Proposal: ACGME stops regulating hours and starts regulating deez ****

[Thanatos]

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So a few days ago I was post call after an untypical evening where the ER did not rain **** on me all night and the services I was covering were shockingly tame. I managed to get almost one whole hour of uninterrupted sleep and compared to most post call days felt pretty decent. So around the late morning after rounds my attending tells me to wrap things up and then get home asap so I don't exceed hours. So I finish up a few things and call the other resident to sign out. It turns out this poor bastard is buried up to his neck in work with an emergency case from his service, multiple OR's running at the same time occupying the other residents, a few sick floor patients, and a handful of consults in the ER. Not to mention a resident on his service is on maternity leave. With a few sick people on my service, my sign out just might push this guy past the edge.

So instead of going home, I stuck around for a few more hours babysitting my service and putting out a few other random fires, and all was well until I ran into my attending who promptly roasted me for still being in the hospital. I realize we all get in trouble for going over and its his ass for "allowing" it to happen, but what's the alternative. I'm not about to drop a ton of work on someone who is barely treading water. Just feels wrong, and I wonder if its dangerous to have him scrubbed for an emergency while leaving sick ER consults and floor patients at the mercy of ER docs and nurses, respectively 😉

I'm not suggesting we all work 200 hours a week, but sometimes things have to give a little. And my program can get in trouble for this? The acgme can blow me.

 

[SLUser11]

I'm not suggesting we all work 200 hours a week, but sometimes things have to give a little. And my program can get in trouble for this? The acgme can blow me.

Props for being a team player, but you are treading on a slippery slope. Imagine instead that you got your @ss kicked the night before, were exhausted, and were forced to stay and work because there are no hour restrictions.

I understand that as surgery residents we're still in a culture where valiant and self-sacrificing behavior is desirable, and we are thought to be a "strong resident" if we don't require any sleep or general maintenance, and vocally and self-righteously denounce our horrible duty hour restrictions.....but still, I just don't but into it.

Here's a couple old threads that addressed this:

I hate 80 hours


I love 80 hours


I think one of the ways we can make the system work is a more consistent and structured home call. I think if residents took calls on all of their established patients from home, whether post-call or just home on a random tuesday, this would eliminate the problems of "shift work" and passing off patients. It would also eliminate the unfair and sometimes unsafe cross-covering of patients.

When I say home call, however, I don't mean a situation where the resident would take new consults from home, or be forced to come in from home to see a patient. Any new consults or problems on existing patients that couldn't be handled over the phone would be addressed by the in-house call team.

With residents taking calls from home, the 80 hour work week would remain intact, there would be improved continuity of care, and the resident would have a better sense of patient ownership and autonomy. Honestly, I don't know why more places don't do this currently....

 

[JackADeli]

...around the late morning after rounds my attending tells me to wrap things up and then get home asap so I don't exceed hours. ...With a few sick people on my service, my sign out just might push this guy past the edge.

So instead of going home, I stuck around for a few more hours babysitting my service and putting out a few other random fires, and all was well until I ran into my attending who promptly roasted me for still being in the hospital. ...I'm not about to drop a ton of work on someone who is barely treading water...

...sometimes things have to give a little. And my program can get in trouble for this? The acgme can blow me.

As someone having dealt with the same situation for seven plus years.... I think your perspective is wrong (though it is right-on the way "old school" attendings like it).

You are not the savior, you are a trainee. If there is a "person-power" shortage, it is not your place to solve it, it is the attending's. You were instructed to leave. Go home. If you were aware of an unsafe situation, you should contact the attending/chief resident/etc.... then depart. While some might find it admirable that you CHOSE to stick around and engaged in patient care after one hour of sleep and after being instructed to go home, it's not. It in itself raises concerns about patient safety. I have seen residents deposed and asked why they were in the hospital when they were not supposed to be.

Bottom line, the ACGME is trying to assure a safe training program with consistency and integrity. Physicians have demonstrated ~forever that they will always find a justification why someone should work more.... because "the patient comes first". Yet, in community practice without residents, seems to work...😕 Speak with your seniors and/or attendings if you believe the support system is innadequate for safe patient care. You would be angry if your junior residents ignored or decided to countermand your instructions because he/she knew better. As you expect from junior residents, show respect to your attending and leave when he/she instructs you to leave.

