Neurosurg. Residents dislike work restrictions.

[Law2Doc]

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+1 for hearing this from lots of residents. Because you can only stay 16 hours you no longer have a full 24 day off every 3rd. Instead you work 13 days straight then get a single day off.

It messes up your life outside of the hospital because you can't perform basic life management tasks, let alone spend time on building (or cultivating) a family. You go home, you sleep, you go back.

The opinions of the younger residents where I am is that things are worse for everyone because people are miserable, though well rested.

There's actually an additional negative wrinkle. Because the interns can only work 16 hours, that means more of the intern workload now falls onto the upper year residents, whose limit currently is 24 hours. It's likely pretty annoying when your intern doesn't get the work done and leaves you a pile of stuff to take care of in a year when you are supposed to be starting to ease into a more supervisory/teaching role. So basically everybody gets screwed under the new system. You learn less, you are more tired, you still make just as many mistakes, you don't get post-call days, you have fewer electives (because the hospitals lack man hours to send their interns off to do a month of rheum, etc) etc.

 

[tiedyeddog]

Why are interns only allowed 16 hours shifts and more senior residents allowed 24 hour shifts? Can someone explain the logic behind it to me?

 

[Law2Doc]

Why are interns only allowed 16 hours shifts and more senior residents allowed 24 hour shifts? Can someone explain the logic behind it to me?

Somebody still has to do the work. I guess the thinking is that once you have a year under your belt, your sleep deprived decisions are still better than an interns, and that the non-"prelim" folks are less likely to be abused than the folks doing prelim medicine/surgery who are only 1 year rentals. Probably true.

 

[michaelrack]

Whatever happened to the concept that you can learn from every patient?.

you can learn from every pt, but some are higher yield than others for learning purposes. You can learn from reading every medical journal, but there isn't time to read them all.

 

[neusu]

Why are interns only allowed 16 hours shifts and more senior residents allowed 24 hour shifts? Can someone explain the logic behind it to me?

Limits are: Interns 16, PGY-2 or above 28. Minimum 10 hours between shifts. Minimum 1 day off per week. Maximum of 80 hours per week, unless you have the 10% exemption in which case the number is 88 (incidentally, >50% of the programs that have exemptions are neurosurgery programs and >50% of neurosurgery programs have exemptions). All of these parameters are analyzed on a floating 4 week window.

What I have noticed from experience:

1) Continuous 28 hour call is far better in both safety and for resident satisfaction. A 28 hour call decreases the number of signouts, increasing efficiency. On slow nights, the 28 hour call resident can rest and, perhaps get some sleep. On busy nights, his adreneline is keeping him awake and sharp. Alternatively on slow nights, the 16 hour shift resident is either also sleeping (more likely) or trying to figure out the patients on his list because he has no idea who they are. On busy nights, he is too busy putting out fires to find the idiosyncratic subtleties of patients that is garnered by following them for extended periods and knowing what is going on because of that. On his post call day off 28 hour call resident gets to run errands, get his hair cut, mow the lawn, and sleep. Twenty-eight hour call resident also gets one day off per week mandated by ACGME. Meanwhile, 16 hour shift resident comes home tired, goes to sleep tired, wakes up tired. The day has long ended by the time he is done with work. He is long haired, unkempt. He has a day off a week.
2) Restricted intern hours results in interns not accomplishing their responsibilities. This causes more senior residents to have to do the intern work, at the cost of the work at their level. At my institution, the general surgery chief residents have had to do discharge summaries because the interns were over hours.
3) Increasing mid level practitioners can help, but is not a complete solution. The graded responsibility of residency is meant to teach how to be a doctor both clinically and administratively.
4) Hiring additional residents is not a feasible option. Current guidelines for safe practice have a requirement for a minimum case log by each resident prior to graduation. Dilution of the current cases by adding additional residents may allow for decreased work hours, however, it will result in under trained physicians.

 

[KnuxNole]

you can learn from every pt, but some are higher yield than others for learning purposes. You can learn from reading every medical journal, but there isn't time to read them all.

What exactly do you "learn" from patients? Like....if they have a co-morbid disease, you see how it presents and learn to manage it, and read about the disease later?

Also, is it possible for interns to leave earlier, like instead of being EXACTLY 16, 6am-10pm, 6am-6/7pm? Or is the 16hr limit means its mandated they must work 16 hrs and never less?

Maybe for SURGERY specialities it's different(which i know is what the OP is about). But, then again, a bulk of residents are not surgical specialties, etc.

 

[eccentric jet]

What exactly do you "learn" from patients?

?

 

[KnuxNole]

lol...it's probably a dumb question....

