New residency rules

[Perrotfish]

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Hey, thought y'all might be interested in this. The ACGME Task Force on Quality Care and Professionalism just released their new residency standards for 2011, which includes new work hour rules (interns can only work 16 hours at a time, and everyone else is limited to 28 continuous hours rather than 30). More importantly for military residents, though, is that fact that from this point onwards ALL moonlighting counts towards the residency's 80 hour cap, which basically makes moonlighting illegal for everyone that's not in their last year of either psych or PM&R. From a financial standpoint, this makes the military a better deal, since now there's nothing unique about the military's ban on moonlighting and even the most motivated civilian residents have no hope of cutting down on their debt before they finish their programs.

 

[met19]

Hey, thought y'all might be interested in this. The ACGME Task Force on Quality Care and Professionalism just released their new residency standards for 2011, which includes new work hour rules (interns can only work 16 hours at a time, and everyone else is limited to 28 continuous hours rather than 30). More importantly for military residents, though, is that fact that from this point onwards ALL moonlighting counts towards the residency's 80 hour cap, which basically makes moonlighting illegal for everyone that's not in their last year of either psych or PM&R. From a financial standpoint, this makes the military a better deal, since now there's nothing unique about the military's ban on moonlighting and even the most motivated civilian residents have no hope of cutting down on their debt before they finish their programs.

you can moonlight in an em residency even with the new rules.

 

[StarboardMD]

Are "proposed standards" actual regulations or just suggestions? If interns can't work more than 16 hours, we basically can't take call on the same day we work...

 

[SeminoleFan3]

Are "proposed standards" actual regulations or just suggestions? If interns can't work more than 16 hours, we basically can't take call on the same day we work...

According to the website, they're taking comments until the end of August, and voting in September for rules to go into effect July 2011.

 

[bobbyseal]

Maybe I misread this, but I thought that the 80 hr work week applied to moonlighting already. So, if you worked 70 hrs at the hospital in residency, you could only put in another 10hrs moonlighting.

Am I incorrect?

 

[backrow]

Maybe I misread this, but I thought that the 80 hr work week applied to moonlighting already. So, if you worked 70 hrs at the hospital in residency, you could only put in another 10hrs moonlighting.

Am I incorrect?

Looks like it only counted if you moonlighted within the same institution you were a resident.

 

[GtownCobra]

Why exactly can't we moonlight in the military?

For instance, I'm in my last year of residency in Pathology, and an Air Force FAPer at a civilian program.

I'm not lying when I say that there are times this year where I don't actually work much (we have 7 months of elective time used for board study). Basically I sit at my desk, read, and look at slides.

During the day, I have the opportunity to walk over to the medical examiner's office and participiate in death investigations, which I can get paid for. It also gives me the chance to do some extra autopsies, and since I've been approved to do a Forensic Pathology fellowship, I figure it's good experience.

Where's the harm in that? And how do we define "moonlighting?"

 

[GtownCobra]

And, out of curiosity, this is how the ACGME defines moonlighting:

Moonlighting: Patient care activities external to the educational program that residents/fellows engage in at sites used by the educational program (internal moonlighting) and other healthcare sites.

So does receiving compensation as an "assistant medical examiner" to perform autopsies even count as moonlighting?

 

[Saipan]

So does receiving compensation as an "assistant medical examiner" to perform autopsies even count as moonlighting?

So, I guess your point is that you're not really moonlighting if your patients are dead? Nice try.😍

How about IM residents and others? Would it only be moonlighting if the patient recovered? If the patient died, it wouldn't be moonlighting as it would fall into your grey area.

As to why you are allowed/not allowed to moonlight in the military....well, the last time I checked, an enlisted guy needed his commander's permission before he was allowed to"moonlight" at WalMart on the weekends. Even many civilian jobs require permission before you can take on other employment.

 

[RugbyJC]

And how do we define "moonlighting?"

This was what my program director had told me last year after I discovered I accidentally had moonlit. She said that if you accept ANY compensation outside of your DOD paycheck, it can be considered moonlighting. This includes jobs completely NOT related to medicine, which was my case. Never went as far as looking it up in anything but our training manual, so this information might not be the most accurate, but residents in other departments have confirmed that this applies to them as well.

