New doctors still too tired for safety

[MsKrispyKreme]

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http://www.msnbc.msn.com/id/28017425

Some excerpts:

Tuesday, a panel of the prestigious Institute of Medicine recommended easing the workload a bit more: Anyone working the maximum 30-hour shift should get an uninterrupted five-hour break for sleep after 16 hours.

The panel urged the ACGME to adopt the recommendations within two years. The independent Institute of Medicine provides advice to U.S. policymakers.

The government asked the institute to study the current caps. Violations of current limits are common and residents seldom complain, the committee found. While quality of life has improved, there's still a lot of burnout.

Sadun, a medical student at University of Southern California's Keck School of Medicine, added that her association hears many accounts from residents about how the current 80-hour work weeks in reality are 100-hour work weeks, with school administrators insisting that residents fill out time logs dishonestly.

What are your thoughts?

 

[meister]

Well I'm no resident yet but I have to admit the idea of guaranteed sleep during a 30 hour shift seems fair. But the idea of extending residency programs even more is kind of horrifying.

So I dunno.

 

[Jwax]

Well I'm no resident yet but I have to admit the idea of guaranteed sleep during a 30 hour shift seems fair. But the idea of extending residency programs even more is kind of horrifying.

So I dunno.

I'd rather be sleep deprived for 3 years than be well rested but still working 80 hours a week for 4 years. Wether or not that is what's best for patients is beyond me, although I believe there have been studies showing that there are a lot of medical errors associated with the constant trading off of patients from resident to resident once their shifts are over.

 

[psy]

Studies also showed that sleep deprived students exhibit the same mental acuity as a drunk person. I can live with longer residency. I'd rather be well rested and alert than have someone's life screwed up because I made a mistake from being sleepy.

 

[sirus_virus]

What kind of idiot buys into the theory that you need an extra year of residency to make up for 5 hours of sleep during 30 hour shifts? At what point will the medical community find some conscience and stop openly exploiting resident doctors?

 

[sexyman]

I think I am definitely more alert with 4-5 beers in me then when I havent slept for more than 20 hours...

How about we get our sleep and keep the residency length the same. It doesnt make a difference anyway lets be serious.

 

[masterofmonkeys]

I think I am definitely more alert with 4-5 beers in me then when I havent slept for more than 20 hours...

How about we get our sleep and keep the residency length the same. It doesnt make a difference anyway lets be serious.

here here! Enough of the guild system and indentured servitude.

And god forbid they ever move on the idea of taking residency down to 56 hour weeks and extending the length by 50%.

 

[Suaveness]

I'm not really sure since I haven't exactly experienced any of this, but I would certainly function better with more sleep, and I think I'd be ok with spending more time if need be so long as I wasn't a zombie.

 

[DocPsychosis]

Well I'm no resident yet but I have to admit the idea of guaranteed sleep during a 30 hour shift seems fair. But the idea of extending residency programs even more is kind of horrifying.

So I dunno.

Patient safety be damned. To hell with it, let's just turn 4-year residencies into a single 2-year, 16000-hour shift and whip right through that bad boy.

 

[meister]

Patient safety be damned. To hell with it, let's just turn 4-year residencies into a single 2-year, 16000-hour shift and whip right through that bad boy.

I'm pretty sure you have stairs in your house t/f

 

[diosa428]

5 hours of uninterrupted sleep would be fantastic... but I have no idea how residency programs would swing it. The only use they have for making residents stay in house for 30 hours is if you work day --> night --> 1/2 day. 16 hours in would put you at about midnight, give or take. Programs are not going to want to have someone come in from midnight --> 5am to cover for the sleeping doctor. The only real solution to this would be shifts...

 

[smq123]

How about we get our sleep and keep the residency length the same. It doesnt make a difference anyway lets be serious.

.

Yes it does.

The residencies that are most affected by it are the surgical residencies.

The problem with being a surgeon or an OB/gyn is that you MUST have someone covering the hospital at all times. Always. You don't want to be in a head-on car crash during a time when there isn't a trauma surgeon to be found in the entire hospital campus.

Furthermore, the problem is worse because, in surgery and in OB/gyn, you MUST learn by actually doing procedures. You can't read about procedures, or watch them on a video. They're trying to create surgical simulators with Wii game systems, etc., but that's not feasible either.

When you're sleeping, you're not doing procedures, and you're not learning. That means that when you graduate residency and start seeing patients on your own, you are screwed. If you do 100 procedures, you have less experience than your colleague, who graduated with 450 procedures under his belt. If something goes wrong, and you've never seen that complication before, your patient is f***ed. Not a good feeling.

While I CERTAINLY can attest to the importance of sleep, you must also recognize that it will take a toll on the quality of your training, particularly if you don't increase the number of years of residency.

 

[StevenRF]

We had an interesting discussion today with the one of the department heads who was also our team attending. He was thinking that the most likely conclusion is that we all end up moving to shift work like in EM to coordinate the hours properly, but also a likely an increase in hospitalists/NPs to make up the difference since hospitals aren't getting permission for more residency slots given patient loads.

The truth of the matter is that residents are free labor, pure and simple, and any of these cuts affects the bottom line. They don't give two ***** about anything else, and you are deluding yourself if you think otherwise. If you look at the typical hospital setup, the attendings show up for a bit, delineate the work, and the resident scut monkey's implement it. That single attending then gets to bill for all of those patients/cpt's for the hospital. How much will throughput fall off if the attending had to do everything? Also, there are massive inefficiencies throughout the hospitals that are never addressed because they are taken care of with cheap labor.