I was just thinking...it's probably that you learn how to treat and manage them in person. I'm still in the med school phase where you learn about patients by reading their conditions. 😳

 

[eccentric jet]

I subscribe to the school of thought that there are no dumb questions. Things change a lot as you transition into the clinical years, and you will be amazed how much you can learn about a disease simply by speaking with and examining patients, let alone following/managing their course.

I do not mean to present myself as some grizzled veteran of medicine, I am merely a 4th year student. But, at least in my experience, it is the patient encounters that stick with you and bring substance to the endless pages you read in the first two years. Of course, reading remains important, but there is no substitute to learning first hand from the people you take care of.

 

[45408]

What exactly do you "learn" from patients? Like....if they have a co-morbid disease, you see how it presents and learn to manage it, and read about the disease later?

Let's just say that I had a hard time understanding/remembering how to manage a patient in DKA until I had one. All the pieces fell into place, and when I was taking the medicine shelf, there were a great many questions that I was able to answer just by thinking "Well, what did we do for the patient with sepsis/DKA/pneumonia/chest pain/etc?"

Books are great, but you will never have to treat a book. There's a ton to learn by seeing the patients and learning how diseases actually present. The book will always give you a more clear-cut scenario than you'll actually find. The book will say "Your patient has these vital signs, these physical findings and these labs, the patient obviously has an MI." In real life, the nurse calls and says Doris was a little confused, but they were able to re-direct her and now she's feeling okay. Do you have to rush to see the patient? What's going on? Is it serious? Is it nothing?

You learn from patients how to treat patients.

 

[OneTyme]

lol...it's probably a dumb question....

I was just thinking...it's probably that you learn how to treat and manage them in person. I'm still in the med school phase where you learn about patients by reading their conditions. 😳

It's the same reason that people who solely have PhDs would be very bad at patient care. Don't get me wrong, PhDs are obviously incerdibly intelligent. It's just that the way things present in books or the lab are much different than how they appear in the clinic or on the ward. I'm only in first year but I've already heard several docs during my preceptorship say, "Oh, it never actually presents like that in 'real life'."

And, +1 for the real life making it easier to remember. I've had that happen more than once on exams in first year already just based upon interviewing patients and remembering drugs for treatment on an exam.

 

[45408]

One of the reasons that it "never presents like that in real life" is that a lot of classic findings were based on a time when we didn't have advanced imaging or labs and diseases would present much later. Ideally, you won't be waiting to see Grey Turner's sign or Cullen's sign before you diagnose your patient with pancreatitis.

 

[Conqueror]

I'm quite concerned by the PGY-1 hour restrictions. The way the system is now structured, the first day of PGY-2 year some ex-intern is going to get handed the consult pager for the first time, and not only has he never been forced to juggle 12 consults at once, but he's never worked a long shift before as a physician. You want to talk medical mistakes? Add the sheer terror and unending flood of covering the ED pager for the first time to the fatigue of never having worked more than 16hrs in a row, and see how long it takes to miss a perf'ed sigmoid or a cold leg or a growing pupil.

 

[dreamweaver1988]

There are no such legal loopholes. You need to leave or the program runs the risk of penalties. You can't volunteer, or stay on in your own time. The reason being that if that was an option, some residency program somewhere would browbeat it's residents into "volunteering" regularly, and the duty hours would be meaningless.

Truth of the matter is that in many fields, not just NS, you are going to start to realize later in residency that you aren't going to have seen enough of everything and done enough of everything to be proficient at your specialty. Duty hours sound great, in the abstract, but sometimes it stands in the way of your training, rather than protects you from anything. So you will really start to resent duty hours that stand in the way of the cool case that shows up at the end of your shift. Yes, you want to go home, but there will be times when you feel it would be in your interest not to. And yet you don't have that choice.

Does hours of training actually matter, though? We all know that MD/DO = DNP yet DNPs have fewer training hours. Ergo, more training does not lead to more skills. Can't neurosurgery residencies be offered online, like DNP programs?

 

[Bartemius]

Does hours of training actually matter, though? We all know that MD/DO = DNP yet DNPs have fewer training hours. Ergo, more training does not lead to more skills. Can't neurosurgery residencies be offered online, like DNP programs?

lol dreamweaver1988 for the win

 

[Staradmiral]

Limits are: Interns 16, PGY-2 or above 28. Minimum 10 hours between shifts. Minimum 1 day off per week. Maximum of 80 hours per week, unless you have the 10% exemption in which case the number is 88 (incidentally, >50% of the programs that have exemptions are neurosurgery programs and >50% of neurosurgery programs have exemptions). All of these parameters are analyzed on a floating 4 week window.