 

[DrMetal]

Hey, thought y'all might be interested in this. The ACGME Task Force on Quality Care and Professionalism just released their new residency standards for 2011, which includes new work hour rules (interns can only work 16 hours at a time,

How do they keep tabs on these hours??? Suppose I'm on my 16th hour and I wanna stay at the hospital to get some labs, or I have patient coding, whatever. Is my PD gonna send me home if I tell him I've already worked 16 hours? What's to stop someone from lying, and saying they've only worked 12 hours, so they can stick around to tend to something urgent or see an interesting case?

In other words, is this all just gun-decked on paper with a wink wink, or are have they started to hand out time cards?

 

[Mirror Form]

How do they keep tabs on these hours??? Suppose I'm on my 16th hour and I wanna stay at the hospital to get some labs, or I have patient coding, whatever. Is my PD gonna send me home if I tell him I've already worked 16 hours? What's to stop someone from lying, and saying they've only worked 12 hours, so they can stick around to tend to something urgent or see an interesting case?

These are all the exact same questions people asked when they implemented the current work rules.

 

[Mirror Form]

Hey, thought y'all might be interested in this. The ACGME Task Force on Quality Care and Professionalism just released their new residency standards for 2011, which includes new work hour rules (interns can only work 16 hours at a time, and everyone else is limited to 28 continuous hours rather than 30). More importantly for military residents, though, is that fact that from this point onwards ALL moonlighting counts towards the residency's 80 hour cap, which basically makes moonlighting illegal for everyone that's not in their last year of either psych or PM&R. From a financial standpoint, this makes the military a better deal, since now there's nothing unique about the military's ban on moonlighting and even the most motivated civilian residents have no hope of cutting down on their debt before they finish their programs.

About time, I wish that had come out during my internship and residency.

 

[a1qwerty55]

Hey, thought y'all might be interested in this. The ACGME Task Force on Quality Care and Professionalism just released their new residency standards for 2011, which includes new work hour rules (interns can only work 16 hours at a time, and everyone else is limited to 28 continuous hours rather than 30). More importantly for military residents, though, is that fact that from this point onwards ALL moonlighting counts towards the residency's 80 hour cap, which basically makes moonlighting illegal for everyone that's not in their last year of either psych or PM&R. From a financial standpoint, this makes the military a better deal, since now there's nothing unique about the military's ban on moonlighting and even the most motivated civilian residents have no hope of cutting down on their debt before they finish their programs.

This should be the death knell for physicians -

Our current crop of graduating medical students are to put it nicely marginal, (sorry ladies and gentleman but each year seems to yield a crop which is intellectually weaker and less motivated) add to that the current culture that working hard is a real drag, then add the idea the it really doesn't matter how the patient does - "I'm done with my hours" and physicians essentially cease being different from physician extenders. Nurse practitioners and PA's will be the winners as physicians move towards being technicians with hourly schedules. Fine work America.

 

[AF M4]

This should be the death knell for physicians -

Our current crop of graduating medical students are to put it nicely marginal, (sorry ladies and gentleman but each year seems to yield a crop which is intellectually weaker and less motivated) add to that the current culture that working hard is a real drag, then add the idea the it really doesn't matter how the patient does - "I'm done with my hours" and physicians essentially cease being different from physician extenders. Nurse practitioners and PA's will be the winners as physicians move towards being technicians with hourly schedules. Fine work America.

Hey now Mr. Grumpy-pants, every generation always says that the new blood is lazy and spoiled. First, let's acknowledge that the current work schedule for residents and many attendings is ludicrous: after all, we're still "only" allowed to work 80 hours a week? C'mon. All those times you were in that zombified "I've been up for 30 hours and I've still got rounds" state, exactly how much were you learning? How many things about your patients were you missing because you could barely see straight? And let's not even bring up the effect that these hours had on your family and social life.

Yup, the health care system is screwed up. However, I don't think it's because the latest generation is somehow less motivated. I think that new blood is always good, because every new generation comes in with fresh eyes, and they look upon the current medical education system and say, "hey guys, this is friggin' stupid. We're going to change it now; real sorry that you had to go through it but that doesn't mean that everyone else has to suffer without purpose too."

And as far as the lying about hours thing, well, all residency programs still have a code of ethics about lying, and none of them want the ACGME sniffing around looking to put 'em on probation. So go home and get some rest; you're gonna need it.

