as ever.

When it is 3 people covering those 36 hours, there are at least 3 handoffs in that time instead of 1. The more handoffs, the more errors. This IS well documented and evidence based So now, intern 1 signs out to intern 2. Intern 2 signs out his and intern 1's patients to intern 3. Intern 3 signs out second and third hand signout to intern 4. Have you ever played telephone?


The more handoffs, the more errors. If you think for an instant during an emergency you will have time to look through each of the long ass note to figure out who the patient is, you are sorely mistaken. Things move very fast in the hospital. And now, the same amount of work has to fit into a shorter time frame. Add to that the fact that there are now twice as many handoffs which take 30min-1 hour to do properly.

One thing I'd like to point out is that according to resident input here, the current "new" system doesn't actually reduce sleep deprivation in residents

The issue is that people chose NOT to use their time to sleep. So the amount of sleep was the same.

To clarify, the new rules only apply to interns. Residents still do 30 (well now 28 hour) calls. Interns can work 16h at a time with a 10h break between shifts. Both interns and residents can only work a max of 80 hours averaged over 4 weeks.

Then overlap shifts like circulus suggested.

Already do that. Still doesn't limit the handoffs because the person who is really taking care of the patient is gone half of the time.

 

[Law2Doc]

...
I take particular issue with your last sentence. If the current system still results in legitimate sleep deprivation (read: loss of fitness to provide care) then it is not acceptable alternative to the old system. It is an alternative, yes, but not a solution. Complacency about an issue that has been for so long accepted a necessary evil of medical training lends no hand to progress, and holds back those who would advocate concern for everyone involved.

bingo. The ACGME has replaced a bad system with one that is arguably worse for residents, and declared victory, all in the name of "window dressing" for the public. It's a joke. Most folks who have lived under both systems are not confused by the fact that you are much better off with longer shifts and post call days then endless weeks of 6 day stretches of night float.

As for the solution, I think the only realistic one would be to extend residency, but most of us wouldn't make that trade for a million bucks.

 

[Law2Doc]

...

The issue is that people chose NOT to use their time to sleep. So the amount of sleep was the same.

To clarify, the new rules only apply to interns. Residents still do 30 (well now 28 hour) calls. Interns can work 16h at a time with a 10h break between shifts. Both interns and residents can only work a max of 80 hours averaged over 4 weeks...

I would clarify this that it's not really an issue of choice in terms of sleep. Ill give folks a real example. Version 1 was working a couple of 30 hour shifts each week, followed by post call days and round out the week with a lighter day or two. Grand total of, say 78 hours. Version 2 is working night float, 13 hours a night 6 nights a week, for a grand total of 78 hours. You are at work the exact same number of hours. The difference is that you are forced to sleep during the day, which rarely gives you the same quality of sleep, and only get one night off a week, usually Saturday, and if you try to do something with friends etc Saturday and sleep Saturday night, you are now off schedule again and show up exhausted Sunday night to start the next week. somehow this latter schedule is more "humane" than the one that gives you two post call days and actually let's you stay on a day-based schedule for the nights you are not pulling all nighters. Given those examples, which are how things play out at a lot of programs, I don't think it's a big mystery that residents who have actually lived these can tell you you aren't better off now. At the end of the day, it's really not as hard to be a resident as it must seem looking in -- you will be more worried about the practicing medicine aspects than the loss of sleep once you get going. All I'm saying is dont get too excited about the new and improved hours -- the emperor has no clothes.

 

[luckyducky87]

So, I have to ask - how do residents make any sort of life outside medicine work? I'm getting scared just reading the numbers here of how much interns are at the hospital for... and presumably doing this for 4 or more years during their 20's and 30's. Not to sound uncommitted to medicine, but how does any sort of personal relationship work when one person is barely home and when they ARE home, they want to do nothing but crash in bed? Or have any time for unwinding (hobbies) to stay sane?? And it sounds like all residents do this every week, for years and years...

