Question about residency work hours

[SeekerOfTheTree]

Yes, every drunk guy thinks they drive better than everyone else on the road. Most drunk drivers can't pull this off, maybe some can. Wanna trust dear grandma with that drunk stranger

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[Law2Doc]

Laborists, hospitalists, ER, trauma surgery....I wouldn't necessarily say shift work is not working...

the jury is truly still very much out on this. Only premeds laude shift work as a sure fire home run. There are many pundits in all fields which do shift work who worry about sustainability and quality, particularly during the residency and early years. There are even a few ED programs which require prelim non-shift years, and I suspect we will see more of that down the road. Bottom line is if you don't log enough hours in the hospital during your earlier years you simply don't see enough to be proficient. The whole point if residency and the first couple if years of practice is immersion. But at any rate shift work is very much a new thing in medicine, and though it provides a nice lifestyle benefit it is not without negatives and powerful detractors. I'd probably wait another four or five years before I label it a success rather than a fad.

 

[Law2Doc]

Yes, every drunk guy thinks they drive better than everyone else on the road. Most drunk drivers can't pull this off, maybe some can. Wanna trust dear grandma with that drunk stranger

I don't think any scientific journal has demonstrated that going without a nights sleep is equivalent to being drunk, and they certainly haven't demonstrated that doing six nights of night float at 13 hours a night makes you less impaired than doing two 30 hour shifts a week followed by post call days. There simply is no justification for equating sleep deprivation to inebriation. It really seems like the premeds and med students are grasping at straws here to justify not wanting to work long shifts, despite the hordes if residents (most of whom have experience under both systems) assuring them it's both doable and probably in the patients interests.

 

[michaelrack]

I don't think any scientific journal has demonstrated that going without a nights sleep is equivalent to being drunk, and they certainly haven't demonstrated that doing six nights of night float at 13 hours a night makes you less impaired than doing two 30 hour shifts a week followed by post call days. There simply is no justification for equating sleep deprivation to inebriation. It really seems like the premeds and med students are grasping at straws here to justify not wanting to work long shifts, despite the hordes if residents (most of whom have experience under both systems) assuring them it's both doable and probably in the patients interests.

http://www.ncbi.nlm.nih.gov/pubmed/21595697
"Previous research shows that sleep deprivation (SD) produces cognitive impairment similar to that caused by alcohol intoxication...."

There are some similarities between the sleep deprivation and alcohol consumption, although they were not found in this study. I agree that they are not equivalent.

 

[michaelrack]

J Sleep Res. 2011 Dec;20(4):585-8. doi: 10.1111/j.1365-2869.2010.00901.x. Epub 2011 Jan 12.
Prolonged nocturnal driving can be as dangerous as severe alcohol-impaired driving.

Verster JC, Taillard J, Sagaspe P, Olivier B, Philip P.
Source

Utrecht University, Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacology, Utrecht, The Netherlands. [email protected]

Abstract

In industrialized countries one-fifth of all traffic accidents can be ascribed to sleepiness behind the wheel. Driver sleepiness can have many causes, including the use of medicinal drugs or prolonged driving. The present study compared the effects of prolonged highway driving at night with driving impairment caused by alcohol. A cross-over balanced design tested 14 healthy young men who drove three sessions during night-time on the open road. The driving sessions were of 2, 4 and 8 h (03:00-05:00, 01:00-05:00 and 21:00-05:00 hours) duration. Standard deviation of lateral position (SDLP, cm), measuring the weaving of the car in the last driving hour of each session, was the primary parameter. Only 2 h of continuous nocturnal driving were sufficient to produce driving impairment comparable to a blood alcohol concentration (BAC) of 0.05%; after 3 h of driving impairment corresponds to a BAC of 0.08%. In conclusion, a maximum of two continuous nocturnal driving hours should be recommended.
2011 European Sleep Research Society.

 

[michaelrack]

J Psychosom Res. 2007 Dec;63(6):569-72.
Do sleep deprivation and alcohol have the same effects on psychomotor performance?

Yegneswaran B, Shapiro C.
PMID: 18061745 [PubMed - indexed for MEDLINE]

Unfortunately no abstract. Perhaps someone with academic/electronic access can find out what this study found?