As for a sudden loss of cases, patients, learning experiences... bollocks. To make case requirements for accreditation they are finally going to have to offload the scut to someone they have to pay. That will save hours a day easily. As for surgery, most programs are already starting to implement case simulations to attain initial proficiency, starting cases during pgy1 and 2 instead of pure scut for 2 years, and having some method of measuring proficiency before moving on. Oh yea, most of those studies on improving medical errors are crap as well. On the one hand rates are fairly low, so improved sleep isn't going to solve everything. On the other, NO ONE does just 80 hours. I've seen PD's straight up tell residents to lie, and some programs have gotten shut down for it. Also, residents in other countries are attaining skills without spending 80-100 hrs in the hospital per week.

 

[Blesbok]

I think 5 might be a little excessive though. At that point you might as well not have call. 2 would be more realistic IMO.

 

[sirus_virus]

.

Yes it does.

The residencies that are most affected by it are the surgical residencies.

The problem with being a surgeon or an OB/gyn is that you MUST have someone covering the hospital at all times. Always. You don't want to be in a head-on car crash during a time when there isn't a trauma surgeon to be found in the entire hospital campus.

Furthermore, the problem is worse because, in surgery and in OB/gyn, you MUST learn by actually doing procedures. You can't read about procedures, or watch them on a video. They're trying to create surgical simulators with Wii game systems, etc., but that's not feasible either.

When you're sleeping, you're not doing procedures, and you're not learning. That means that when you graduate residency and start seeing patients on your own, you are screwed. If you do 100 procedures, you have less experience than your colleague, who graduated with 450 procedures under his belt. If something goes wrong, and you've never seen that complication before, your patient is f***ed. Not a good feeling.

While I CERTAINLY can attest to the importance of sleep, you must also recognize that it will take a toll on the quality of your training, particularly if you don't increase the number of years of residency.

I disagree. Training you receive during sleep deprived hours are only good for wiping your rectal area. Especially when you consider that your motivation, comprehension, and creativity are all impaired at that point. Not to mention the lives being endangered. You take away sleep deprivation and you will still have very competent surgeons. The folks in Europe have figured that out a long time ago, while we are here deceiving ourselves with our macho nonsense.

 

[smq123]

As for surgery, most programs are already starting to implement case simulations to attain initial proficiency, starting cases during pgy1 and 2 instead of pure scut for 2 years, and having some method of measuring proficiency before moving on.

It isn't pure scut for the first two years, though. Do you suggest that a PA or an NP should be running the ICU - overseeing a dozen patients, many of whom have VDRF/sepsis/DIC? Or that a PA/NP should be seeing all consults that come in to the ER? Or that a PA/NP should be running traumas?

And simulation takes you only so far. It doesn't help with any open cases, or any of the unusual cases that you may run into. It's one thing to do a forceps delivery on a slim rubber model....and another to do a forceps delivery on an obese woman who is screaming, crying, and writhing around the bed uncontrollably.

*****​

This is the most useless report ever. Great, so they want to revamp the residency system....except....

The main implication of the economic model is that the proposed reform is costly - $1.7 billion in 2008 dollars. The costs of achieving these reforms relative to the total costs of graduate medical education would be approximately 9 percent of current GME payments now borne by all payers ($1.7 billion of the $18.7 billion estimated for 2003 by Wynn, 2006)

Wow....$1.7 billion?!? Where, exactly, is that $1.7 billion going to come from?

Determining the financial capacity of teaching institutions to absorb some portion of these costs was beyond the scope of the study.

Ooh, helpful.

If some hospitals are unable to absorb these costs fully, it could impact other parts of service delivery.... Without sufficient staff, patients also might have decreased access to hospital services.

But....weren't all these changes supposed to HELP patient safety?

 

[DoctaJay]

l'm all for sleep but I'm more for continutity. Sometimes you need to be up for 20 hours straight to see a patient from start to end. If we switch to the system of shifts, then the patients will start complaining that the new doctor that came on shift had no idea what the prevous doctor did, and he/she is not as nice either, and blah blah blah blah. People are never happy. I would rather see what are start to completion, and if that means I have to stay up then i'm cool with that. I think there will be just as many things that fall through the cracks when residents change shifts...something will be missed.

 

[howelljolly]

Think outside the box people.

This isnt meant to be insulting (as apparently everything I say is) - just a bit of direction for everyone... If you want to make good suggestions, look at what other countries are doing. Theres no need to re-invent the wheel.

If one resident is sleeping for 5 hours, another resident can be awake. Its not like they have to sleep together. If something interesting or educational is happening, someone can wake you up. The once in a blue moon that this happens, maybe they'll forget the "uninterrupted" part.

Naptime does not have to be at 5am, when everyone is having their MI, or at 7am when everyone is having their elective surgery.

Theres no reason to throw the baby out with the bathwater. Signoffs cause medical mistakes, so we should work longer, and signoff less. What say we generate ways to standardize and impove signoff?

Surgery and procedeures are not done for 30 hours continuously by a resident. You cant learn surgery in your sleep, but I'd argue that you cant learn much of anything in your sleep.. procedures or otherwise. The need/indication/number of procedures will not change. The nurse is not going to start putting in the central lines because the resident needs their snoozywoozy. The time at which the procedures are perfomed is what will change.

Lateral Thinking, people!

My own dos pesos... I think 5 hours might be a bit excessive. I think we can function like brand-spanking-new on 4 hours of continuous sleep. Other things, such as rounds. didactics, and signoffs will be MUCH more useful for everyone if this happens. Imagine LEARNING something during grand rounds rather than dozing off! What you lose from one hand will be gained in the other.
I think if that 4 hours of sleep is intentionally worked into the schedule, and a paradigm shift happens regarding the superman image of a resident into a doctor in training, the housestaff (and the nurses who call for nonsense at 3am) will simply have to learn to manage time differently.