 

[Gastrapathy]

Thanks for writing a smug article that makes us look bad to the public. What was the point of this piece? Did you read the comments? Good for you.

There is a balance between work-hours and hand-offs. The 2011 revision finally swung the pendulum too far. The old system helped to instill a culture of ownership that is lost in the shift-work era. That cultural change, along with the glorification of "ROAD" specialties, has changed the way medicine will be practiced when we're all old enough to sundown.

If you want proof that work-hours are a farce, it takes only a single simple observation. There are no work hour rules for attendings.

 

[Instatewaiter]

So, I have to ask - how do residents make any sort of life outside medicine work? I'm getting scared just reading the numbers here of how much interns are at the hospital for... and presumably doing this for 4 or more years during their 20's and 30's. Not to sound uncommitted to medicine, but how does any sort of personal relationship work when one person is barely home and when they ARE home, they want to do nothing but crash in bed? Or have any time for unwinding (hobbies) to stay sane?? And it sounds like all residents do this every week, for years and years...

Again, it's really not that hard, well at least with the old schedule. For instance, I got married during residency.

Old schedule:
Day 1- spend the night in the hospital (go home day 2)
Day 2- get home between noon and 2
Day 3- usually home at 5-6pm
Day 4- usually home at 5-6pm

New Schedule where I am
Day 1- come in AM, stay until 9pm
Day 2 Come in at 9pm and stay overnight
Day 3- Post call day (you were here overnight and leave around noonish)
Day 4- come in AM, stay until 9pm
Day 5- come in AM and stay until 5-6pm (clinic day)

 

[UCFKnight]

Loved the article!

 

[HoltMD]

Because for many being a physician isn't the end goal of life.

(sent from my phone - please forgive typos)

Then why bother? They should just go to pharmacy school. I feel that people go into medicine for the wrong reasons. My roommate who is a second year thought medicine was about prestige until the day a nurse asked her to help clean up a patient. She came home crying. 🙁

 

[nancy mcgunter]

Then why bother? They should just go to pharmacy school. I feel that people go into medicine for the wrong reasons. My roommate who is a second year thought medicine was about prestige until the day a nurse asked her to help clean up a patient. She came home crying. 🙁

Okay but to be fair, what a CNA does is very different from what a physician does. You don't have to want to help people in every conceivable way in order to be a good physician. If you did, you would be just as happy as a hairdresser or nurse. People are interested in medicine because doctors help people in a certain way (lead/manage care, etc.), and doctors are happy because they help people in a certain way.

 

[tn4596]

Again, it's really not that hard, well at least with the old schedule. For instance, I got married during residency.

Old schedule:
Day 1- spend the night in the hospital (go home day 2)
Day 2- get home between noon and 2
Day 3- usually home at 5-6pm
Day 4- usually home at 5-6pm

New Schedule where I am
Day 1- come in AM, stay until 9pm
Day 2 Come in at 9pm and stay overnight
Day 3- Post call day (you were here overnight and leave around noonish)
Day 4- come in AM, stay until 9pm
Day 5- come in AM and stay until 5-6pm (clinic day)

So, are you saying that the new system is actually worse for residents? From what I've read, you guys end up working the same amount of hours while the hours restriction make the training more inefficient (less long cases, more handoffs, etc.) Are these things significant enough for them to bring back the old system? And also, is there an equivalence of a labor union for medical residents? because it seems that once you enter residency you are at the whim of your programs and ACGME with no bargaining chip whatsoever.

 

[KnuxNole]

Then why bother? They should just go to pharmacy school. I feel that people go into medicine for the wrong reasons. My roommate who is a second year thought medicine was about prestige until the day a nurse asked her to help clean up a patient. She came home crying. 🙁

I'm confused...are you saying that someone who is gonna be a physician needs to make medicine their entire life? For a lot of physicians, that would sound depressing. Medicine is NOT the end goal of life, it's a career that someone pursues. There is WAY, WAY, WAY more that life offers.