JAD

 

[igap]

B

As someone having dealt with the same situation for seven plus years.... I think your perspective is wrong (though it is right-on the way "old school" attendings like it).

You are not the savior, you are a trainee. If there is a "person-power" shortage, it is not your place to solve it, it is the attending's. You were instructed to leave. Go home. If you were aware of an unsafe situation, you should contact the attending/chief resident/etc.... then depart. While some might find it admirable that you CHOSE to stick around and engaged in patient care after one hour of sleep and after being instructed to go home, it's not. It in itself raises concerns about patient safety. I have seen residents deposed and asked why they were in the hospital when they were not supposed to be.

Bottom line, the ACGME is trying to assure a safe training program with consistency and integrity. Physicians have demonstrated ~forever that they will always find a justification why someone should work more.... because "the patient comes first". Yet, in community practice without residents, seems to work...😕 Speak with your seniors and/or attendings if you believe the support system is innadequate for safe patient care. You would be angry if your junior residents ignored or decided to countermand your instructions because he/she knew better. As you expect from junior residents, show respect to your attending and leave when he/she instructs you to leave.

JAD

To my knowledge, there is no data that supports the claim that the 80 hour rule has any impact on patient safety or medical errors. Can you support your assertion that exceeding 80 hours places patients at risk?

 

[Winged Scapula]

For me, its not about 80 hours; its about staying up all night, with little to no sleep. I don't think JAD was talking about 80 hours either.

I think most of us agree that there is no data that working more than 80 hours negatively impacts patient care but that there is good data that going without sleep for extended periods of time impacts most people. I say most, because I don't need much more than 4 or 5 hours to feel normal. 1 hour? I'd probably feel worse than if I stayed up the whole night, but that's me.

I agree that leaving or even taking days off just because you are over 80 hours doesn't make much sense and that staying to help your overwhelmed colleague even when you are post-call is a nice thing to do, but the RIGHT thing to do would been to have engaged the other resident's Chief, attending or other residents to help him/her out. By staying you put the program at risk. Having been at a program on probation for work hour violations, this is serious stuff whether or not you agree with it, you have to abide by it as much as you can.

 

[JackADeli]

...To my knowledge, there is no data that supports the claim that the 80 hour rule has any impact on patient safety or medical errors. Can you support your assertion that exceeding 80 hours places patients at risk?

I think you should re-read my post. I never cited the "80 hour rule".

As mentioned by others, only 1 hour of sleep does predispose to error. That has been evaluated in numerous areas... I will leave it to you to research if you actually have interest.

However, as my statement seems to be misunderstood, I will spell some facts out for those that feel gungho and so potent:

1. If you exceed alotted duty time, it can be called into question in court.
2. If you were actually instructed to go home and choose to ignore said instructions/directive, you cease to be working under the "supervision" of your program. You are in effect now acting un-supervised and independent... and in direct conflict with your supervisors. We may all have done this. But, understand, should anything at all occur under your ~rogue watch, you will stand alone.
3. If you expect your subordinates to obey/follow your instructions under the presumption that your experience/etc... makes you judgement superior; you had better accept that an attending (likely board certified) expects and deserves the same obedience. It is not hardcore or gungho to disobey.... it is arrogance with a great deal of potential consequences
4. Every resident has signed a contract agreeing to obey the rules.... Not doing so is not just a breach of contract, it is a failure of character.
5. The ACGME consequences are real though, some may argue they are the least of the other (1-4) items above.

A resident only fools themselves when they think they are being some sort of savior (in an oppressive environment....they preserve by lying). Love how residents jump through hoops preserving the status-quo and then look for accolades for their efforts..... Kind of like starting a house fire and then looking for a trophy cause you ran into the house to save the cat.