 

[a1qwerty55]

Hey now Mr. Grumpy-pants, every generation always says that the new blood is lazy and spoiled. First, let's acknowledge that the current work schedule for residents and many attendings is ludicrous: after all, we're still "only" allowed to work 80 hours a week? C'mon. All those times you were in that zombified "I've been up for 30 hours and I've still got rounds" state, exactly how much were you learning? How many things about your patients were you missing because you could barely see straight? And let's not even bring up the effect that these hours had on your family and social life.

Yup, the health care system is screwed up. However, I don't think it's because the latest generation is somehow less motivated. I think that new blood is always good, because every new generation comes in with fresh eyes, and they look upon the current medical education system and say, "hey guys, this is friggin' stupid. We're going to change it now; real sorry that you had to go through it but that doesn't mean that everyone else has to suffer without purpose too."

You learn medicine or surgery by actually taking care of patients - not observing the care of patients.

You need to own them, take responsibility for them, and work them up. The best learning takes place at night when sick people actually come to the hospital. Picking up someone else's admission in the morning is nowhere near as valuable as having seen them in the ER, examined them, read up on their condition, had to actually craft the plan, and dispo them. Every year, I see the caps on the number of patients that a resident can carry lowered, the charting expectations dumbed down, and the expectations from staff lowered. We now just hope you might seem interested and marginally competent. There are still some superlative residents but the bottom half are flat out dangerous - I don't remember there being as big a spread years ago and I'm not that old.

There has to be a sane balance between work and rest/personal time - and I'm not advocating an 80 hour work week, but the caps - let's say 16 hours for Interns - is pretty limiting. I also love how the residents count their facebook, shooting the **** etc. as their work hours. I don't have respect for anyone who adheres to the ethos of dumping work on others, because "my shift is up". That is what the hour caps breeds.

 

[former military]

way around this:
your hospital can do to you what they did to me at David Grant Medical Center to take every day call for months at a time.
tell you that you are not on call every day... you are just required to always carry your pager and cell phone and answer it if they call you.
you are not technically on call... just answering questions and only coming in if absolutely "necessary"
you can enjoy your life when not on call.... just don't travel more than a 30 mile radius, have anything to drink when "off duty" or go swimming or to a waterpark.
everyone wins.
This was implemented by our commanders: one an ER physician and the other a physical therapist... both highly experienced in taking call.

 

[AF M4]

Every week I'm in the .mil I hear another legend about the thing that is the DG. Yeesh.

All of this begs the question that a1 is kind of touching on: why would any reasonably intelligent and sane person want to be a doctor?

 

[Mirror Form]

Our current crop of graduating medical students are to put it nicely marginal, (sorry ladies and gentleman but each year seems to yield a crop which is intellectually weaker and less motivated) add to that the current culture that working hard is a real drag, then add the idea the it really doesn't matter how the patient does - "I'm done with my hours" and physicians essentially cease being different from physician extenders. Nurse practitioners and PA's will be the winners as physicians move towards being technicians with hourly schedules. Fine work America.

LOL, let me just laugh at this hilarious post

What is your training again? For some reason I've always thought you were a PA? Regardless, you don't seem to have much of a grip on reality.

 

[Mirror Form]

You need to own them, take responsibility for them, and work them up. The best learning takes place at night when sick people actually come to the hospital. Picking up someone else's admission in the morning is nowhere near as valuable as having seen them in the ER, examined them, read up on their condition, had to actually craft the plan, and dispo them.

First, perhaps if you bothered reading the work rules, you'd see that the 16 hours rule only applies to interns (given that half of the interns are prelims or transitionals just passing through, they really shouldn't be the ones "owning" the patients anyway). Second, you do not have to work for 36 hours straight to learn patient ownership.

It's actually kind of funny that you think there is some amazing enlightenment that occurs by not sleeping overnight. HAVING SOMEONE ELSE ON YOUR TEAM MONITOR A PATIENT OVERNIGHT DOES NOT IN ANYWAY PREVENT YOU FROM TAKING OWNERSHIP OF A PATIENT AND THEIR PLAN OF CARE. If you think it does then you never learned what patient ownership is.

Every year, I see the caps on the number of patients that a resident can carry lowered, the charting expectations dumbed down, and the expectations from staff lowered. We now just hope you might seem interested and marginally competent. There are still some superlative residents but the bottom half are flat out dangerous - I don't remember there being as big a spread years ago and I'm not that old.