 

[smq123]

If one resident is sleeping for 5 hours, another resident can be awake. Its not like they have to sleep together. If something interesting or educational is happening, someone can wake you up. The once in a blue moon that this happens, maybe they'll forget the "uninterrupted" part.

According to the recommendations, whenever you are woken up for something interesting or educational, you have to document this, and justify why. That is just more paperwork (i.e. "scutwork") that you'll have to do, on top of your mountains of OTHER paperwork.

Second of all, how often do you think that, as a resident, you're going to be woken up when something "interesting" is happening? Because that happens SOOO often to med students who are on L&D night float or night call for trauma.....

I'd think the more likely scenario is that the resident who is awake is going to totally take charge of this interesting or educational situation, and wake up the sleeping resident when this is all over. Not necessarily out of spite, but...it's just how it happens, usually.

The nurse is not going to start putting in the central lines because the resident needs their snoozywoozy. The time at which the procedures are perfomed is what will change.

But the measures are supposed to HELP patient care....and delaying a central line placement is not good patient care!

When a difficult intubation needs to happen at 3:17 AM, it's going to have to happen at 3:17 AM. That's all there is to it. Someone needs an emergent trach at 1:48 AM, then that person is going to get an emergent trach at 1:48 AM.

 

[diosa428]

.

Yes it does.

The residencies that are most affected by it are the surgical residencies.

The problem with being a surgeon or an OB/gyn is that you MUST have someone covering the hospital at all times. Always. You don't want to be in a head-on car crash during a time when there isn't a trauma surgeon to be found in the entire hospital campus.

Furthermore, the problem is worse because, in surgery and in OB/gyn, you MUST learn by actually doing procedures. You can't read about procedures, or watch them on a video. They're trying to create surgical simulators with Wii game systems, etc., but that's not feasible either.

When you're sleeping, you're not doing procedures, and you're not learning. That means that when you graduate residency and start seeing patients on your own, you are screwed. If you do 100 procedures, you have less experience than your colleague, who graduated with 450 procedures under his belt. If something goes wrong, and you've never seen that complication before, your patient is f***ed. Not a good feeling.

While I CERTAINLY can attest to the importance of sleep, you must also recognize that it will take a toll on the quality of your training, particularly if you don't increase the number of years of residency.

I find it interesting that you seem to think surgery and ob/gyn are the only specialties affected by this. ALL specialties have emergencies in the middle of the night, and ALL specialties must be covered all night long. And ALL residents must learn to manage emergencies in their respective specialty. Sure maybe if you end up going into private practice dermatology you might never need to know how to handle necrotizing fasciitis, but that doesn't mean you shouldn't learn how to handle it in residency. And internal medicine residents, psych residents, peds residents, etc, all work all night long just like surgery residents and ob/gyn residents...

Additionally, surgeons and ob/gyns are not the only doctors that perform procedures and need to get a certain number under their belt.

 

[diosa428]

Think outside the box people.

This isnt meant to be insulting (as apparently everything I say is) - just a bit of direction for everyone... If you want to make good suggestions, look at what other countries are doing. Theres no need to re-invent the wheel.

If one resident is sleeping for 5 hours, another resident can be awake. Its not like they have to sleep together. If something interesting or educational is happening, someone can wake you up. The once in a blue moon that this happens, maybe they'll forget the "uninterrupted" part.

Naptime does not have to be at 5am, when everyone is having their MI, or at 7am when everyone is having their elective surgery.

Theres no reason to throw the baby out with the bathwater. Signoffs cause medical mistakes, so we should work longer, and signoff less. What say we generate ways to standardize and impove signoff?

Surgery and procedeures are not done for 30 hours continuously by a resident. You cant learn surgery in your sleep, but I'd argue that you cant learn much of anything in your sleep.. procedures or otherwise. The need/indication/number of procedures will not change. The nurse is not going to start putting in the central lines because the resident needs their snoozywoozy. The time at which the procedures are perfomed is what will change.

Lateral Thinking, people!

My own dos pesos... I think 5 hours might be a bit excessive. I think we can function like brand-spanking-new on 4 hours of continuous sleep. Other things, such as rounds. didactics, and signoffs will be MUCH more useful for everyone if this happens. Imagine LEARNING something during grand rounds rather than dozing off! What you lose from one hand will be gained in the other.
I think if that 4 hours of sleep is intentionally worked into the schedule, and a paradigm shift happens regarding the superman image of a resident into a doctor in training, the housestaff (and the nurses who call for nonsense at 3am) will simply have to learn to manage time differently.

I don't really understand what solution you're offering here... yes, one resident could sleep while the other is awake... but isn't the whole point of having an on-call resident that there's... only one on-call resident? So that everyone else can go home? And even if you leave the resident AND the intern on, the intern may or may not be able to let the resident to sleep for 5 hours b/c s/he may or may not be able to handle the floor by themselves...

In addition, sure the resident doesn't HAVE to sleep from midnight until 5 am, but the guidelines state that the resident has to have a break after 16 hours... since most shifts start in the morning, 16 hours would fall around midnight. I suppose a resident could work 30 hours starting at night, but it would make more sense to just have a night float.

I also don't quite understand how you think that any of this would minimize handoffs...

And I agree with smq that you can't just tell everyone to leave the resident alone for 4-5 hours. Medical emergencies happen when they happen. That's the whole point of having an on-call doctor.