 

[HoltMD]

I'm confused...are you saying that someone who is gonna be a physician needs to make medicine their entire life? For a lot of physicians, that would sound depressing. Medicine is NOT the end goal of life, it's a career that someone pursues. There is WAY, WAY, WAY more that life offers.

No, I don't expect someone to live in a hospital for the rest of their lives. If you go into medicine then you should be fully aware that it is a demanding field. If that's unattractive then choose a less demanding field, like pharmacy or landscaping. I just hate complainers. 😀

 

[HoltMD]

Okay but to be fair, what a CNA does is very different from what a physician does. You don't have to want to help people in every conceivable way in order to be a good physician. If you did, you would be just as happy as a hairdresser or nurse. People are interested in medicine because doctors help people in a certain way (lead/manage care, etc.), and doctors are happy because they help people in a certain way.

So, if a patient needs a little bit of non-medical attention, you think that a medical student is way above that to give a hand????

 

[nancy mcgunter]

So, if a patient needs a little bit of non-medical attention, you think that a medical student is way above that to give a hand????

Yes, that's exactly what I said. 😎

No, what I said is that it's possible to want to help people, in the role of a physician, and have no interest whatsover in giving showers to old people, or being a nurse, or a dentist, or a pharmacist, or a PA. There's a reason we all want to be physicians.

In your example, I would say yes and no. Hopefully, no, the medical student doesn't feel "above" wiping someone's butt. But there are CNAs for that, so it's reasonable for said student to defer to those trained and employed to do such tasks.

 

[KnuxNole]

No, I don't expect someone to live in a hospital for the rest of their lives. If you go into medicine then you should be fully aware that it is a demanding field. If that's unattractive then choose a less demanding field, like pharmacy or landscaping. I just hate complainers. 😀

Ahh ok 😀

Personally, I know it's quite demanding. But, at the same time, I want to keep on having awesome life experiences, etc. Although it does sound sad to see most people in their 20s and 30s who are able to go out to bars/out to eat 6x a week, and not be tired at all, I'd rather do a career I like, then do a career I find horrible.

 

[HoltMD]

Ahh ok 😀

Personally, I know it's quite demanding. But, at the same time, I want to keep on having awesome life experiences, etc. Although it does sound sad to see most people in their 20s and 30s who are able to go out to bars/out to eat 6x a week, and not be tired at all, I'd rather do a career I like, then do a career I find horrible.

Who does that? Lindsey Lohan??? 😀 I have friends who are med students and they have time to hang out, go to movies, and even binge drink.

 

[KnuxNole]

Who does that? Lindsey Lohan??? 😀 I have friends who are med students and they have time to hang out, go to movies, and even binge drink.

lol good point 😛
Although, like I mentioned earlier in this thread, it seems browsing through Facebook, the 20s crowd seem to be living completely stress free.

And I do agree, med students can have time to hang out, check out movies, and go to bars as well as personal hobbies, which thankfully, helps to keep sanity high 🙂

BUT, with that said, rotations taught me that being worked for so many hours, on a Friday night, I feel "eh" and can't find the energy to do much, and would rather just sleep. Sometimes, on a light week/easy Friday I'll do something fun. Otherwise, I don't wanna be a bore, so I just end up crashing :/

 

[HoltMD]

lol good point 😛
Although, like I mentioned earlier in this thread, it seems browsing through Facebook, the 20s crowd seem to be living completely stress free.

And I do agree, med students can have time to hang out, check out movies, and go to bars as well as personal hobbies, which thankfully, helps to keep sanity high 🙂

BUT, with that said, rotations taught me that being worked for so many hours, on a Friday night, I feel "eh" and can't find the energy to do much, and would rather just sleep. Sometimes, on a light week/easy Friday I'll do something fun. Otherwise, I don't wanna be a bore, so I just end up crashing :/

I certainly enjoy "alone" times. Gives me time to introspect or just watch TV movies and bake cookies. 🙂

People on Facebook are losers! LOL You should be happy that you are living your dream. Millions of people on this planet won't even have the chance to dream.