What I have noticed from experience:

1) Continuous 28 hour call is far better in both safety and for resident satisfaction. A 28 hour call decreases the number of signouts, increasing efficiency. On slow nights, the 28 hour call resident can rest and, perhaps get some sleep. On busy nights, his adreneline is keeping him awake and sharp. Alternatively on slow nights, the 16 hour shift resident is either also sleeping (more likely) or trying to figure out the patients on his list because he has no idea who they are. On busy nights, he is too busy putting out fires to find the idiosyncratic subtleties of patients that is garnered by following them for extended periods and knowing what is going on because of that. On his post call day off 28 hour call resident gets to run errands, get his hair cut, mow the lawn, and sleep. Twenty-eight hour call resident also gets one day off per week mandated by ACGME. Meanwhile, 16 hour shift resident comes home tired, goes to sleep tired, wakes up tired. The day has long ended by the time he is done with work. He is long haired, unkempt. He has a day off a week.
2) Restricted intern hours results in interns not accomplishing their responsibilities. This causes more senior residents to have to do the intern work, at the cost of the work at their level. At my institution, the general surgery chief residents have had to do discharge summaries because the interns were over hours.
3) Increasing mid level practitioners can help, but is not a complete solution. The graded responsibility of residency is meant to teach how to be a doctor both clinically and administratively.
4) Hiring additional residents is not a feasible option. Current guidelines for safe practice have a requirement for a minimum case log by each resident prior to graduation. Dilution of the current cases by adding additional residents may allow for decreased work hours, however, it will result in under trained physicians.

How do you people work 28 straight hours? I've never worked more than 13h straight in my life and that's with 2hours of break in that 13h. There is no way I am ever going into a residency with 28hour shifts, i'm not on cocaine and I don't drink coffee. I've never even pulled an allnighter in my life. When i'm a doctor post residency, i'm gonna be working 8:00am-4:00pm mon-fri. There are things to do outside the hospital....

 

[bassvp]

Does hours of training actually matter, though? We all know that MD/DO = DNP yet DNPs have fewer training hours. Ergo, more training does not lead to more skills. Can't neurosurgery residencies be offered online, like DNP programs?

I've actually wondered about this. If there is an across-the-board problem with mid-level encroachment, it seems that society is telling us that physicians are over-trained as it is.

 

[Law2Doc]

I've actually wondered about this. If there is an across-the-board problem with mid-level encroachment, it seems that society is telling us that physicians are over-trained as it is.

Society has no clue what is involved in medicine. They are happy with anyone in a white coat. That doesn't mean the idea is a good one. It's actually medicines role to educate the public as to why residency training is important, and why midlevel care is not the same as physician care, not let society dictate a lower cost substandard option out of ignorance.

 

[vicinihil]

derm.

 

[typhoonegator]

How do you people work 28 straight hours? I've never worked more than 13h straight in my life and that's with 2hours of break in that 13h. There is no way I am ever going into a residency with 28hour shifts, i'm not on cocaine and I don't drink coffee. I've never even pulled an allnighter in my life. When i'm a doctor post residency, i'm gonna be working 8:00am-4:00pm mon-fri. There are things to do outside the hospital....

You don't need cocaine or coffee to work for 30 hours. And you don't need a nap. If I can still do it as a PGY-7, then you can do it as an intern.

Wait until you have kids. My call nights in the neuroICU are more restful than a night at home with a 2 month old. When my baby first came home from the hospital, with no family around to help (he arrived early) I don't think my wife or I got more than an hour or two of uninterrupted sleep at a time for 6 consecutive days. Your body can do this stuff, if you are willing to try.

 

[neusu]

Two studies in the March volume of the Journal of Neurosurgery address issues related to duty hours

1) Increased rate of complications on a neurological surgery service after implementation of the Accreditation Council for Graduate Medical Education work-hour restriction ( http://thejns.org/doi/abs/10.3171/2011.9.JNS116 ): Morbidity statistically increased while mortality remained unchanged.

2) The effect of call on neurosurgery residents' skills: implications for policy regarding resident call periods ( http://thejns.org/doi/abs/10.3171/2011.9.JNS101406?prevSearch=&searchHistoryKey= ): no statistical difference in surgical skill pre/post call.

 

[ArcGurren]

One of the reasons that it "never presents like that in real life" is that a lot of classic findings were based on a time when we didn't have advanced imaging or labs and diseases would present much later. Ideally, you won't be waiting to see Grey Turner's sign or Cullen's sign before you diagnose your patient with pancreatitis.

That's about the point you'd want to be calling the morgue

 

[bassvp]

Society has no clue what is involved in medicine. They are happy with anyone in a white coat. That doesn't mean the idea is a good one. It's actually medicines role to educate the public as to why residency training is important, and why midlevel care is not the same as physician care, not let society dictate a lower cost substandard option out of ignorance.