 

[smq123]

I find it interesting that you seem to think surgery and ob/gyn are the only specialties affected by this. ALL specialties have emergencies in the middle of the night, and ALL specialties must be covered all night long.

a) I never said that surgery and OB/gyn are the "only" specialties affected by this. They're just the ones that would be most affected.

b) Not all specialties have emergencies in the middle of the night, and certainly not all specialties "must" be covered all night long.

Anesthesia and Emergency Medicine is already designed to be shift work. That's not as huge of a deal.

Derm, PM&R, and path don't really have emergencies. Particularly not path.

Sure maybe if you end up going into private practice dermatology you might never need to know how to handle necrotizing fasciitis, but that doesn't mean you shouldn't learn how to handle it in residency.

Where in this country do derm residents handle nec fasc?

Surgery (usually trauma and/or plastics) handles necrotizing fasciitis. Since it IS an emergency, and the only real treatment is surgical debridement, it will be handled by a surgeon. Dermatologists can't do major surgical debridements, and if you left it in their hands, the patient would almost certainly die. The derm consult (in the rare event that you'd consult derm and not, for instance, ID) usually swings by in the morning.

Similarly, Fournier's is handled either by urological surgeons or general surgeons. Not dermatologists.

And internal medicine residents, psych residents, peds residents, etc, all work all night long just like surgery residents and ob/gyn residents...

Additionally, surgeons and ob/gyns are not the only doctors that perform procedures and need to get a certain number under their belt.

IM, psych, and peds residents work all night long doing admissions. That can certainly be done in shift work, without losing out on procedures.

While IM, peds, and psych residents need a certain number of procedures in order to graduate, the number of each procedure that they need is almost laughably small in comparison. The procedures also tend to be less invasive and easier to master.

For instance, at our hospital, an internal medicine resident needs THREE spinal taps in order to be "certified." Compare that to a surgery resident who, after just 3 small bowel resections, is definitely not competent enough to perform them solo. And would you want your OB to do an amniocentesis on you, knowing that she has only done three in her entire career?

 

[turkeyjerky]

According to the recommendations, whenever you are woken up for something interesting or educational, you have to document this, and justify why. That is just more paperwork (i.e. "scutwork") that you'll have to do, on top of your mountains of OTHER paperwork.

Second of all, how often do you think that, as a resident, you're going to be woken up when something "interesting" is happening? Because that happens SOOO often to med students who are on L&D night float or night call for trauma.....

I'd think the more likely scenario is that the resident who is awake is going to totally take charge of this interesting or educational situation, and wake up the sleeping resident when this is all over. Not necessarily out of spite, but...it's just how it happens, usually.



But the measures are supposed to HELP patient care....and delaying a central line placement is not good patient care!

When a difficult intubation needs to happen at 3:17 AM, it's going to have to happen at 3:17 AM. That's all there is to it. Someone needs an emergent trach at 1:48 AM, then that person is going to get an emergent trach at 1:48 AM.

Leave it to med students to rally against a policy that would significantly better their lives over the next several years. If there's a more masochistic group of people in this country, I've yet to see it.

You're seriously defending a policy that's set up to bolster the hospitals' bottom lines with cheap, excuse me, free labor?

God forbid they have to hire someone to role the patients down to radiology!

 

[diosa428]

a) I never said that surgery and OB/gyn are the "only" specialties affected by this. They're just the ones that would be most affected.

Granted I've only done a surgery rotation at my home institution, but surgery would be one of the LEAST affected residencies here. The residents work in day and night shifts. The interns work 12 hour shifts so that during the day there is one intern per team on the floor, and at night there is approx one intern for every 3 teams on the floor. The residents who are responsible for a team during the day are covered at night by SARs doing a night float rotation. Usually the only people working 30 hour shifts are the fellows and the attendings and whoever is on the trauma team.

IM, psych, and peds residents work all night long doing admissions. That can certainly be done in shift work, without losing out on procedures.

While IM, peds, and psych residents need a certain number of procedures in order to graduate, the number of each procedure that they need is almost laughably small in comparison. The procedures also tend to be less invasive and easier to master.

For instance, at our hospital, an internal medicine resident needs THREE spinal taps in order to be "certified." Compare that to a surgery resident who, after just 3 small bowel resections, is definitely not competent enough to perform them solo. And would you want your OB to do an amniocentesis on you, knowing that she has only done three in her entire career?

No, but I wouldn't want someone doing an LP on me, or a paracentesis, knowing they had only done 3 in their entire career either. But it's not just about procedures. It's about knowledge... knowing how to manage an emergency when one arises, etc. Furthermore, learning how to admit patients and work them up properly is exactly what you need to know how to do in those specialties, so taking away that is probably just as detrimental to an internist as telling a surgeon they can't operate. Additionally, IM residency is... 3 years. Peds residency is... 3 years. Surgery residency is 5 years - aka, almost twice as long. Add a fellowship to that - 8 years.

Edit: I just did the math. If you are doing internal med, and you don't do your night admissions... let's say a team caps at 7 new admits b/c that's what our teams cap at. So let's just say for argument's sake that, by not doing night float, you miss out on 5 new admits b/c you wouldn't always cap, some would come in during the day, etc. So you're on gen med for a month and you're Q4 call. So you would be missing out on 7.5 call nights, which means that you'd be missing out on 37.5 admits in a month. And then, let's say you do 9 gen med months as an internal medicine resident - that's 337.5 admits that you would miss out on in your training.

 

[78222]

Leave it to med students to rally against a policy that would significantly better their lives over the next several years. If there's a more masochistic group of people in this country, I've yet to see it.

You're seriously defending a policy that's set up to bolster the hospitals' bottom lines with cheap, excuse me, free labor?

God forbid they have to hire someone to role the patients down to radiology!