Live it up!

 

[Charles_Carmichael]

Would additional years compensate for the lost education or training time?

I would really rather not have the number of years of residency extended beyond what they currently are. Medical training already requires a minimum of 7 years of post-collegiate training. It would suck to increase that by another year or two.

I don't think anyone's denying the effect sleep deprivation has on cognitive ability. At the same time, there is evidence that increased hand-offs lead to increased errors and several studies haven't shown an improvement in morbidity/mortality since duty-hours were first instituted (I actually remember reading one or two abstracts where mistakes actually increased after work-hour regulations were enacted...haven't looked at articles recently, so I don't know what the current consensus is).

I understand what you're saying about the hours improving resident health (and it intuitively makes logical sense), but I don't think the issue of residency hours was ever primarily approached from that angle. It was always from the idea that work-hour regulations will improve patient safety. That always seemed to be the primary goal, not residents' health. But it doesn't look like there has been convincing evidence that the changes have actually improved patient safety significantly.

I'm not really advocating for increasing hours back or for decreasing them even more. Either way, I'll have to deal with them when I hit residency. I just want some convincing evidence before drastic changes are instituted. As far as I'm aware, there was really no evidence stating that the new rules for interns were a good idea before the changes were implemented. The premise was that residents worked too many hours and are, thus, making mistakes due to fatigue and that, by cutting down the number of hours residents worked, fewer fatigue-related mistakes would be made. Is that countered by the increase in hand-offs? Is a better-rested resident who doesn't know a patient that well better than a more fatigued resident who has handled your care for the last 24 hours? I don't think we know the answers to these questions yet. I want reasonable hours too! I have a lot of hobbies outside of academics that I enjoy. But the mantra in medicine these days is EBM. And I'd like to see strong evidence before system-wide changes are enacted rather than enacting them due to public pressure and then retrospectively trying to figure out whether it was a good idea or not.

 

[Hanguk]

This article sheds some light on issues with residency but it just seems more of a "when I was a resident" narrative. I was expecting an actual informative article digging deeper into the problem.

 

[Law2Doc]

So, are you saying that the new system is actually worse for residents? From what I've read, you guys end up working the same amount of hours while the hours restriction make the training more inefficient (less long cases, more handoffs, etc.) Are these things significant enough for them to bring back the old system? And also, is there an equivalence of a labor union for medical residents? because it seems that once you enter residency you are at the whim of your programs and ACGME with no bargaining chip whatsoever.

1. Yes the residents on this thread are saying the current rules are worse than the rules of 2 years ago.
2. Yes you work the same amount but with more trade offs to your training than before.
3. No the old system will never come back because it's not about the training, it's about window dressing -- being able to tell the public that interns taking care of them haven't been in the hospital for 30 hours (although second year residents who have been there 28 hours is apparently fine).
4. In a couple of states folks have tried to unionize, but by and large it's regarded by residents as a bad idea -- residency is just a couple of years, and most people would jest as soon keep their heads down and their eyes on the prize. Would you really want to put a target on your back to fix a " problem" that trains you well and that wont even be your problem in a quick 3-5 years? Most people realize that it's less about hazing and more about packing the maximum training into the minimum number of years, and are okay with that for a finite period of time.
I think a lot of these issues go away once you are a resident and are actually working the hours. You won't die, you won't get sick from the lack of sleep. Yes, you will be tired, but you will be learning a whole lot more than you think, despite that. (Every resident claims at times that they are too tired to learn or absorb anything and yet the differential of knowledge between first and second and third year residents is pretty dramatic, somehow -- the training does work). Every attending you work with has done the same hours or worse, so it's not like they haven't walked the walk. Bottom line is that there is a ton you don't know starting residency and most people want to be full fledged doctors in 3-5 years, and most of the learning you need is on the job training, so you need to rack up the hours on the ward. Yes, I think extending residency could get you to the same level of training, but few people want to spend five years as a resident when with worse hours they can be done in three. And in the fields that are already 5-7 years, most would jest as soon not make it 8-10, and so on.