 

[michaelrack]

Final abstract I am going to post on the question (those with more time on their hands can go to pub med and enter "sleep deprivation and alcohol")

Sleep. 2003 Dec 15;26(8):981-5.
Ethanol and sleep loss: a "dose" comparison of impairing effects.

Roehrs T, Burduvali E, Bonahoom A, Drake C, Roth T.
Source

Henry Ford Hospital, Sleep Disorders and Research Center, Detroit, Michigan 48202, USA. [email protected]

Abstract

STUDY OBJECTIVES:

Studies to assess the risks associated with sleep loss relative to the well-documented risks of alcohol are limited in number and design. This study compared the "dose"-related sedative, performance-impairing, and amnestic effects of sleep loss to those of ethanol ingestion.
DESIGN:

Mixed-design experiment with random assignment to a sleep loss (n=12) or ethanol (n=20) group, with each participant assessed under 4 conditions.
PARTICIPANTS:

Thirty-two healthy normal adult volunteers, aged 21 to 35 years.
INTERVENTIONS:

In sleep loss, participants had 8, 6, 4, and 0 hours time in bed, producing 0, 2, 4, and 8 hours of sleep loss. For ethanol, participants ingested 0.0 g/kg, 0.3 g/kg, 0.6 g/kg, and 0.9 g/kg ethanol from 8:30 AM to 9:00 AM after 8 hours of time in bed the previous night. Each participant received his or her 4 doses of ethanol or sleep loss in a Latin square design with 3 to 7 days between doses.
MEASUREMENTS:

All subjects completed the Multiple Sleep Latency Test (MSLT) at 9:30 AM, 11:30 AM, 1:30 PM, 3:30 PM, and 5:30 PM and a performance battery at 10:00 AM, 12:00 NOON, 2:00 PM, and 4:00 PM consisting of memory, psychomotor vigilance, and divided attention tests.
RESULTS:

Ethanol and sleep loss reduced the average daily sleep latency on the MSLT, both as a linear function of dose, with sleep loss in hours being 2.7 times more potent than ethanol in grams per kilogram. Ethanol and sleep loss also slowed reaction time on the psychomotor vigilance test in a linear dose-related function with the 2 being equipotent in their impairing effect. On the divided attention test, tracking deviations were increased by both ethanol and sleep loss in an equipotent and linear dose-related function. Memory recall was reduced in a linear dose-related function by both ethanol and sleep loss with ethanol being slightly more potent. Finally, sleep loss doses produced a linear decrease in self-rated quality of performance, while only at the highest ethanol dose was performance rated as poorer.
CONCLUSIONS:

At the studied doses, sleep loss was more potent than ethanol in its sedative effects but comparable in effects on psychomotor performance. Ethanol produced greater memory deficits, and subjects were less aware of their overall performance impairment.

PMID: 14746378 [PubMed - indexed for MEDLINE]

 

[45408]

Yes, every drunk guy thinks they drive better than everyone else on the road. Most drunk drivers can't pull this off, maybe some can. Wanna trust dear grandma with that drunk stranger

An incredibly high percentage of adults in my state drove under the influence in the past year, according to a federal govt survey (nearly the highest on the list). They did not all get pulled over.

I'm not saying that it's safe, but I am saying that getting a DUI is effectively based on how you act. If you don't drive like you're drunk (or crash), then you won't get pulled over, and you won't ever be tested.

 

[Sol Rosenberg]

An incredibly high percentage of adults in my state drove under the influence in the past year, according to a federal govt survey (nearly the highest on the list). They did not all get pulled over.

I'm not saying that it's safe, but I am saying that getting a DUI is effectively based on how you act. If you don't drive like you're drunk (or crash), then you won't get pulled over, and you won't ever be tested.

You must have never encountered a DUI checkpoint?

 

[45408]

You must have never encountered a DUI checkpoint?

They're unconstitutional. I just happen to live in a state that realizes that.

To answer your question, no, I haven't. I realize they exist though. I guess I should have qualified my statement to "unless you're in a state that violates your 4th amendment rights."

 

[SeekerOfTheTree]

You gotta admit now we are just being silly. Remember those puppies they studied where when they didn't get sleep they died? The poor puppies.

 

[Buzz Me]

I could see where a month of nights could be rough, since you would be out of contact with your family and friends for that entire time.

For what it's worth, unfortunately, in any busy residency you're not going to be seeing much of your family and friends during your regular workdays.