A resident can lie and decieve. In the end, I don't see one lying for glory/bravado/misguided savior complex to be anything great.... it just means the resident is a liar. The funny thing is that at every residency I interviewed folks always talked about "never lie". I guess the real message is never lie unless..... Bottom line is that ACGME rules ~fail as a result of residents. Stop the whining of wanting to be old school, patient first, patient safety, etc..... If one wants to be gungho, show bravado, be a savior; stand-up and tell the truth. This crap has been going on too many years.

JAD

 

[SLUser11]

A resident only fools themselves when they think they are being some sort of savior (in an oppressive environment....they preserve by lying). Love how residents jump through hoops preserving the status-quo and then look for accolades for their efforts..... Kind of like starting a house fire and then looking for a trophy cause you ran into the house to save the cat.

A resident can lie and decieve. In the end, I don't see one lying for glory/bravado/misguided savior complex to be anything great.... it just means the resident is a liar. The funny thing is that at every residency I interviewed folks always talked about "never lie". I guess the real message is never lie unless..... Bottom line is that ACGME rules ~fail as a result of residents. Stop the whining of wanting to be old school, patient first, patient safety, etc..... If one wants to be gungho, show bravado, be a savior; stand-up and tell the truth. This crap has been going on too many years.

JAD

You've posted 400 times and said some good things, but IMO this is your best post ever. Agree 100%.

 

[karatekid]

For me, its not about 80 hours; its about staying up all night, with little to no sleep.

I think most of us agree that there is no data that working more than 80 hours negatively impacts patient care but that there is good data that going without sleep for extended periods of time impacts most people. I say most, because I don't need much more than 4 or 5 hours to feel normal. 1 hour? I'd probably feel worse than if I stayed up the whole night, but that's me.

There is acutally a research done at USC (trauma devision i believe) that showed the mortality rate was the same but morbidity rate increased after the 80 hours restriction was started. Bias? I dont know, but for someone working in Europe, when we compare our mortality and morbidity rates with busy centers in US we can not argue in the favour of our 56 h work weeks!

 

[JackADeli]

...for someone working in Europe, when we compare our mortality and morbidity rates with busy centers in US we can not argue in the favour of our 56 h work weeks!

We could get into alot of debate over Europe vs USA or Socialized vs USA. I think the comparison would not be realistic; if for no other reason then we throw alot of dollars at alot of traumas. As for the current debate, I again refer back to my respected colleague WS's statement:

...there is good data that going without sleep for extended periods of time impacts most people...

... and Mr. Speaker, I reserve the balance of my time. (oh crap, I'm starting to speak congressional).

JAD

 

[Thanatos]

I think you should re-read my post. I never cited the "80 hour rule".

As mentioned by others, only 1 hour of sleep does predispose to error. That has been evaluated in numerous areas... I will leave it to you to research if you actually have interest.

However, as my statement seems to be misunderstood, I will spell some facts out for those that feel gungho and so potent:

1. If you exceed alotted duty time, it can be called into question in court.
2. If you were actually instructed to go home and choose to ignore said instructions/directive, you cease to be working under the "supervision" of your program. You are in effect now acting un-supervised and independent... and in direct conflict with your supervisors. We may all have done this. But, understand, should anything at all occur under your ~rogue watch, you will stand alone.
3. If you expect your subordinates to obey/follow your instructions under the presumption that your experience/etc... makes you judgement superior; you had better accept that an attending (likely board certified) expects and deserves the same obedience. It is not hardcore or gungho to disobey.... it is arrogance with a great deal of potential consequences
4. Every resident has signed a contract agreeing to obey the rules.... Not doing so is not just a breach of contract, it is a failure of character.
5. The ACGME consequences are real though, some may argue they are the least of the other (1-4) items above.

A resident only fools themselves when they think they are being some sort of savior (in an oppressive environment....they preserve by lying). Love how residents jump through hoops preserving the status-quo and then look for accolades for their efforts..... Kind of like starting a house fire and then looking for a trophy cause you ran into the house to save the cat.