Residency is about training you to be a good physician, not to make sure you get enough beauty sleep. If you don't want to work 80 hours a week, don't go into a specialty that requires that kind of committment. I tend to agree with smq123, this will hurt surgical specialties the most and I really do think it will affect the quality of surgeons produced (especially since in surgery, your practice is limited to cases you performed during residency. I think it would serve us well and our patients to quit viewing hard work in residency/medschool as being such a bad thing when it largely determines how competent a physician we'll be.

 

[Habeed]

The feeling I get here is that most posters are drinking the koolaid.

The simple equation is this : long periods without sleep change the chemistry of the brain, and cause many other poorly understood changes in neuron function. No drug exists that can reverse these changes : only sleep works to make an exhausted person effective again.

No amount of training or practice changes what the brain does when it is subject to sleep deprivation. I strongly suspect that the only adaptation is behavioral : you get "used" to being tired, and you with practice you try to simplify your medical decision making so that you usually still make the right call even when exhausted.

Ergo, to prevent doctors screwing up, they need to sleep.

Once you acknowledge reality, it then becomes a problem that needs to be solved. Many posters have suggested tons of ways that things could be tweaked to make them more efficient.

Ultimately, it is going to cost more money than is being spent now to make changes happen.

Oh, and one final thing : 1.7 billion is 0.4 percent of medicare's budget (medicare funds most GME)

 

[smq123]

Leave it to med students to rally against a policy that would significantly better their lives over the next several years.

And leave it to the pre-clinical student to a) vigorously defend recommendations that he hasn't carefully read yet, and b) to only think in the short term.

AT SOME POINT, these recommendations are going to bite you in the *****. So it makes your life marginally easier in residency; great. What about when you're a senior resident, and have to take extra calls because the call schedule turns over so quickly? What about when you're a fellow, and have to pick up extra shifts, because the residents can't go over hours, but the hospital can't be staffed only by MS3s? What about when you're an attending, and covering trauma all alone because your residents are over hours?

I know even residency is kind of off in the horizon for you, but someday you'll be the attending, cursing those residency work hour requirements that make YOUR life harder.

Granted I've only done a surgery rotation at my home institution, but surgery would be one of the LEAST affected residencies here. The residents work in day and night shifts. The interns work 12 hour shifts so that during the day there is one intern per team on the floor, and at night there is approx one intern for every 3 teams on the floor. The residents who are responsible for a team during the day are covered at night by SARs doing a night float rotation. Usually the only people working 30 hour shifts are the fellows and the attendings and whoever is on the trauma team.

I think you're seeing this with blinders on. Again, like you said, you've only observed how a surgery service works at your home institution.

Surgery would, without a doubt, be one of the MOST affected residencies.

a) If you are at an institution with nightfloat, there are most likely enough residents than you can shift things around without TOO much hassle. (Well, even that's debateable, but whatever.)

Smaller institutions, with fewer residents, would be affected to the point where they would probably have to shut down.

b) Again, like many of the other posters here, you haven't read the requirements. It isn't an interrupted 30 hour shift - "any shift over 16 hours must have a 5 hour protected sleep break that counts toward 80 hours." There is a standing 30 hour shift LIMIT. Furthermore, they prohibit Q2 call.

While few residents at your hospital work 30 hours, I can GUARANTEE that MANY of them work 24. Trying to space out everyone's mandatory "5 hour sleeping break" is going to be REALLY tough.

Furthermore, the new regulations would have a maximum of 4 night shifts in a row, and a required 48 hours off after those 4 night shifts.

Nightfloat, even at its most benign, is 5 night shifts (covering Sun, Mon, Tues, Wed, and Thurs.). So even nightfloat, as we know it, would be impossible.

Are you still going to stand by your statement that surgery would be minimally affected?

c) Then, there's the issue of prohibiting Q2 call. The problem with that is what to do when nightfloat gets their weekend off. Who covers the hospital? The other residents take call, obviously....but one of those groups of on-call residents is usually Q2. They cover Friday night, and then come in again on Sunday.

If they prohibit Q2 call, they're going to need THREE groups of residents to cover the weekend. In a program that only has four residents, that means 3/4 weekends in the hospital. That would really, really, suck.

 

[smq123]

No, but I wouldn't want someone doing an LP on me, or a paracentesis, knowing they had only done 3 in their entire career either. But it's not just about procedures. It's about knowledge... knowing how to manage an emergency when one arises, etc. Furthermore, learning how to admit patients and work them up properly is exactly what you need to know how to do in those specialties, so taking away that is probably just as detrimental to an internist as telling a surgeon they can't operate. Additionally, IM residency is... 3 years. Peds residency is... 3 years. Surgery residency is 5 years - aka, almost twice as long. Add a fellowship to that - 8 years.

Knowledge is easier to get in a shorter time.

a) The number of procedures that are now done by general surgeons (or their subspecialists) is astounding.

b) Procedures take longer to master, there's just no way around it.

For instance, how long did it take you to get a basic sense of how to run a trauma? Maybe an hour or two.

How long did it take you to do a decent sub-Q closure while on your gen surg rotation? Probably a few weeks, at a minimum.

Oh, and one final thing : 1.7 billion is 0.4 percent of medicare's budget (medicare funds most GME)

Thanks for that non-sequitor.

That still doesn't answer the question of WHERE THE MONEY IS GOING TO COME FROM.

I'm sure that Medicare has a real good use for that $1.7 billion!

 

[diosa428]

While few residents at your hospital work 30 hours, I can GUARANTEE that MANY of them work 24. Trying to space out everyone's mandatory "5 hour sleeping break" is going to be REALLY tough.