 

[Law2Doc]

I'm confused...are you saying that someone who is gonna be a physician needs to make medicine their entire life? For a lot of physicians, that would sound depressing. Medicine is NOT the end goal of life, it's a career that someone pursues. There is WAY, WAY, WAY more that life offers.

I won't lie -- medicine is a huge time draw. You pretty much have to fit life around it, not expect it to shoehorn around your life. The number of family events and holidays you will miss during residency is not small. I've certainly eaten turkey sandwiches on the wards every thanksgiving I can remember. And there was always an attending on call those days if I needed him/her. This is simply part of the price you pay to be in some of the long houred professions.

 

[JESSFALLING]

Perhaps med school should be restructured to better prepare students for PGY-1?

Why not something like this ?? ~

Premed: Globally require premeds to take genetics, biochem, physiology, and a microbiology elective (e.g. bacteriology, Immunology, etc) to assist with an expedited basic science curriculum.
Pre-Clinical: Reduce to ~1.7 years. Start Clinical in April-May of 2nd Year. Reduce summer vacation time to 1 month. (Offer a no-charge 1-year pre-doc research fellowship to those that desire research experience).
Clinical: Standard Clerkships/electives till January of 4th year
Sub-I: 5 months as follows:
1-2 months in medicine or pediatrics
1-2 months in intensive care
1-2 months in surgery or procedure-intensive field (e.g. anesthesiology)
1-2 months in chosen (matched) or related specialty

(I realize that some schools are already close to this. Has anyone heard if it improves outcomes?)

 

[Iswhatis]

Perhaps med school should be restructured to better prepare students for PGY-1?

Why not something like this ?? ~

Premed: Globally require premeds to take genetics, biochem, physiology, and a microbiology elective (e.g. bacteriology, Immunology, etc) to assist with an expedited basic science curriculum.
Pre-Clinical: Reduce to ~1.7 years. Start Clinical in April-May of 2nd Year. Reduce summer vacation time to 1 month. (Offer a no-charge 1-year pre-doc research fellowship to those that desire research experience).
Clinical: Standard Clerkships/electives till January of 4th year
Sub-I: 5 months as follows:
1-2 months in medicine or pediatrics
1-2 months in intensive care
1-2 months in surgery or procedure-intensive field (e.g. anesthesiology)
1-2 months in chosen (matched) or related specialty

(I realize that some schools are already close to this. Has anyone heard if it improves outcomes?)

What happened to Step 1?

 

[JESSFALLING]

What happened to Step 1?

From what I've heard, students at the few schools that are on a 18-month pre-clinical curriculum still take step 1 around the same time as everyone else. They are allowed to start clinical w/o having completed it.

 

[235788]

So, are you saying that the new system is actually worse for residents? From what I've read, you guys end up working the same amount of hours while the hours restriction make the training more inefficient (less long cases, more handoffs, etc.) Are these things significant enough for them to bring back the old system? And also, is there an equivalence of a labor union for medical residents? because it seems that once you enter residency you are at the whim of your programs and ACGME with no bargaining chip whatsoever.

Maybe they should form the residency equivalent of student government.

 

[gettheleadout]

Perhaps med school should be restructured to better prepare students for PGY-1?

Why not something like this ?? ~

Premed: Globally require premeds to take genetics, biochem, physiology, and a microbiology elective (e.g. bacteriology, Immunology, etc) to assist with an expedited basic science curriculum.
Pre-Clinical: Reduce to ~1.7 years. Start Clinical in April-May of 2nd Year. Reduce summer vacation time to 1 month. (Offer a no-charge 1-year pre-doc research fellowship to those that desire research experience).
Clinical: Standard Clerkships/electives till January of 4th year
Sub-I: 5 months as follows:
1-2 months in medicine or pediatrics
1-2 months in intensive care
1-2 months in surgery or procedure-intensive field (e.g. anesthesiology)
1-2 months in chosen (matched) or related specialty

(I realize that some schools are already close to this. Has anyone heard if it improves outcomes?)