A resident can lie and decieve. In the end, I don't see one lying for glory/bravado/misguided savior complex to be anything great.... it just means the resident is a liar. The funny thing is that at every residency I interviewed folks always talked about "never lie". I guess the real message is never lie unless..... Bottom line is that ACGME rules ~fail as a result of residents. Stop the whining of wanting to be old school, patient first, patient safety, etc..... If one wants to be gungho, show bravado, be a savior; stand-up and tell the truth. This crap has been going on too many years.

JAD

interestingly enough, this is what i look like in real life:

and this is what JAD looks like:

deep breathing my brother...i wouldn't want you to stroke out in the middle of the night and be taken care of by a sleepy resident 😉 (disclaimer: i'm totally kidding you, don't get upset)

Back to the topic, i really don't have any type of savior-complex. If anything, i firmly believe that my spot in the pecking order relegates me to somewhat more useful than the janitor. But I do have some responsibilities, and I do take those seriously. It doesn't feel right to just dump all that responsibility when the clock hits a certain hour. Don't we as a culture criticize other specialties for exactly that? I stayed late mostly to help out my beleaguered colleague, and it really did seem like the right thing to do at the time. I will admit I am a little surprised at the amount of **** i'm getting for it though.

I have nothing but respect for my seniors and attendings (many of you are in that category), they put in their time to earn where they are and i'm not screwing with that. On the other hand, although he was less than thrilled about me staying late I'm willing to bet he would have been MUCH angrier if he had strolled into morning rounds and those 5 patients that were supposed to go home yesterday afternoon are still there because somebody (me) wasn't around to write those d/c summaries. I am further certain his anger would not be lessened by me stating "well I was at my hours so I signed out, to where it suddenly became not my problem anymore. You told me I could go, remember? So I blazed a trail right out the front door!" The cross cover is too busy to do them, so unless my attending is going to do them (extremely unlikely) its not getting done. And I think thats the bottom line: somebody has to do all this stuff! Normally there would have been somebody else to sign that stuff out to, but an emergent case plus one missing resident kind of created a perfect storm. My program is actually a well oiled machine when it comes to covering everything, but this one day things kind of got crazy.

I mainly posted this anecdote to complain about the 80 hour work week overall and how arbitrary it seems. At hour 79 I'm a living/breathing paperwork machine with a working DEA number, and 61 minutes later I'm a rogue menace hell bent on killing everything in site. And even worse, I'm suddenly dishonest? You're calling my character into question at 80.1 or 30.1 hours? Does that seem flat out stupid to anybody else?

You all make good points, I accept your criticisms and for legal reasons I shouldn't stay late. As for patient safety, I never want to do anything to hurt anyone. But I have to point out that supposedly its acceptable for our attendings to work over 80 on a regular basis, and many do. Several of you have stated in over threads you don't want your first "31st" hour lap chole to be when you're an attending, I don't think I do either.

Can you imagine if we go to 56 hours? I will have to teach my attendings how to replace electrolytes using the new electronic medical records system 😀

 

[maxheadroom]

I mainly posted this anecdote to complain about the 80 hour work week overall and how arbitrary it seems. At hour 79 I'm a living/breathing paperwork machine with a working DEA number, and 61 minutes later I'm a rogue menace hell bent on killing everything in site. And even worse, I'm suddenly dishonest? You're calling my character into question at 80.1 or 30.1 hours? Does that seem flat out stupid to anybody else?

I don't think anyone is actually calling your character into question. We all appreciate a strong intern who wants to get the work done. The thing that people are finally starting to recognize in surgery is that if you're going to make people fill out a form that says they're following the duty hour restrictions, then they have to really follow the rules. End of story. Why? It only takes one disgruntled whistleblower to land the WHOLE PROGRAM in a world of hurt.

Pair up duty hour logs that reflect a consistent disregard for the rules along with evaluations to the RRC that include words like, "unsupervised, unsafe, retaliation, service without education" and a strong program can quickly get into a whole lot of trouble (I've seen it happen at a friend's program).

If your program takes the duty hours seriously, then it's your job to follow them. If your program doesn't take the duty hours seriously, then it sucks to be you (and I was in that boat).