Well, since you obviously haven't been to my home institution I find it ironic that you're GUARANTEEING how much my residents work. They do not, in fact, work 24 hour shifts. They are there 6 DAYS a week. They do not work overnight unless they are on trauma.

Are you still going to stand by your statement that surgery would be minimally affected?

I never said that surgery would be minimally affected. I said that I did not believe that it would be the MOST affected. I think that there are other specialties out there that would have just as much taken away from them in terms of what the residents are supposed to get out of residency.

c) Then, there's the issue of prohibiting Q2 call. The problem with that is what to do when nightfloat gets their weekend off. Who covers the hospital? The other residents take call, obviously....but one of those groups of on-call residents is usually Q2. They cover Friday night, and then come in again on Sunday.

If they prohibit Q2 call, they're going to need THREE groups of residents to cover the weekend. In a program that only has four residents, that means 3/4 weekends in the hospital. That would really, really, suck.

Again, all of these problems are program-specific. You can't tell me that my arguments are illogical because they only apply to my program and then present me with arguments that only apply to programs with 4 residents... yes, obviously some programs would suffer more than others - but wouldn't that again, be true in MULTIPLE specialties? Again, my point isn't that surgery wouldn't be affected, it's that everyone is going to be affected.

 

[diosa428]

Knowledge is easier to get in a shorter time.

a) The number of procedures that are now done by general surgeons (or their subspecialists) is astounding.

b) Procedures take longer to master, there's just no way around it.

For instance, how long did it take you to get a basic sense of how to run a trauma? Maybe an hour or two.

How long did it take you to do a decent sub-Q closure while on your gen surg rotation? Probably a few weeks, at a minimum.

Ummm ok well it may take a couple of hours to get a "basic sense" of how to run a trauma, but it takes about 5 minutes to get a "basic sense" of how to do a sub-Q closure. You're comparing apples to oranges here. Having a "basic sense" of how to run a trauma is not the same as actually running the trauma.

And, again, surgery residency is already LONGER than other residencies for the reasons you just stated above.

 

[howelljolly]

By my previous post I wasnt trying to propose any solutions, only point out that the system chooses to overwork the residents, and it doesnt have to.

I find it interesting that you seem to think surgery and ob/gyn are the only specialties affected by this. ALL specialties have emergencies in the middle of the night, and ALL specialties must be covered all night long. And ALL residents must learn to manage emergencies in their respective specialty. Sure maybe if you end up going into private practice dermatology you might never need to know how to handle necrotizing fasciitis, but that doesn't mean you shouldn't learn how to handle it in residency. And internal medicine residents, psych residents, peds residents, etc, all work all night long just like surgery residents and ob/gyn residents...

Additionally, surgeons and ob/gyns are not the only doctors that perform procedures and need to get a certain number under their belt.

I agree

a)
While IM, peds, and psych residents need a certain number of procedures in order to graduate, the number of each procedure that they need is almost laughably small in comparison. The procedures also tend to be less invasive and easier to master.

?

Not like it matters, but you lost me there.

Maybe my surgery rotation was unique, but the on-call surgery team, after working all day, spent the whole night following up on things, and doing things that they didnt get around to during the day. And the senior resident actually slept for a good 5 hours every night. What I see surgery residents doing most is pushing stretchers to radiology, and drawing blood. I think they can hire someone else to do that.

Most hospitals in the country do not have residents at all. So these changes making it harder for attendings is a moot point.

Ive seen a case of fourniers, which came in at night, and in that case, the surgery team didnt handle anything emergently. They screamed and cried, and waited for the attending urologist to come in.

If central lines and chest tubes need to be placed emergently, the overworked and un-rested surgical resident is not the only one who can do that. Every single specialty which has overnight call (including Psych to some extent) is expected to be proficient at emergent procedures and ACLS. In fact, any hospital based speciality... Emergency Med, IM (which is where hospitalists come from), Critical Care... needs to be more proficient at these procedures than your garden variety surgeon, who only consults and operates. Your observation that surgical residents have more of these procedures to log doesnt pan out. In practice, a surgoen will never again do an LP... ER docs and neurologists will..... if they cant get it they'll call anesthesia. Unless they go into Trauma/SCC they'll never again do a cric... but an EM doc will. Virtually all bedside procedures are done by non-surgeons.

That appy that comes in at 3am, will take more than an hour to get into the OR, and it doesnt take a brain surgeon (hehehe) to operate on that. And how often does that happen? And when it does isnt the surgical resident as indisposed as if he were asleep?

Most procedures are not emergent. Most emergencies are not emergent. You usually dont need an LP at 4am. And in fact, if such a patient is crashing, the last thing he needs is an LP. I see a lot of residents getting all caught up in emergencies, while the attending knows better. Ive seen a patient in SVT, with the residents getting ready to go ACLS on his @$$. The attending told them to stop, and called the cardiologist for an elective cardioversion.

Basically, I think you are painting a VERY glorified picture of surgery which I did not see in practice.

 

[howelljolly]

Sub-Q closures dont have to happen at 3am on 30 hours of no sleep.

 

[howelljolly]

Residency is about training you to be a good physician, not to make sure you get enough beauty sleep. If you don't want to work 80 hours a week, don't go into a specialty that requires that kind of committment. I tend to agree with smq123, this will hurt surgical specialties the most and I really do think it will affect the quality of surgeons produced (especially since in surgery, your practice is limited to cases you performed during residency. I think it would serve us well and our patients to quit viewing hard work in residency/medschool as being such a bad thing when it largely determines how competent a physician we'll be.