What does this have to do with the autonomous training and experience they need to gain in residency?

 

[JESSFALLING]

What does this have to do with the autonomous training and experience they need to gain in residency?

My thought was that a 1/2 year Sub-I at the end of med school would help students become more prepared for intern year by placing them in a situation similar to their future role. 5 months of such training might help offset the reduced PGY-1 exposure..........though I realize that nothing prepares one for intern year like intern year 😎

 

[gettheleadout]

My thought was that a 1/2 year Sub-I at the end of med school would help students become more prepared for intern year by placing them in a situation similar to their future role..........though I realize that nothing prepares one for intern year like intern year 😎

It's not a matter of preparation though... An incoming intern could be comfortable and competent with the new responsibility they're given, but it's a matter of them having enough experience (time) carrying out those responsibilities before functioning independently as an attending.

 

[JESSFALLING]

It's not a matter of preparation though... An incoming intern could be comfortable and competent with the new responsibility they're given, but it's a matter of them having enough experience (time) carrying out those responsibilities before functioning independently as an attending.

What if med school were 3.5 years, and internship was bumped to 18 months? Would that make a difference? A few schools have 3-year MS programs already.....so it's possible to push things along. My idea just tries to replicate that thought within the framework of the 4-year program.

I can't say from experience, yet, but it seems that an extended Sub-I experience would better prepare students for Intern year than random electives......though I think those are important too (which is why I thought that this idea would require shortening the pre-clinical training time.)

 

[Law2Doc]

What if med school were 3.5 years, and internship was bumped to 18 months? Would that make a difference? A few schools have 3-year MS programs already.....so it's possible to push things along. My idea just tries to replicate that thought within the framework of the 4-year program.

I can't say from experience, yet, but it seems that an extended Sub-I experience would better prepare students for Intern year than random electives......though I think those are important too (which is why I thought that this idea would require shortening the pre-clinical training time.)

The problem with this is that the sub I experience isn't really the intern experience. It's sort of like learning to drive a race car on a simulator -- you can't really crash and burn, and so you never really learn any of te hard lessons of internship. There's only so much you can learn before you actually get thrown into the fray, and current rules prevent sub Is from having the full level of responsibility and the same expectations as an intern, as much as they tell you otherwise. It's very different when you are the customer paying a school for education versus you being house staff and "owned" by the hospital. You really can't replicate internship outside of internship. And if you are suggesting shortening med school, I'd suggest that the less med school you have the more of an uphill climb internship would be. Many of us already had multiple Sub-Is and that was merely very minimal foundation, not the equivalent of a couple of early months of internship.

 

[JESSFALLING]

The problem with this is that the sub I experience isn't really the intern experience. It's sort of like learning to drive a race car on a simulator -- you can't really crash and burn, and so you never really learn any of te hard lessons of internship. There's only so much you can learn before you actually get thrown into the fray, and current rules prevent sub Is from having the full level of responsibility and the same expectations as an intern, as much as they tell you otherwise. It's very different when you are the customer paying a school for education versus you being house staff and "owned" by the hospital. You really can't replicate internship outside of internship. And if you are suggesting shortening med school, I'd suggest that the less med school you have the more of an uphill climb internship would be. Many of us already had multiple Sub-Is and that was merely very minimal foundation, not the equivalent of a couple of early months of internship.

Thanks, I appreciate the insight.

 

[Buzz Me]

Wait why do residents believe reducing work hour limits would impair their education? Most surgeries are done during the day are they not? I would think most of a resident's education would be during the day/early evening when the attending is around to educate them.