 

[Winged Scapula]

Thanatos (and despite your user name, I do believe you want to save patients 😉 ):

you're right of course. There is nothing magical about 80 hrs. We all realize that. And we (or perhaps I) didn't mean to imply there was or that there was anything less honorable about your intentions.

You were in a tough spot. One most of us have been in. Follow attending directions or screw colleague? Neither is palatable and we realize that staying a few extra hours doing discharge summaries, taking a few calls, isn't likely to have hurt anyone and probably did the service a world of good.

But what we suggest is that there are better ways to go about it. Leave the hospital, do the DCs from home, answer pages from home, have your fellow intern call you later for sign-out. This will get you off the premises, out of the sight of your attending but still helping your fellow intern. Or ask for help from others so that he isn't swamped.

So of course these rules are arbitrary and stupid. But they are rules, and not following them, AS OFTEN AS POSSIBLE, hurts your program and your colleagues more.

 

[JackADeli]

...this is what JAD looks like...

I am greatly offended. I spend too much on my Brasilian waxes and my thong is too smoking to be portrayed that way!!!

...i really don't have any type of savior-complex. ...But I do have some responsibilities, and I do take those seriously. ...Don't we as a culture criticize other specialties for exactly that?

We all have a perception of ourselves throughout all specialties. We save lives or at least are around folks that save lives and may believe it was us. You don't have to look very far in these forums to find numerous examples and discussions about how important our jobs are and how different they are from society. It is as you say the culture that is pounded into us from medical school through residency. We are different. As surgical residents we are the hardest workers and most overworked and irreplaceable members of the hospital staff... It is a great mantra. It doesn't feel right because the "culture" wants to use your emotions to push YOU to choose to break and violate the rules. It is worse then peer pressure. But, let's be serious. You are a trainee. Staffing and lack of staffing are the responsibilities of the administration, attendings, GME office. You were directed to leave. If you saw an unsafe situation or had some concerns, you should contact your senior and/or attending. They will then instruct you as to what if any role you should play in the solution.

...I have nothing but respect for my seniors and attendings ...i'm not screwing with that. On the other hand, although he was less than thrilled about me staying late I'm willing to bet he would have been MUCH angrier if...

If nothing but respect, then follow directions and do not second guess. The second guessing and "self sacrifice" that endangers a program and enhances one's appearance as a "team player" is not respect.

...bottom line: somebody has to do all this stuff! ...

Bottom line, in this situation it wasn't suppose to be you. You chose to do it. An act that countermanded your attending's instructions. Then you rage against the ACGME. Remember, it was your choice. If everyone in your program and every program accross the country toed the line, then everyone will have the turn of leaving and the turn of being the one in the hospital to do the work. It's not that you need to draw the line.... it's that the line has already been drawn and it's not your place to cross it.

...But I have to point out that supposedly its acceptable for our attendings to work over 80 on a regular basis, and many do.

Again, you are not the attending. Also, the attending has residents taking calls throughout the night enhancing their rest.... you do NOT...

....At hour 79 I'm a living/breathing paperwork machine with a working DEA number, and 61 minutes later I'm a rogue menace hell bent on killing everything in site. And even worse, I'm suddenly dishonest? You're calling my character into question at 80.1 or 30.1 hours? Does that seem flat out stupid to anybody else?....

We can argue if you like. The point is more generalized to residents in general:

1. You didn't say you lied. But, If you (generic) lie on your declared hours, yes I call your character into question if for no other reason then you are a liar.
2. If you signed a contract stating you will abide by the rules and follow the instructions of your attending and then disregard or countermind them because it doesn't feel right or you believe something different, yes, you are acting outside your station. If you are on a trainee license, it is that much worse. Either way, your conduct is not sanctioned and/or protected once you cross that line. There was actually a publication in the surgery magazin some years ago about attendings being dropped from lawsuits because... the resident was acting independently of instruction/etc.... It's real boys & girls.

Again, this crap has been going on too long. It is not a "new 80hr rule". Programs that have failed in five plus years to develop a solution and back-ups and safety nets are programs in which residents are lying. Residents need to stop trying to prove their "strength" and "team player attributes" at the expense of their character and honesty. Numerous hospitals run without residents. Teaching programs would too if residents would toe the line and hold their programs accountable.