Wow, that wasn't anything like where I did my internship and residency. Sure you're not actually practicing somewhere in Europe?

There has to be a sane balance between work and rest/personal time - and I'm not advocating an 80 hour work week, but the caps - let's say 16 hours for Interns - is pretty limiting. I also love how the residents count their facebook, shooting the **** etc. as their work hours. I don't have respect for anyone who adheres to the ethos of dumping work on others, because "my shift is up". That is what the hour caps breeds.

So let me guess, you're a PA who gets annoyed when residents don't do your work for you? So that's what this whole attitude of yours is really about . . .

 

[pgg]

This should be the death knell for physicians -

Our current crop of graduating medical students are to put it nicely marginal

Enh, I bet the kids'll be all right.

I'll grant you that the HPSP crop may have declined in quality over the last 10 years, but that's more a consequence of a couple wars hurting the top end of recruiting than some kind of cultural laziness paradigm shift. Could be that you're just getting a skewed view of medical students because you're in the military.

 

[BOHICA-FIGMO]

Enh, I bet the kids'll be all right.

I'll grant you that the HPSP crop may have declined in quality over the last 10 years, but that's more a consequence of a couple wars hurting the top end of recruiting than some kind of cultural laziness paradigm shift. Could be that you're just getting a skewed view of medical students because you're in the military.

Well I'd like to think that at least some of us are/were good! Actually, I was an intern representative on some of the committees that review these things and it was noted that more interns are having to remediate this past year than usual.

As for the work hours, I gotta say, 30 hr shifts SUCK, but I always hated presenting a patient form someone elses H& P (which could happen from time to time due to work hour rules). I'd say a 24hr max on shifts seems reasonable. As for the 80 hr rule: I averaged ~72 hours a week during all of internship (~76/wk on my primary service) with only 6 weeks over 80 hrs (sometimes way over). I know that is specialty dependent, but it seems like the current rules work, at least in a military setting.

 

[Saipan]

I'm not advocating an 80 hour work week, but the caps - let's say 16 hours for Interns - is pretty limiting.

Well, what are you advocating? Because it's unclear. And what exactly is limiting about a 16 hr shift. I think that's plenty time for good learning experiences.

I've done rotations in abusive environments with no checks and balances, and I can flat out state that I learnt nothing after being on past 24 hours. There is no justifcation for 80 hour weeks and your comments about residents wasting time on facebook amount to little more than a rant. We've all read similarly illogical comments on other threads from other posters in an absurd attempt to justify 80 hr weeks or 30 hr shifts.

Other industries have reformed. We don't put six year old boys up chimneys anymore. Why can't medicine reform? Is it because Medicine has a lot more in common with a Fraternity than we care to admit.

 

[AnesCoord]

During my 20-year career in the USAF, any civilian employment, as a doctor, a bartender, an auto mechanic, or whatever, had to be approved by the member's commander, officers and enlisted alike. I know this because a) I worked in the Orderly Room and had to process the applications, and b) worked in most of those occupations myself, at different points in my career. Working at a civilian job without permission could get you in a lot of trouble if caught.

After retiring I was a program coordinator for many years. Most programs (regardless of specialty) prohibit external moonlighting--working outside the facility where you are completing your residency. Most residents only have a training license anyway, until their last year of training, and you can't moonlight with a training license. Lots of programs allow internal moonlighting though, within your own department, and occasionally other departments in your institution. Internal moonlighting is just taking on additional call shifts (after satisfying your required call for residency training purposes) for pay. Internal moonlighting MUST be counted towards the 80-hour work week.

 

[pgg]

Well I'd like to think that at least some of us are/were good! Actually, I was an intern representative on some of the committees that review these things and it was noted that more interns are having to remediate this past year than usual.

Naturally I don't mean that all or most of them suck these days. Everyone who gets a spot in a US medical school has met a certain threshold of qualification.

But in the last 15 years competition for HPSP has really dropped off.

• Part of it is because of the wars - fewer professionals and professionals-to-be are interested in the military during wartime. When HPSP doesn't fill or barely fills, there's clearly less competition and instead of the best qualified people we just get whichever qualified people happen to apply.
• Financially the program was slipping until they bumped the $s a couple years ago. This also hurt recruitment.
• There has been a shift toward more applicants from expensive private DO schools, because those applicants are staring down the barrel of more debt than their MD school colleagues - certainly don't mean to bash DOs at all, but on average their admission #s are lower than MDs.