Actually, a lot of education happens at night when seeing consults, taking care of sick patients and doing emergency cases as well.

 

[45408]

bingo. The ACGME has replaced a bad system with one that is arguably worse for residents, and declared victory, all in the name of "window dressing" for the public. It's a joke. Most folks who have lived under both systems are not confused by the fact that you are much better off with longer shifts and post call days then endless weeks of 6 day stretches of night float.

As for the solution, I think the only realistic one would be to extend residency, but most of us wouldn't make that trade for a million bucks.

In cash? I'd take that.

If you want proof that work-hours are a farce, it takes only a single simple observation. There are no work hour rules for attendings.

Yes and no. Yes, in that if someone has a ruptured AAA at 10pm, they will not be getting a well-rested vascular surgeon. They're going to get someone who has been up all day and will definitely be up all night. If they're unlucky, he was up all last night too.

With that said, the average general surgeon works 56 hours/week according to the General Surgery News magazine that is sent to my house unsolicited, which is significantly less than what I'm working as a general surgery resident.

 

[toxicwombat]

Same here. What a nice surprise!

 

[TeddyBoomBoom]

I would clarify this that it's not really an issue of choice in terms of sleep. Ill give folks a real example. Version 1 was working a couple of 30 hour shifts each week, followed by post call days and round out the week with a lighter day or two. Grand total of, say 78 hours. Version 2 is working night float, 13 hours a night 6 nights a week, for a grand total of 78 hours. You are at work the exact same number of hours. The difference is that you are forced to sleep during the day, which rarely gives you the same quality of sleep, and only get one night off a week, usually Saturday, and if you try to do something with friends etc Saturday and sleep Saturday night, you are now off schedule again and show up exhausted Sunday night to start the next week. somehow this latter schedule is more "humane" than the one that gives you two post call days and actually let's you stay on a day-based schedule for the nights you are not pulling all nighters. Given those examples, which are how things play out at a lot of programs, I don't think it's a big mystery that residents who have actually lived these can tell you you aren't better off now. At the end of the day, it's really not as hard to be a resident as it must seem looking in -- you will be more worried about the practicing medicine aspects than the loss of sleep once you get going. All I'm saying is dont get too excited about the new and improved hours -- the emperor has no clothes.

I hadn't thought about quality and timing vs quantity of sleep. Good post.

 

[celling]

You're going to hear differing opinions on this subject. Earlier in my residency, I thought that residents were way over worked and sleep deprived. I believed that residency hours should even be lowered to 60hrs/wk.

However, as my residency has progressed my opinions have changed dramatically. I'm currently ready to start my 6th year of general surgery residency at a major university hospital and have already matched for a 3 year Cardiothoracic Surgery Fellowship. My current opinion is that my training trumps everything including my time off and sleep.

Like everyone else, I've lied on my duty hours. I've stayed past 30 hrs straight on duty, so that I can scrub on an interesting case. I've come into the hospital on my day off so that I can scrub on cardiac and thoracic cases. Now is the best time to learn, not when you're the attending and on your own. The best place to learn is in the hospital and in the line of fire, not in bed.

I know that this thread is in the pre-med forum and it could be easily in the med school forum and the discussion would be very similar. The people you should hear from should be the current residents (the ones doing the long hours with little sleep & pay). You'd be surprised that a lot of the senior residents have similar opinions to mine.

 

[911 Turbo]

You're going to hear differing opinions on this subject. Earlier in my residency, I thought that residents were way over worked and sleep deprived. I believed that residency hours should even be lowered to 60hrs/wk.

However, as my residency has progressed my opinions have changed dramatically. I'm currently ready to start my 6th year of general surgery residency at a major university hospital and have already matched for a 3 year Cardiothoracic Surgery Fellowship. My current opinion is that my training trumps everything including my time off and sleep.