I can't prove it, but I'll bet that this is not the case. If you've been a surgeon for 30 years, you can only use the techniques that were available 30 years prior? Theres no CME for surgeons? What about reconstructive plastics or oncologic surgery, where no two cases are even remotely the same? I think thats just plan nonsense.

I was in the OR with an orthopedic surgeon with 10 or so years of experience, and just before the surgery, he sat in the locker room and read a recent journal article about some new modification to the procedure, and he applied it right then and there. I was also in on two other surgeries, where two attendings were scrubbed in, because one was teaching the procedure to the other. In fact, in one of those, the teacher had 10 years of experience, and the "student" had 25 years on the job.

We signed up for a lifetime of on-the-job training.

Interesting history trivia...
The first appendectomy that was ever performed onboard a US military submarine during WW-II was done by a Navy pharmacy tech. He was the only medically trained person on board. He had seen one or two of them done in is civilian work as an EKG tech.

So, its not brain surgery.

 

[78222]

I can't prove it, but I'll bet that this is not the case. If you've been a surgeon for 30 years, you can only use the techniques that were available 30 years prior? Theres no CME for surgeons? What about reconstructive plastics or oncologic surgery, where no two cases are even remotely the same? I think thats just plan nonsense.

I was in the OR with an orthopedic surgeon with 10 or so years of experience, and just before the surgery, he sat in the locker room and read a recent journal article about some new modification to the procedure, and he applied it right then and there. I was also in on two other surgeries, where two attendings were scrubbed in, because one was teaching the procedure to the other. In fact, in one of those, the teacher had 10 years of experience, and the "student" had 25 years on the job.

We signed up for a lifetime of on-the-job training.

Interesting history trivia...
The first appendectomy that was ever performed onboard a US military submarine during WW-II was done by a Navy pharmacy tech. He was the only medically trained person on board. He had seen one or two of them done in is civilian work as an EKG tech.

So, its not brain surgery.

If you don't believe me, go ask surgeons at your hospital. If you don't learn a procedure during residency your options are either to
A) find someone in your group who does that kind of surgery and do several surgeries with them (if they let you).
B) Do a fellowship
Surgery is about repetition and honing your skill and residency is about assuring that when you finish you are ready to handle whatever is thrown at you in the real world. Would you want someone operating you if they've only done a few cases during their training? Studies have shown that the mortality of a Whipple is much lower if the surgeon performed 8 (I think) over the course of the last year.
Sure you continue to learn and apply new information after residency but if you start off at a deficiency because someone decided you were required to get X numbers of hours off in a shift and only work X number of hours a week you will be behind the curve and doing a disservice to yourself and your patients.

 

[smq123]

Well, since you obviously haven't been to my home institution I find it ironic that you're GUARANTEEING how much my residents work. They do not, in fact, work 24 hour shifts. They are there 6 DAYS a week. They do not work overnight unless they are on trauma.

I had this long post typed...and then SDN lost it. <sigh>

- How do they "not work 24 hour shifts," but yet still work overnight?

- Even if they work 6 days a week, there is still the question of who covers the hospital at night when nightfloat gets their mandatory day/days off. Unless you're trying to say that they're on-call every weekend...in which case they ARE working 24 hour shifts.... You're not making much sense.

Or else you're saying that nightfloat is on for 7 nights a week....in which case I wouldn't say that too publically, as that is a clear violation of work-hours.

- Actually, now that I think about it, IM at many large institutions would not be affected AT ALL. Since most IM programs went to a combination of short call and night float, IM residents rarely (if ever) work more than 24 hours in a row. In fact, most IM residents tend to cap out at 16 hours in a row, so they wouldn't be affected by the new regulations at all.

Even the smaller community programs could adjust their resident work hours fairly easily. What would probably end up happening is that the on-call resident would take a "break" in the mid-afternoon, and then come back on duty a few hours later. That way, since they haven't worked 16 hours in a row, they'd be "exempt" from the required 5-hour sleeping break. It'd be a little awkward, but it would be doable.

So I do not buy your argument that surgery would be equally affected as other specialties. Other specialties can adapt more easily than surgery or OB could.

And the senior resident actually slept for a good 5 hours every night.

Yeah, the senior residents sleep.

But under the new regulations, the senior residents would sleep less, because they'd have to help cover while the junior residents get their required 5 hours of sleep. The IOM report openly admits that senior/chief residents and fellows would most likely have to pick up the slack for those five hours. While it might be nice as a junior resident, you'll probably hate it when you're a chief!

What I see surgery residents doing most is pushing stretchers to radiology, and drawing blood. I think they can hire someone else to do that.

That has less to do with the ACGME regulations, and more with the nature of your region. It's a separate issue, in my opinion.

I would be willing to bet that you did your surgery rotation in NYC, which is a widely known exception. NYC nurses are heavily unionized, and through these unions have managed to excuse their nurses from tasks such as drawing blood, doing EKGs, and pushing stretchers. That has less to do with resident regulations, and more with the nursing unions in that particular area of the country.

This doesn't happen that often, even in hospitals just a couple of hours north or south.

If central lines and chest tubes need to be placed emergently, the overworked and un-rested surgical resident is not the only one who can do that. Every single specialty which has overnight call (including Psych to some extent) is expected to be proficient at emergent procedures and ACLS. In fact, any hospital based speciality... Emergency Med, IM (which is where hospitalists come from), Critical Care... needs to be more proficient at these procedures than your garden variety surgeon, who only consults and operates. Your observation that surgical residents have more of these procedures to log doesnt pan out.

You're ignoring the issue of territory/politics.