I agree. So who's gonna educate the public? DNP's and their studies about their "equivalent" care?

Sorry. </tangent>

 

[Law2Doc]

I agree. So who's gonna educate the public? DNP's and their studies about their "equivalent" care?

Sorry. </tangent>

I've already suggested on other threads that physicians are missing an easy window to address this, which nobody seemed to like. Because the current administrations health care plan embraces the idea of midlevels, the pundits on the other side of the red state/blue state discussion are going to naturally embrace any concept that intelligently attacks this plan. I'm not sure why physicians and physician groups haven't given the Bill O'Reilly/Glen Beck/Rush Limbaugh types this football and let them run with it. (Mind you, I don't agree with any of these guys politically, but I have no problem with using them to raise awareness of a topic). Scaring the public into realizing that their doctor is going to be replaced with someone without a medical degree and a fraction of the training, and that basically under this new plan they could end up going to Wallmart and get the equivalent care of someone who isn't a doctor but stayed at a Holiday Inn Express, in the name of affordable healthcare. We also need to be compiling lists of complications and morbidities of patients treated by midlevels without physician supervision -- if we can show that a lack of training results in more problems (seems intuitive, but someone needs to compile the data) that would be useful ammunition. So yeah, basically I threw out some suggestions previously. I'm sure others have better approaches. But it's probably time to do something.

 

[Substance]

Um no. We switched from a supposedly "sleep deprived" system, and error rates didn't go down. That generally means either they hypothesis was simply wrong (certainly possible) or that there's another error fraught component in the system that increased when you cut down the hours (more likely). The leading contenders for new sources of error are (1) loss of continuity of care and (2) more errors incident on increased numbers of handoffs. Given that cutting down hours did not fix the problem, but did negatively impact training, I think logic dictates at a minimum not doing additional hour cuts until there's some evidence to support them.

(Just for the readers here who might think a US resident is breaking ranks, Substance is in Canada, training under a very different system, and based on other threads, considers a lot of what is routine here in US residencies as "malignant').

There you go again with your trying to discredit me because I am a Canadian resident. For someone with experience in law, you sure like to employ the use of flawed assumptions. FYI, Canada might be indeed tougher than the US now, since we have no 80 hour rule. Some programs in hardcore surgical subspecialties like ortho have employed night-float, which from anecdotal reports from those residents seems to be a significant improvement from their previous 40 hour shifts.

What I say and believe still stands: long shifts are dangerous and inhumane, for doctors, patients, and the public at large, and that is always true. Handover and all the organizational stuff is only dangerous if it is disorganized, and that can be fixed with some effort. Unfortunately many doctors opt to take your attitude of maintaining an inherently flawd status quo, and that's just lazy. That's just the kind of attitude that will have docs working for 25 year old MBAs in the future.

 

[MilkmanAl]

Unfortunately many doctors opt to take your attitude of maintaining an inherently flawd status quo, and that's just lazy. That's just the kind of attitude that has docs working for 25 year old MBAs.

Fixed, but totally agree.

 

[KnuxNole]

There you go again with your trying to discredit me because I am a Canadian resident. For someone with experience in law, you sure like to employ the use of flawed assumptions. FYI, Canada might be indeed tougher than the US now, since we have no 80 hour rule. Some programs in hardcore surgical subspecialties like ortho have employed night-float, which from anecdotal reports from those residents seems to be a significant improvement from their previous 40 hour shifts.

What I say and believe still stands: long shifts are dangerous and inhumane, for doctors, patients, and the public at large, and that is always true. Handover and all the organizational stuff is only dangerous if it is disorganized, and that can be fixed with some effort. Unfortunately many doctors opt to take your attitude of maintaining an inherently flawd status quo, and that's just lazy. That's just the kind of attitude that will have docs working for 25 year old MBAs in the future.

I personally agree with the 2nd paragraph, but it's the minority opinion so meh. I think for most people, it's very hard to stay up for 24 hours or more and actually use your brain, etc. I know for ME, if I was in a surgery at 1am, I would fall asleep instantly. Then again, this is someone who hates surgery with a passion, finds it boring, so a bit biased of an opinion...compared to someone who loves surgery, I'm sure after a 3 hour case at midnight, they are amped to go to another one 1 hour later 😀

 

[Kneuro]

Neurosurgery starts PGY-2 so the 16-hour rule is not even applicable to them. PGY-1 is gen. surg. The management of 50+ floor patients is PGY-2 responsibility in neurosurg. and an extremely difficult year.

 

[tiedyeddog]

Neurosurgery starts PGY-2 so the 16-hour rule is not even applicable to them. PGY-1 is gen. surg. The management of 50+ floor patients is PGY-2 responsibility in neurosurg. and an extremely difficult year.