 

[ele190]

Hi everyone, i'm an italian wannabe-resident (my admission test will be next month) who attended a surgical department for 4 years during university and post-university spare year (yes, we do have one) and i was awestruck by this discussion! Our system is totally different, with the exception of ED a ICUs practically the whole of the medical work is done from 8 am to 8 pm: in public hospitals and private clinics there are just a couple of doctors on call (excluding ER a ICUs) in the whole hospital and they are paged very rarely! In our departments the patients basically are quiet all night long and trivial issues are managed by nurses, they just call the doctor if the patient is actually crashing..so my question is, how is it possible that you have that amount of work during the night? In here services like radio or endoscopy are just available for emergencies (mostly with the on-call doctor at home!) during the night, patients are not discharged and rarely admitted so there's basically nothing much to be done.
I know i don't have much experience but i still agree with the fact that sleep deprivation is dangerous, and this sacrifice might be not so necessary..in fact in here all of the doctors on night shifts are granted a full day off to recover and they also quit the hospital much earlier if they're on the next night shift (residents included).

 

[Law2Doc]

Hi everyone, i'm an italian wannabe-resident (my admission test will be next month) who attended a surgical department for 4 years during university and post-university spare year (yes, we do have one) and i was awestruck by this discussion! Our system is totally different, with the exception of ED a ICUs practically the whole of the medical work is done from 8 am to 8 pm: in public hospitals and private clinics there are just a couple of doctors on call (excluding ER a ICUs) in the whole hospital and they are paged very rarely! In our departments the patients basically are quiet all night long and trivial issues are managed by nurses, they just call the doctor if the patient is actually crashing..so my question is, how is it possible that you have that amount of work during the night? In here services like radio or endoscopy are just available for emergencies (mostly with the on-call doctor at home!) during the night, patients are not discharged and rarely admitted so there's basically nothing much to be done.
I know i don't have much experience but i still agree with the fact that sleep deprivation is dangerous, and this sacrifice might be not so necessary..in fact in here all of the doctor on night shifts are granted a full day off to recover and they also quit the hospital much earlier if they're on the next night shift (residents included).

There are 5-6 things which account for the differences. 1. Liability. If you can't be sued, nurses can do more, doctors can get away with doing less. Defensive medicine probably adds a few hours to the daily grind. 2. Volume. The number of patients to doctors is simply much higher here. Most of our hospitals in every city are larger than their counterparts in Italy. There's a big difference covering a 50 bed hospital as compared to a 300 bed hospital. We have dozens of admissions daily. And ideally a similar number of discharges because it's driven by what insurance will pay. 3. Patient expectations. In a socialized medicine system, patients have no rights to procedures and a lot if the less emergent things get put off, indefinitely. In the US we have patient bill or rights, and every patient expects every study and procedure his insurance covers during the current hospital stay. We have no patients who are quiet all night long. We have patients who "sundown" and start causing you management headaches all night long as they start to Brady down, tacky up, demand drugs, want to see a doctor immediately, threaten to leave AMA or reveal psych issues. Nights are frequently not quiet. 5. Profitability -- the MRI machines and other diagnostic tools run 24/7 in the US because time is money, and downtime is lost income. And since half of the studies get done in the middle of the night, you find lots of things you'd rather not sit on over night while on call which force your hand in doing even more things overnight. 6. We have different personal health issues here. Italy doesn't have the same level of drug trade, the gun play or the national obesity (along with related heart disease, hypertension and diabetes) we have in the US. The former two groups typically mostly present at the ED at night. But also I think the US simply does a much higher volume of much sicker crash and burn patients in it's ICUs, because waiting for someone to come in from home to perform or read an emergent study is simply not realistic or accepted here. There is going to be at least a resident on the ground in any potentially emergent service who can get things started 24/7. Or there will be a multimillion dollar lawsuit because it was negligent for the hospital to not be prepared for such a case.

It's just a very different system, to which the US as adapted. We have for generations pointed to other countries with less expensive versions of medicine, and saud "why can't we do it like that", and after a lot if small scale trials, the consensus is that while aspects of some systems might work, an overall system like used in Italy doesn't work here, for the reasons I outlined above.