All this means that compared to the 90s, HPSP isn't recruiting the best MS1s in the nations. 15 years ago the military could pick and choose; people who would've been denied a slot then are welcomed with signing bonuses today.

 

[notdeadyet]

But in the last 15 years competition for HPSP has really dropped off.

• Part of it is because of the wars - fewer professionals and professionals-to-be are interested in the military during wartime. When HPSP doesn't fill or barely fills, there's clearly less competition and instead of the best qualified people we just get whichever qualified people happen to apply.
• Financially the program was slipping until they bumped the $s a couple years ago. This also hurt recruitment.
• There has been a shift toward more applicants from expensive private DO schools, because those applicants are staring down the barrel of more debt than their MD school colleagues.

Good list, but I think you're leaving off arguably the most important one:

• Lack of confidence in the military residency training system

Many of us are interested in military service but stopped from taking HPSP when we did our homework and found ourselves underwhelmed by what we saw in the military education system.

- GMO tours. That's a show-stopper for many. Aside from the professional ramifications, some have ethical problems with being put in a physician's role after one year of post-school training.
- Quality. While many of us would like to serve, residency training is important and the military is not top notch in most fields. For a lot of applicants that worked hard in medical school, they'll have much higher quality training prospects in their fields on the civilian side and will defer joining til after they're trained.

I think it's impossible to undervalue how much the military's residencies and residency process turn off many highly qualified potential applicants.

 

[pgg]

Good list, but I think you're leaving off arguably the most important one:

• 
  [*]Lack of confidence in the military residency training system

Many of us are interested in military service but stopped from taking HPSP when we did our homework and found ourselves underwhelmed by what we saw in the military education system.

- GMO tours. That's a show-stopper for many. Aside from the professional ramifications, some have ethical problems with being put in a physician's role after one year of post-school training.
- Quality. While many of us would like to serve, residency training is important and the military is not top notch in most fields. For a lot of applicants that worked hard in medical school, they'll have much higher quality training prospects in their fields on the civilian side and will defer joining til after they're trained.

I think it's impossible to undervalue how much the military's residencies and residency process turn off many highly qualified potential applicants.

You may be right, but I'm not totally convinced. I know I didn't have a solid grasp of the military residency issues when I was a pre-med and early MS1 (when most people would be applying for and accepting HPSP). I didn't even know what specialty I'd be going into then. Residency was a far-off afterthought behind the hurdle of just getting into med school and figuring out how to pay for it. Maybe I was unusually naive or clueless, but I think it's unusual for people at that stage to really understand all the issues associated with residency training (beyond 'Harvard good, BFE bad').

The internet and forums like this one has surely made today's pre-meds better informed, on average. But I don't know if the applicants dissuaded by this forum's overall negative tone are turned off by the GME trends or by the stories about all the ankle-biting annoyances that come with military service.

GMO tours haven't changed appreciably in the last 15 years, so I don't think that really helps account for the drop in interest.

 

[notdeadyet]

Maybe I was unusually naive or clueless, but I think it's unusual for people at that stage to really understand all the issues associated with residency training (beyond 'Harvard good, BFE bad').

I doubt your average applicant understands the nuances either. But like you said, they know 'Harvard good, BFE bad' and they also know that most military residencies are far closer to BFE than Harvard.

And while your average applicant may not be thinking residencies, I think we're talking about top quality applicants. They tend to be far ahead of the curve and when thinking of things like HPSP, they're thinking through the process from sign-on --> med school --> residency--> attending and how HPSP will enable or limit them in their careers. And like you said, the relatively recent rise of available info on the Internet makes it very easy to find this out.

I think the applicant that says, "Wow! $150K! That's a lot! I'll just sign up for this HPSP thing..." is not the high callibre applicant we're talking about.

But I don't know if the applicants dissuaded by this forum's overall negative tone are turned off by the GME trends or by the stories about all the ankle-biting annoyances that come with military service.

Most applicants are sophisticated enough to dig through the gripes, moans and chest beating to get what they're looking for. When I was making the decision on HPSP, I was digging through this forum with very specific questions in mind and had those answered. The negative tone didn't really impress me. What career-focused forum isn't skewed towards the negative?