Many neurosurgery programs are integrating PGY-1 (someone from Columbia posted this earlier.)

 

[Law2Doc]

There you go again with your trying to discredit me because I am a Canadian resident. For someone with experience in law, you sure like to employ the use of flawed assumptions....

the flawed assumption here is that I'm trying to "discredit " you. You are absolutely entitled to your opinion. The opinion of a canadian resident on the US residency system is about as valuable as the opinion of a US resident on the Canadian residency system.

However when you jump onto a thread of predominantly US allo med students and weigh in as simply a " resident", it might be helpful for folks to know that the system you are commenting on is not even your own. It's much much easier to throw around words like "inhumane" and "malignant" when you are in a totally different system. when you identify yourself as a resident and comment on US residency issues, it cloaks your opinion with the reasonable assumption that it's coming from a US resident. It confuses people.

A lot of us have the same criticisms of another poster, from Mexico, who also omits that she's in a different system when she posts.

 

[michaelrack]

You don't need cocaine or coffee to work for 30 hours. And you don't need a nap. If I can still do it as a PGY-7, then you can do it as an intern.

Wait until you have kids. My call nights in the neuroICU are more restful than a night at home with a 2 month old. When my baby first came home from the hospital, with no family around to help (he arrived early) I don't think my wife or I got more than an hour or two of uninterrupted sleep at a time for 6 consecutive days. Your body can do this stuff, if you are willing to try.

It is often mentioned at Sleep medicine conferences that certain specialties (mainly surgical) self-select for those better able to withstand sleep deprivation. It is speculated that if you took a group of surgery residents and a group of non-surg residents, put them in a lab and sleep-deprived them followed by a test of sleepiness (MSLT); that the surgery residents would be less sleepy on standard testing. No one has carried out this test, to my knowledge

 

[Substance]

the flawed assumption here is that I'm trying to "discredit " you. You are absolutely entitled to your opinion. The opinion of a canadian resident on the US residency system is about as valuable as the opinion of a US resident on the Canadian residency system.

However when you jump onto a thread of predominantly US allo med students and weigh in as simply a " resident", it might be helpful for folks to know that the system you are commenting on is not even your own. It's much much easier to throw around words like "inhumane" and "malignant" when you are in a totally different system. when you identify yourself as a resident and comment on US residency issues, it cloaks your opinion with the reasonable assumption that it's coming from a US resident. It confuses people.

A lot of us have the same criticisms of another poster, from Mexico, who also omits that she's in a different system when she posts.

It cannot be argued that any type of system that demands its workers subject themselves to extreme sleep deprivation and physical exhaustion while exposing patients to exhaustion-induced errors is a poor system, regardless of whether its in Uganda or the USA. It's more like a bonded labor system than a training system. I cannot defend it no matter how ingrained into the status quo it is.

The American and Canadian systems are similar enough for me to have a valuable opinion on both. Many of the residencies here are seen as equivalent to their American counterparts, and vice versa - the same cannot be said for Mexico. There is nothing to be confused about here.

Nonetheless, I am disappointed that people on either side of the argument are not considering ways to improve the inherent ineffeciencies in the system that were the result of administrations taking cheap, inexhaustible resident labor for granted.It's high time we admit to the flaws in the system and figure out how to fix them. Call-shifts are a flaw. Ineffecient handovers are a flaw. Scut is a flaw. Time is limited, so we must maximize the ratio of education and worthwhile patient care to time.

 

[tiedyeddog]

It cannot be argued that any type of system that demands its workers subject themselves to extreme sleep deprivation and physical exhaustion while exposing patients to exhaustion-induced errors is a poor system, regardless of whether its in Uganda or the USA. It's more like a bonded labor system than a training system. I cannot defend it no matter how ingrained into the status quo it is.

Couple of points:

1. Do you have any actual data on sleep deprivation being causative of medical errors?

2. What about attending physicians? I have no idea how the payment schedule is setup in Canada, but I doubt the US pay schedule, especially for highly procedural fields, could ever be based on shift work. Why put residents on a shift work schedule when they're going to come out and not to able to cope with the attending lifestyle.