....You were in a tough spot. One most of us have been in. Follow attending directions or screw colleague? Neither is palatable ....

Final note, Thanatos, you and others often suggest or outright declare an understanding of the leadership structure/hierarchy. If that is the case, it is quite easy, you follow the attending over your fellow residents. Especially when given a black & white directive. Sometimes there may be room for identifying a creative solution. What you have described is not one of those times.

...But what we suggest is that there are better ways to go about it...

... but the RIGHT thing to do would been to have engaged the other resident's Chief, attending or other residents to help him/her out. ...this is serious stuff whether or not you agree with it, ...

...if you're going to make people fill out a form that says they're following the duty hour restrictions, then they have to really follow the rules. End of story...

JAD

 

[SocialistMD]

An interesting corollary to this is coming to work sick. Every program has the story of the resident rounding with his/her IV pole and my ego has brought me to work on several occasions where I should have probably stayed home. However, with the current H1N1 pandemic, it might be wise to follow the rules on this one, too. I heard through the grapevine that a certain program in Georgia was down 15% of their resident staff (at once) recently due to the flu, most likely because a lot of people were trying to tough it out at work and ended up infecting their colleagues. If you have a fever- stay home!

 

[JackADeli]

An interesting corollary to this is coming to work sick. Every program has the story of the resident rounding with his/her IV pole and ...ego has brought ...to work on several occasions where ...should have probably stayed home. However, with the current H1N1 pandemic, ...If you have a fever- stay home!

yep, I have heard the stories.... residents in all differing programs having a significant surgical procedure post-call Friday to take call Monday. Residents hospitalized, on meds, etc... happen to be in the room next door to a code and getting up an running code in hospital gown (and medicated). Residents on crutches on pain meds, on etc.... We have all probably heard or seen it and the initial thing is to praise how gungho, team player, hardcore they were. The problem is you are flying solo if something goes wrong.... and face it, you are in a hospital often with more physicians and ancillary staff then most hospitals in Canada. It's not the jungles of Cambodia. You won't be able to justify it.

On another note, I have heard attendings b@*ch about how the residents are using the rules in a one sided manner. When they have nothing going on at home/in their lives, they break the rules and grunt about how hardcore they are.... when hollidays roll around, families in town, they got a new hottie, residents suddenly start talking about the rules.... It really is quite self serving to break the rules when it's convenient, seek praise for your "sacrifice", then moan about your hardcore lifestyle, and finally enforce the rules for your sister's wedding.

....I understand that as surgery residents we're still in a culture where ....but still, I just don't [buy] into it...

JAD

PS: note how the hospital and healthcare system doesn't collapse when you got the swine flu or chicken pocks or EBola..... it seems to work fine in your complete absence. Why do we really believe all hell will break loose if you obey the rules/guidelines and go home post-call?

 

[Buckeye(OH)]

Anyone see the JBJS article about poorer outcomes from 6p-4a versus 6a-4p? I worked 70hrs in 3 days this......I RULEEEEEEE

 

[njbmd]

An interesting corollary to this is coming to work sick. Every program has the story of the resident rounding with his/her IV pole and my ego has brought me to work on several occasions where I should have probably stayed home. However, with the current H1N1 pandemic, it might be wise to follow the rules on this one, too. I heard through the grapevine that a certain program in Georgia was down 15% of their resident staff (at once) recently due to the flu, most likely because a lot of people were trying to tough it out at work and ended up infecting their colleagues. If you have a fever- stay home!

Our residents have been told to stay home if sick and don't come back until fever is gone for 24 hours. So far, we have had one or two gone here and there but not huge percentages of folks. Swine flu (or any flu for that matter) IS one to stay home on because us "old folks" can weather this one better than the young folks. Stay home please and rest so that you can get on your feet faster.

There were times when I came in with 40C fevers, chills and tried to "gut it out" but those days are gone. Not only did I put the patients at risk, I put my fellow workers at risk. Now, if I am sick, I stay home and I have sent others home for illness. It's not worth the risk.