Surgical patients get trached by surgeons - i.e. someone from either the primary team or from the SICU (which is staffed by surgeons). It's a question of responsibility for YOUR patient, which YOUR team is taking care of....i.e. not coming in on rounds one morning and being like, "What random ER resident decided to intubate Mr. Jones?!??!"

It's the same reason why, generally, if you didn't put a JP drain in, then you don't d/c it. You don't know why the primary team put the JP in, when they did, how long it's supposed to be in there for, what it's draining, etc....so you do not touch it. You're not the primary team, so you don't have a lot of input as to the patient's plan.

 

[smq123]

I can't prove it, but I'll bet that this is not the case. If you've been a surgeon for 30 years, you can only use the techniques that were available 30 years prior? Theres no CME for surgeons?

Actually, a pre-med just asked this in the surgery forum.

CME does NOT guarantee proficiency new techniques. They show you the basics, but it's up to you to figure out how to either a) teach yourself proficiency (which is rare), or b) find someone who can really work with you to improve.

The first appendectomy that was ever performed onboard a US military submarine during WW-II was done by a Navy pharmacy tech. He was the only medically trained person on board. He had seen one or two of them done in is civilian work as an EKG tech.

So, its not brain surgery.

Well...obviously. Even OB/gyns (usually gyn-oncologists) do appendectomies, if indicated. It's not THAT hard to do.

But that's hardly the only case that a surgeon needs to know how to do.....

What about reconstructive plastics or oncologic surgery, where no two cases are even remotely the same?

That's the point I've been trying to make.

First of all, it's an exaggeration that "no two cases are even remotely the same." There are a limited number of variations, even in surgical oncology. You vary it depending on the particular patient, but the underlying technique is the same.

But that's WHY a surgery resident MUST do a large number of cases! In order to learn how to deal with the variety of patients that they will see as an attending.

 

[howelljolly]

If you don't believe me, go ask surgeons at your hospital. If you don't learn a procedure during residency your options are either to
A) find someone in your group who does that kind of surgery and do several surgeries with them (if they let you).
B) Do a fellowship
Surgery is about repetition and honing your skill and residency is about assuring that when you finish you are ready to handle whatever is thrown at you in the real world. Would you want someone operating you if they've only done a few cases during their training? Studies have shown that the mortality of a Whipple is much lower if the surgeon performed 8 (I think) over the course of the last year.
Sure you continue to learn and apply new information after residency but if you start off at a deficiency because someone decided you were required to get X numbers of hours off in a shift and only work X number of hours a week you will be behind the curve and doing a disservice to yourself and your patients.

Wow, so I guess I was seeing Option A.

just, wow

Im just thinking ........... thats not much different then a nurse-practitioner.

 

[78222]

Wow, so I guess I was seeing Option A.

just, wow

Im just thinking ........... thats not much different then a nurse-practitioner.

An older, but relevent article. The snipped part is regarding how surgeons dealt with learning the laparoscopic gallbladder when the procedure first became popular. Even now, a 4th yr Surgical Resident I worked with said he might end up doing a fellowship in laparoscopy because he didn't feel adequately prepared by our home institution - and I saw him do at least 10 lap choleys.

THE DOCTOR'S WORLD; When Patient's Life Is Price of Learning New Kind of Surgery

But the new technique, introduced by surgeons in France and the United States in 1989, is one of the few major procedures to come out of community hospitals. Its development and rapid acceptance caught most teaching hospitals off guard.

In a break from the usual collegiality in surgical teaching, some surgeons who performed it initially charged other surgeons $500 to watch them do one procedure. Responsible surgeons then practiced on animals and moved on to patients by assisting colleagues already skilled in the procedure. But some surgeons began doing the procedure on their own with little further training.

Soon courses were set up, often financed by equipment manufacturers as is customary. Most courses are conducted on weekends, where the tuition fees run up to $4,000. The curriculum and quality vary widely. Beyond lectures and videotaped instruction, the best courses offer hands-on practice on animals, often pigs.

 

[dilated]

Wow, so I guess I was seeing Option A.

just, wow

Im just thinking ........... thats not much different then a nurse-practitioner.

What? How do residents learn how to operate? By doing cases with someone who knows how to do the case. Attendings can do the exact same thing, except they already have lots of experience in other types of surgery to help them adjust faster.

Seriously, this is not unusual. There are so many technological developments that surgeons never saw in their residency that it's a pretty common thing. It's not like learning stops when you finish residency. I saw an old school CT attending with his junior partner (<5yrs from fellowship) regularly to pick up new techniques.

 

[howelljolly]

http://www.msnbc.msn.com/id/3032619/#28052268

 

[howelljolly]

What? How do residents learn how to operate? By doing cases with someone who knows how to do the case. Attendings can do the exact same thing, except they already have lots of experience in other types of surgery to help them adjust faster.

Seriously, this is not unusual. There are so many technological developments that surgeons never saw in their residency that it's a pretty common thing. It's not like learning stops when you finish residency. I saw an old school CT attending with his junior partner (<5yrs from fellowship) regularly to pick up new techniques.

I dunno. My brain works by concepts. And I think of surgery as similar to engeneering. I assumed that as an attending surgeon gains experience, they develop concepts and have a natural learning curve which enables them to absorb new techniques. After a while, they know the anatomy cold, and can see a new technique once... they make sense of it, conceptualize it as something theyve done a thousand times before, with a variation, and can do it. Example, if they've done a many lap-whatevers, and many open-whatevers... they can do a hand assisted lap whatever just by seeing how its done, and making the mental connections. I also figured that they learned from each other, as i mentioned before.

Anyway... Ive derailed this thread....

 

[maceo]

its just one big exploitation. To think that you need to extend residency longer for residents to get sleep. What a crock? and people are buying the bulls h i t.