3. It is very apparent that doing a shift work type deal for residents would lead to a couple things:

a. More residents, either as is more per PGY or longer residencies. This ultimately is going to hurt physician pay, as more people are turned out from residencies, making most fields more competitive. While I do favor competition, I think this is a huge problem in the US due to the average dent of a US graduate and also, the time spent training. Isn't the cost of a medical education relatively cheap in the Great White North? Or, in the case of longer residencies, the debt situation would be much worse for most people. This leads to point:

b. Where is the money for this new shift work system going to come from? Hiring more residents or extending residencies is going to cost money. Big programs will probably be fine, but what about smaller, community based programs? Maybe you're not aware of this: http://www.medscape.com/viewarticle/758533
"Medicare funding of residency training programs also would fall by $10 billion, with the Obama administration reasoning that they are overcompensated for their costs." Obviously, the government and public are not in favor or throwing any more money at residency programs. $10 billion is also kind of a paltry sum when you consider how much was on the table to be cut a few months ago, our situation could have even been worse.

tl;dr I think the funding situation for medicine between Canada and the USA is so different your suggestion is not realistic for our situation. I am not saying your idea is a bad one, I am just saying no one is going to throw more money at residency programs to make this possible.

Edit: One more point. People aren't throwing out suggestions because many of us don't think the system is broken. I've yet to see hard data on sleep deprivation leading to errors, so what are we fixing?

 

[45408]

How do you people work 28 straight hours? I've never worked more than 13h straight in my life and that's with 2hours of break in that 13h. There is no way I am ever going into a residency with 28hour shifts, i'm not on cocaine and I don't drink coffee. I've never even pulled an allnighter in my life. When i'm a doctor post residency, i'm gonna be working 8:00am-4:00pm mon-fri. There are things to do outside the hospital....

You'll do it if your job/career/future depend on it, as well as your patients. 13 hours? That's just a long day on an elective rotation.

There you go again with your trying to discredit me because I am a Canadian resident. For someone with experience in law, you sure like to employ the use of flawed assumptions. FYI, Canada might be indeed tougher than the US now, since we have no 80 hour rule. Some programs in hardcore surgical subspecialties like ortho have employed night-float, which from anecdotal reports from those residents seems to be a significant improvement from their previous 40 hour shifts.

He wasn't discrediting you. He was just saying that your opinion doesn't represent a break in the overall consensus from US residents that the "fixes" to our system are not an improvement, which is true.

You've also been making quite a few unsubstantiated claims that I'd like to see some support for, as tiedyeddog pointed out above.

 

[phenylacetone]

It is often mentioned at Sleep medicine conferences that certain specialties (mainly surgical) self-select for those better able to withstand sleep deprivation. It is speculated that if you took a group of surgery residents and a group of non-surg residents, put them in a lab and sleep-deprived them followed by a test of sleepiness (MSLT); that the surgery residents would be less sleepy on standard testing. No one has carried out this test, to my knowledge

I am under the impression the chronic sleep deprivation results in subjective adaptation to feeling of sleepiness. In this respect, I wonder of the surgeons would just report less subjective sleepiness relative to their objective sleep latency (whether due to adaptation or inherent difference).

 

[Substance]

You'll do it if your job/career/future depend on it, as well as your patients. 13 hours? That's just a long day on an elective rotation.


He wasn't discrediting you. He was just saying that your opinion doesn't represent a break in the overall consensus from US residents that the "fixes" to our system are not an improvement, which is true.

You've also been making quite a few unsubstantiated claims that I'd like to see some support for, as tiedyeddog pointed out above.

1. http://www.nejm.org/doi/full/10.1056/NEJMoa041406

2. Sure he was. To say that my opinion is less valid because I am a resident in Canada is discrediting my opinion. If you believe that the Canadian and American residency systems are so different as to not be interchangeable, then that would make sense. But they are not, so it doesn't.

3. As for the opinion that the system's fixes are not an improvement, could you please link to any data to substantiate that claim? Though I do agree that your new work restrictions are somewhat of an ineffective band-aid solution, that does not mean there is not another system that would be better than the one used prior to the work restrictions.

 

[Law2Doc]

.... If you believe that the Canadian and American residency systems are so different as to not be interchangeable, then that would make sense...

yes, this is what I and others are saying.

My point is that you are throwing around words like inhumane and malignant, which carry very different import if you are a US resident commenting on your own system versus if you are outside of the system. I think a lot of us find the US system in most cases both fairly benign and humane, but most importantly a necessary means to an end in our training. I've worked both a ton of 30 hour shifts as well as many months of night float, and I have come to my own personal conclusion that the 30 hour shift with a post call day is simply a better deal for the resident -- Yes, it was rough at the end of those shifts, but ultimately I was less worn down over the weeks, and the days flew by much faster under that former system. Someone who has, by their own admission never worked 13 hours in a row simply doesn't have the same frame if reference as the typical US resident, or even a lot of US med students (many if whom stay for overnight call with their residents).

 

[Substance]

yes, this is what I and others are saying.

Well I disagree, and I see no evidence to support your claim that our systems are so divergent as to be incomparable.

 

[Law2Doc]

Well I disagree, and I see no evidence to support your claim that our systems are so divergent as to be incomparable.