It's like extrapolating a kibbutz to a national communist state. The former works great because it's small sized with fewer issues. But once you ramp it up to China or the former USSR, it's hardly the utopia it's originators were contemplating. There are many more things to keep you up all night.

You don't get points saying it's no big deal to tend to a tree, so I don't get why tending to a Forrest of totally different flora would be a big deal either... I don't mean to sound snide, but this whole "why can't the US work like other smaller countries" notion has been in our discourse for decades, and smarter minds than you and I have more or less beat the topic to death, after a lot of small scale trial and error, and the consensus is that only small aspects will work here, and even then maybe not without consequences we don't like (ie rationing, "death panels").

So we have the system we have, give or take coming tweaks. And it demands 24/7 coverage. And there's no money to add residents. So hospitals will max out the duty hours. We didn't have a ton of errors when people were working under the 30 hour shift rules (as much as the premeds would like ti characterize us as a bunch if bumbling drunks) and we aren't seeing any fewer errors now that folks are doing 13 hour night float shifts. From my own perspective folks are more beat up and tired now, but premeds aren't going to believe that until they experience it, I guess. The overnight with a post call day was a blessing compared to what we have now, but it's all about window dressing and making the lay public think their doctors aren't sleep deprived. It's a form over substance distinction, I think. Sorry to ramble.

 

[ele190]

Thank you so much for the answer! I disagree with your point "volume", cause the hospital i work in is very big (i'm bad with estimes, but i think kind of 1000 patients), it's actually one of the biggest in the country.
I also disagree with the "liability", because patients' expectations getting higher everyday and we often have to face lawsuits and practice defence medicine (which i frankly hate with my whole heart); probably we're not at your level yet but i think we'll get there soon!
It's probably true you have a lot more incoming cases because of the guns and drugs, cause for example the affluence in our ERs is not that massive at night, but it's hard to believe you just have THAT more work to do...i don't know, i'd like to spend a period there and see
For example, my department has 34 beds and a doctor is paged about..i don't know...once in five days at night! What do they usually page you for? What are your night activities (sorry but i couldn't get it right from your answer)

 

[Law2Doc]

Thank you so much for the answer! I disagree with your point "volume", cause the hospital i work in is very big (i'm bad with estimes, but i think kind of 1000 patients), it's actually one of the biggest in the country.
I also disagree with the "liability", because patients' expectations getting higher everyday and we often have to face lawsuits and practice defence medicine (which i frankly hate with my whole heart); probably we're not at your level yet but i think we'll get there soon!
It's probably true you have a lot more incoming cases because of the guns and drugs, cause for example the affluence in our ERs is not that massive at night, but it's hard to believe you just have THAT more work to do...i don't know, i'd like to spend a period there and see
For example, my department has 34 beds and a doctor is paged about..i don't know...once in five days at night! What do they usually page you for?...)

Residents do a lot of cross covering of patients from multiple teams. A typical intern year night, you may be carrying 3 pagers and have one of them going off every 15 mins or so all night. Nurse X thinks patient Y doesn't look right, can you come and see him? Patient Z is vomiting blood. Pharmacy calling to ask if when the daytime resident ordered a certain med, did he really mean such a high dose? The lab calling, there's a critical lab value on Ms A. Radiology calling, patient C has an actively bleeding Hematoma. Nurse H calling, can the patient who is NPO for a procedure have ice chips? Nurse G calling, patient R is upset and acting crazy, wants to leave AMA, can you come and talk to him. ER calling, we want to admit Mr t to your service. Can you come and see him? And so on. All night long.

 

[ele190]

Wow! And that in a regular department or ER-ICU? How many beds? We actually don't have so much emergencies during the night (we don't even have inpatient emergencies everyday actually). Plus, lab will NEVER EVER call you (you must check the results on the computer) and pharmacy stuff are handled by the nurses.
During our typical night ER and ICU work regularly, radiologies and non-urgent labs and ORs are closed (just like in the weekends) and patients quietly sleep
Another question: your amount of work is at least compensated by the quality of the education? Cause in here residents are treated like *****s till the end (specially in the university departments) and never allowed to make decisions...