GMO tours haven't changed appreciably in the last 15 years, so I don't think that really helps account for the drop in interest.

Agreed. If anything, they've gone down in number (I'm thinking mostly Army here). The difference between now and 15 years ago is that 15 years ago, finding out the existence of GMO tours would have been a challenge. Now, if you sign up for HPSP and don't know about them, you really didn't do your homework.

 

[a1qwerty55]

LOL, let me just laugh at this hilarious post

What is your training again? For some reason I've always thought you were a PA? Regardless, you don't seem to have much of a grip on reality.

What part is hilarious? It is hard to argue that the current generation is as tolerant of long hours and the "messy" aspects of medicine. We are not drawing the best and brightest into medicine and the attack of new subpar medical schools has very negatively affected the military.

Sadly I have a pretty strong grip on reality since I'm the one picking up the resident slack and it is my license on the line when the resident phones it in. Had I not worked the hours I did in residency and carried the loads I did, I suspect I would have a harder time picking up the slack.

You know I'm not a PA, perhaps that was some kind of attempt at insulting me? My point is that the professional ethos of working beyond one's set hours is one of the key concepts distinguishing physicians as a profession from PA's/NP's (recognizing that plenty of PA's and NP's go above and beyond).

 

[a1qwerty55]

Wow, that wasn't anything like where I did my internship and residency. Sure you're not actually practicing somewhere in Europe?



So let me guess, you're a PA who gets annoyed when residents don't do your work for you? So that's what this whole attitude of yours is really about . . .

Point one - team caps at my facility keep going down - Interns/residents often don't have to write H+P's after midnight because that would make it too hard for them to get out before noon. As the number of admissions generally is in the 2-3/night, I can't see why it is so hard to get the charting done -

Point two - What is with the whole PA reference? I'm not one but that would be irrelevant anyway. Where do residents do PA's work? I haven't seen that.

 

[a1qwerty55]

Naturally I don't mean that all or most of them suck these days. Everyone who gets a spot in a US medical school has met a certain threshold of qualification.

But in the last 15 years competition for HPSP has really dropped off.

• Part of it is because of the wars - fewer professionals and professionals-to-be are interested in the military during wartime. When HPSP doesn't fill or barely fills, there's clearly less competition and instead of the best qualified people we just get whichever qualified people happen to apply.
• Financially the program was slipping until they bumped the $s a couple years ago. This also hurt recruitment.
• There has been a shift toward more applicants from expensive private DO schools, because those applicants are staring down the barrel of more debt than their MD school colleagues - certainly don't mean to bash DOs at all, but on average their admission #s are lower than MDs.

All this means that compared to the 90s, HPSP isn't recruiting the best MS1s in the nations. 15 years ago the military could pick and choose; people who would've been denied a slot then are welcomed with signing bonuses today.

This is spot on. The issue isn't one of good versus bad but the spread, we are accepting lower quality graduates, some of whom do not have the requisite skills to be quality physicians. As far as I can tell military medical recruiters today don't take into account the quality of the medical school, only whether the applicant has a pulse and no felonies. The new DO schools are hurting us badly not because DO's are bad but because the really poor DO schools either attract untrainables, or can't educate them.

This is not a DO rant as I have posted several times before that some of my best residents have been DO's. That being said, many if not most of my worst residents have been DO's.

 

[NoMoreAMCAS]

c

 

[Medic101]

Hey guys, so during Residency if I am under FAP, I cannot moonlight/ have limited moonlighting hours?

 

[Perrotfish]

Hey ya'll, thought you might want to know that it's official. As of July 1 of next year Interns are limited to 16 hours/day of work.

So, my question for the Navy guys: do you think this will do anything to reduce the number of GMOs out there? Because if I wasn't going to be comfortable practicing on my own after the old Intern year I'm DEFINITELY not comfortable with this new one.

 

[blee]

That one rule isn't going to change a whole lot. 16 hours a day means an 80 hours over five days, plus the few odd hours you put in covering weekends. It's not going to affect work hours all that much in that sense. What it will do is essentially force every program to adopt a night float (or similar) system, at least for interns. While many programs already do this, the new rules expressly prohibit interns from doing Q3 or Q4 calls.