Like everyone else, I've lied on my duty hours. I've stayed past 30 hrs straight on duty, so that I can scrub on an interesting case. I've come into the hospital on my day off so that I can scrub on cardiac and thoracic cases. Now is the best time to learn, not when you're the attending and on your own. The best place to learn is in the hospital and in the line of fire, not in bed.

I know that this thread is in the pre-med forum and it could be easily in the med school forum and the discussion would be very similar. The people you should hear from should be the current residents (the ones doing the long hours with little sleep & pay). You'd be surprised that a lot of the senior residents have similar opinions to mine.

So many of the residents post at this ungodly hour

Aren't you tired?

 

[Law2Doc]

So many of the residents post at this ungodly hour

Aren't you tired?

The time of day is only meaningful if you know the hours a person is working. He may have just gotten off work or just gotten up.

 

[Law2Doc]

You're going to hear differing opinions on this subject. Earlier in my residency, I thought that residents were way over worked and sleep deprived. I believed that residency hours should even be lowered to 60hrs/wk.

However, as my residency has progressed my opinions have changed dramatically. I'm currently ready to start my 6th year of general surgery residency at a major university hospital and have already matched for a 3 year Cardiothoracic Surgery Fellowship. My current opinion is that my training trumps everything including my time off and sleep.

Like everyone else, I've lied on my duty hours. I've stayed past 30 hrs straight on duty, so that I can scrub on an interesting case. I've come into the hospital on my day off so that I can scrub on cardiac and thoracic cases. Now is the best time to learn, not when you're the attending and on your own. The best place to learn is in the hospital and in the line of fire, not in bed.

I know that this thread is in the pre-med forum and it could be easily in the med school forum and the discussion would be very similar. The people you should hear from should be the current residents (the ones doing the long hours with little sleep & pay). You'd be surprised that a lot of the senior residents have similar opinions to mine.

I agree that as you get further into residency you start to appreciate that the amount of time you have in the safe harbor they call residency is really really short compared to the number of things you will want to have learned before you start practicing without a net. Most senior residents would gladly trade a few hours of sleep to log that one last chance to do X before they are out on their own. It's hard for med students and premeds to appreciate it, but residency is less about torture and more about being an immersion based crash course on the mere minimum you need to know to practice safely and successfully. As you get further along your main goal is going to be to milk every last opportunity out you can, not get home to sleep.

 

[Law2Doc]

...
With that said, the average general surgeon works 56 hours/week according to the General Surgery News magazine that is sent to my house unsolicited, which is significantly less than what I'm working as a general surgery resident.

depends who they include in that average. For every semi-retired 65 year old general surgeon who works two days a week and doesn't take call, there is a 33 year old newbie taking a crazy amount of call in his stead. Probably averages out to reasonable hours but since the game is changing (lower reimbursements, increased workload) the newbie may never get to that semi-retired point, so its a misleading average. At a lot of places the young attendings work more hours than the residents due to the absence of duty hours.

 

[45408]

depends who they include in that average. For every semi-retired 65 year old general surgeon who works two days a week and doesn't take call, there is a 33 year old newbie taking a crazy amount of call in his stead. Probably averages out to reasonable hours but since the game is changing (lower reimbursements, increased workload) the newbie may never get to that semi-retired point, so its a misleading average. At a lot of places the young attendings work more hours than the residents due to the absence of duty hours.

General surgery isn't one of those specialties that's very conducive to the "two days a week, no call" emeritus guy. We don't have anyone who does that, and while I have met one in the past, it's pretty uncommon.

I also haven't met any academic general surgery attendings who work >80 hours/week. Transplant or cardiac? Yes, certainly.

 

[NYCMS2]

From what I've heard, students at the few schools that are on a 18-month pre-clinical curriculum still take step 1 around the same time as everyone else. They are allowed to start clinical w/o having completed it.

I am at an 18 month preclinical school; I will take Step 1 in Feb of MS3, or 3/4 of a year after students in traditional 2 year preclinical schools.

Is it better? I don't know yet...