 

[JackADeli]

...tried to "gut it out" but those days are gone. Not only did I put the patients at risk, I put my fellow workers at risk. Now, if I am sick, I stay home and I have sent others home for illness. It's not worth the risk.

Agreed. A display of machoness/hammerhead/hardcore/old school is self serving ego enhancing conduct that may give one a false sense of accomplishment while endangering others. Take care of your mental and physical health so you can do what you are training to do.... provide the best medical care possible for those in need.

JAD

 

[filter07]

Surgery is one of a few training pathways that design almost no redundancy into the workload. It seems that surgery residencies can only function if 100% of the residents work at peak volume for a full 80 hours a week. Anything else and everyone suddenly has to scramble and go overboard. When residents are overworked, and there's too much work to be done unless people go over hours, that's a system problem. That's a problem with the way the workload is assigned. Surgery is really in the dark ages when it comes to planning for anything unusual in the schedule. We need more residents, or more PAs, or more attendings doing scut. We can't have residents doing 95% of the work all the time, and then act like it's Armageddon when someone has to go to a doctor's appointment, stays home because s/he's sick, or goes on maternity leave.

 

[JackADeli]

...Surgery is really in the dark ages when it comes to planning for anything unusual in the schedule. ...We can't have residents doing 95% of the work all the time, and then act like it's Armageddon when someone has to go to a doctor's appointment, stays home because s/he's sick, or goes on maternity leave.

I concur to some degree.... But, I will restate a sentiment that I have in other threads.....

Why is it that community hospitals & med ctrs seem to function just fine in the absence of cadres of residents/NPs/PAs? Once you leave a large teaching center with multiple residencies, it doesn't seem like armageddon in the community hospitals. That is not to say those hospitals are all completely efficient or managed well. Yet, it does seem to be a different animal. Yes, I also know that community hospitals have the luxury to often transfer "complex" cases on Fridays/etc...

JAD

 

[Miami_med]

Surgical residencies still by and large suffer from a problem that doesn't exist in non-operative fields, which is the fact that more people equals less case exposure. Two medicine residents can see and learn from the same case of CHF, but two surgical juniors can't fix the same inguinal hernia. In many progams, the addition of extra residents is opposed by the residents, as it represents a watering down of potential operative exposure. The addition of PAs, other extenders, attendings doing more scut, etc... would improve flexibility, but it very well might do it at the cost of eliminating what's left of the truly resident run services. It also costs a lot.

Residency is really a very unique position, because it intermixes the role of learner and worker in a very formalized fashion. It is not dissimiler to entry level roles in many careers in which the worker is also learning, but the formality of the whole thing creates a degree of rigidity. In the end, working 120 hours a week probably does begin to tax learning after a time. Coming to work with a high fever is probably not very helpful to one's learning. However, a good deal of what makes a good resident learning experience IS a program that allows itself to be reliant on its residents. This gives them responsibility and the opportunity to see the consequences of different actions. That reliance is a two-edged sword because it also diminishes flexibility.

If there comes a point where programs are no longer allowed to rely on their residents, the residents will slowly but surely become more and more worthless. I came from a medical school where medical students do a lot of the scut type roles (though that is rapidly changing there to), and it made me MUCH more prepared than many of my piers when I got to residency. That responsibility on the part of the residents similarly prepares them for being responsible when they are done. It's not that working sick or 120 hours a week is good. It's the fact that you are given enough responsibility that taking a sick day actually hurts something.

 

[jbean]

I am really impressed. I see a huge difference in this thread compared to similar ones just a few years ago. It seems to me that more and more residents are seeing the work restrictions for what they are - an attempt to end the unsafe practices of working on no sleep - instead of some attempt to water down our learning or make us less macho.

I think perhaps, our culture is a-changing!

 

[SocialistMD]

I think perhaps, our culture is a-changing!

...just in time for us to start complaining about the 56-hour work week...🙄

 

[MossPoh]

Nothing of real benefit to say (I'd be naive to think I did have something), but I do enjoy this thread. It isn't some flame war as much as a reasonable debate.