I think a lot of us would point to your posts as evidence.

 

[45408]

1. http://www.nejm.org/doi/full/10.1056/NEJMoa041406

That was from before any work hour restrictions. I'm not arguing that there should be no restrictions at all, which is the era that study was performed.

2. Sure he was. To say that my opinion is less valid because I am a resident in Canada is discrediting my opinion. If you believe that the Canadian and American residency systems are so different as to not be interchangeable, then that would make sense. But they are not, so it doesn't.

Based on how you're describing the American system, I would say you are not adequately familiar with it to be making the judgments you're making.

 

[Miss Alyssa]

What are typical shifts like for surgical and non-surgical residents in Canada?

 

[Mortal_Lessons]

Two studies in the March volume of the Journal of Neurosurgery address issues related to duty hours

1) Increased rate of complications on a neurological surgery service after implementation of the Accreditation Council for Graduate Medical Education work-hour restriction ( http://thejns.org/doi/abs/10.3171/2011.9.JNS116 ): Morbidity statistically increased while mortality remained unchanged.

2) The effect of call on neurosurgery residents' skills: implications for policy regarding resident call periods ( http://thejns.org/doi/abs/10.3171/2011.9.JNS101406?prevSearch=&searchHistoryKey= ): no statistical difference in surgical skill pre/post call.

Main points/conclusions from the studies if you don't have time to read through them:

1) "Results: The overall rate of morbidity and mortality increased from 103 to 114 per 1000 patients treated after institution of the work-hour restriction, although this increase was not statistically significant (N = 8546 = 2.6, p =0.106). The morbidity rate increased from 70 to 89 per 1000 patients treated after institution of the work-hour restriction(N = 8546 = 10, p = 0.001). The overall mortality rate was diminished from 32 to 27 per 1000 patients treated after institution of the work-hour restriction ( N = 8546 = 3.2, p = 0.075). Morbidities considered avoidable or possibly preventable were seen to increase from 56 to 66 per 1000 patients treated (N = 8546 = 5.7, p = 0.017). Avoidable or possibly preventable mortalities numbered 3 per 1000 patients treated, and this rate did not change after introduction of the work-hour restriction (N = 8546 = 0.08, p = 0.777).
Conclusions: The morbidity rate on a neurological surgery service is increased after implementation of the workhour restriction. Mortality rates remain unchanged."

2) "Results: The neurosurgery residents did not show a statistically significant difference in their surgical skills between the pre- and postcall states (p < 0.3, p < 0.4, and p < 0.2 for movement smoothness, time elapsed, and cognitive errors, respectively). The mean decrement for all residents in the postcall condition was 13.1%.
Conclusions: Postcall fatigue is associated with a marginal decrease in proficiency during simulated surgery in neurosurgery residents. In a similar study, general surgery residents showed a statistically significant decrement of 27.3% in the postcall condition. The impact of fatigue on different specialties should be further investigated prior to implementation of a national physician work-hour policy."

Some illuminative comments from the accompanying editorial:

"Many would argue that the methodology herein applied does not truly approximate the adrenaline-charged response that occurs when one encounters a patient with a dilated pupil in the emergency room...It could be argued that the surgical simulator greatly underestimates the impact of physiological changes that occur when neurosurgeons are faced with actual patients. In the practice of neurosurgery, the stakes are high and time is of the essence; the correct intervention, delivered in a timely fashion, has implications for both the quality and quantity of life for our patients. This study’s methodology may actually understate changes in neurosurgeons’ psychomotor and cognitive capabilities when faced with a real patient. The beauty of medicine lies in its breadth and depth; during the 3rd and 4th years of medical school, students have the opportunity to identify their strengths, weaknesses, and passion as they decide upon a career path. Neurological surgery has long been recognized as an arduous career path, during training as well as after.1 Most medical practitioners would agree that all medical specialties are not created equal; as Dr. Tom Nasca, head of the ACGME, pointed out in his keynote address at the 2011 Society of Neurological Surgeons meeting, “One size does not fit all.” (Keynote speech, May 22, 2011, Portland, Oregon.) The demands of each medical specialty are unique and noncomparable; therefore, applying the same work-hour restrictions to all specialties has little merit. Neurosurgical emergencies do not occur on an 8:00–5:00 schedule; nor do surgical complications obey the standard work-day schedule. It is integral to the job description that a neurosurgeon is able to respond, regardless of the hour or the number of hours worked, to the neurosurgical issues at hand. As a group, we should be unapologetic in regard to the demands of our specialty..."

 

[Instatewaiter]

Sixteen hour shifts are still ridiculous. Not as ridiculous as 30, but still ridiculous. And the "handover is worse" point is moot, since the argument that sleep deprivation is dangerous is no less relevant nor less supported by data.

Residents, especially surgery residents, should stop complaining about how they miss 30 hour shifts and start making their residency experiences more efficient.

Do you guys even work in residency or do you do a virtual residency where you come into the hospital once a week and occasionally take care of patients? (kidding of course... but not really)

I can think of a dozens of jobs where you are expected to work 16 hour days in the US. 16 hours isn't all that bad.

Why are interns only allowed 16 hours shifts and more senior residents allowed 24 hour shifts? Can someone explain the logic behind it to me?

Because surgery flipped their **** when the ACGME made the work hour rules and probably would have left the ACGME if the rules were for all residents.

1. http://www.nejm.org/doi/full/10.1056/NEJMoa041406

2. Sure he was. To say that my opinion is less valid because I am a resident in Canada is discrediting my opinion. If you believe that the Canadian and American residency systems are so different as to not be interchangeable, then that would make sense. But they are not, so it doesn't.

3. As for the opinion that the system's fixes are not an improvement, could you please link to any data to substantiate that claim? Though I do agree that your new work restrictions are somewhat of an ineffective band-aid solution, that does not mean there is not another system that would be better than the one used prior to the work restrictions.

1) A few problems with this article
- the shorter hours group had more interns
- the PREVENTABLE events were not statistically significant
- didn't actually measure if they slept more, just assumed
- Did not blind the medical observers (they knew the intern schedules) and this is coming from one of the hospitals that has really been pushing for work hour restrictions for years

2. First the fact that he was saying your opinion isn't valid, in and of itself is discrediting your opinion. But, for clarity, your opinion is less valid because:
a) you haven't gone through the US system
b) You don't even know what the system entails
c) Canadians, like europeans have a very different take on what are acceptable working hours. Hell, UK physicians were working 48 hours a week as a maximum. What a joke.


3. The Hopkins study should come out soon. I haven't read it but I did go through the trials that are included in the paper and can infer what it is gonig to say.

 

[KnuxNole]

48 hrs a wk? Lucky bastards >.<

I'm aiming to be a clinic doc(cause that's what I tend to enjoy way more than wards), but it seems even THEY work long hours, but if you like the job, the hours aren't a big deal if there is some free time and such.

 

[tiedyeddog]

Do you guys even work in residency or do you do a virtual residency where you come into the hospital once a week and occasionally take care of patients? (kidding of course... but not really)

I can think of a dozens of jobs where you are expected to work 16 hour days in the US. 16 hours isn't all that bad.




Because surgery flipped their **** when the ACGME made the work hour rules and probably would have left the ACGME if the rules were for all residents.






1) A few problems with this article
- the shorter hours group had more interns
- the PREVENTABLE events were not statistically significant
- didn't actually measure if they slept more, just assumed
- Did not blind the medical observers (they knew the intern schedules) and this is coming from one of the hospitals that has really been pushing for work hour restrictions for years

2. First the fact that he was saying your opinion isn't valid, in and of itself is discrediting your opinion. But, for clarity, your opinion is less valid because:
a) you haven't gone through the US system
b) You don't even know what the system entails
c) Canadians, like europeans have a very different take on what are acceptable working hours. Hell, UK physicians were working 48 hours a week as a maximum. What a joke.


3. The Hopkins study should come out soon. I haven't read it but I did go through the trials that are included in the paper and can infer what it is gonig to say.

You're one of my favorite posters on here, keep it up. 👍

 

[eject]

http://www.chicagotribune.com/news/opinion/ct-perspec-0401-intern-20120401,0,6010913.story

money quote:

The new crop of surgical interns will have to work twice as hard to learn the same amount of decision-making skills in half the hours.

 

[MilkmanAl]

I, for one, am perfectly okay with working twice as hard for half as long. I prefer that, actually.

 

[tfc]

Hopkins will soon publish a study that shows the "extra" amount of sleep with the new system is basically neglibile.

The new system was pushed on all residencies without any evidence whatsoever. The ACGME should be ashamed of themselves for such unevidenced based practices. What a joke.

This is great news, I agree this whole thing is a joke.

 

[Law2Doc]

I, for one, am perfectly okay with working twice as hard for half as long. I prefer that, actually.

As do I. I'd be up for ramping back up to longer calls and slightly longer weekly duty hours and shave residency down a year. Like ripping off a bandaid fast, rather than slowly.

 

[Ronin786]

Although I'm not a resident yet, I think for certain people the long shifts provide a certain type of allure. Its an achievement to be able to go 30 hours straight, and when you're busy the whole time it really does fly.

Not to mention, the fact that no significant evidence shows increased physician mistakes, and doctors should be able to choose what they want to do as long as there is no evidence against it.