 

[Law2Doc]

Wow! And that in a regular department or ER-ICU? How many beds? We actually don't have so much emergencies during the night (we don't even have inpatient emergencies everyday actually). Plus, lab will NEVER EVER call you (you must check the results on the computer) and pharmacy stuff are handled by the nurses.
During our typical night ER and ICU work regularly, radiologies and non-urgent labs and ORs are closed (just like in the weekends) and patients quietly sleep
Another question: your amount of work is at least compensated by the quality of the education? Cause in here residents are treated like *****s till the end (specially in the university departments) and never allowed to make decisions...

That's regular floor cross coverage, not ICU. In ICU the problems are bigger, but there are fewer patients. Many ICU patients were floor patients before they took a turn for the worse and become ICU patients though. Labs and radiology will call you -- that's part of the defensive medicine, as long as they tell someone who has the responsibility to fix the problem, they are off the hook. If you don't communicate it and it goes unnoticed, you are F-ed. Radiology machines and the labs never close. ORs are available only for emergencies at night, but there are surgical residents or fellows on site all night. Patients don't quietly sleep in bed because in the US if they aren't that sick, they would already be home -- beds are driven by insurance company reimbursements so unless they have something reimbursement worthy they get sent home faster here. Money drives this system. Compensation for residents is lockstep. You get around 38k intern year and it goes up a couple of thousand a year until you finish fellowship. But you do make a ton of the patient care decisions, particularly overnight. After a few years, attendings give you a lot of leeway and are happy to let you handle things.

 

[ele190]

So you must discharge patients very quickly! In here it happens they stay in a bed a week or two waiting for an endoscopic exam or for the chief (!!) who absolutely want to operate them in person.
Before discharging a patient we think not once but at least 3 times so there are a lot of floor patient who are actually quite fine, just about 10% of them are critical
But we also have very difficult patients we can't absolutely send home, sometimes they stay for months and undergo multiple surgeries...what do you do with them with your insurance system? In here private hospitals just send difficult patients to the public one or randomly discharge them
Ah...by compensation i didn't mean money (we earn 18700 a year tax-free), i meant growing up professionally

 

[Winged Scapula]

IMHO acuity is a big difference, having worked in both the US and a country with a nationalized health system.

As you note, patients in foreign hospitals will often sit around for days-weeks waiting for a procedure. That simply does not happen (in isolation) in the US; if patients are not sick enough to be in house, they go home. For example, I have an acquaintance who is undergoing a benign breast lumpectomy in Japan. She was told to expect to stay for 1 week post-op; a lumpectomy (even for breast cancer) is an outpatient procedure in the US. Thus, if you have a ward full of people who are POD #7 after a laparoscopic appendectomy or whom have recovered from a bout of diverticulitis but are waiting for a colonoscopy or CT scan, then your nights may very well be much quieter.

I'd also like to add to L2D's notes about what sort of calls residents and fellows get at night: they are not all emergencies (as a matter of fact, I would venture that most are not). Lets not forget:

a) "Patient X's family is here and would like to talk to you NOW"
b) "Patient Y had a temperature of 100.1 and I gave him the Tylenol you ordered; just wanted you to know"
c) "Patient Y has a temperature of 100.1; can I give him Tylenol? Oh its ordered? I didn't see it. Sorry."
d) "You've written for a Foley to be placed, but I can't get it in/find the urethra/patient wants the doctor to do it."
e) "Patient Z is cursing at me; I want you to come and tell him to be nice to me"

and so on...

In regards to education, it is fairly well recognized that many countries outside of the US follow an apprenticeship model, with less responsibility and autonomy than here.

 

[ele190]

Yes, late discharging or insane waiting lists for recovered patients are a big issue in my hospital; i think sometimes the discharging is delayed for too long just because of laziness or defensive issues, it's not good for the patient to stay in the hospital too long in my opinion. Another HUGE issue causing late discharging is the massive lack of post-acuity places: sometimes you have to keep many old patients in the ward doing basically nothing because they don't have the support they need at home.
What do you do in those cases (89 year-old Alzheimer patient with family living far away and so on...)? And about the very-long recovered? Sorry if i go OT but i'm madly curious!

 

[Law2Doc]

...

I'd also like to add to L2D's notes about what sort of calls residents and fellows get at night: they are not all emergencies (as a matter of fact, I would venture that most are not). ....

yeah, I agree, didn't mean to give a skewed perspective, which is why I threw the "ice chips" question in there. But yeah, we all have gotten tons of the "can i give Tylenol" questions.

 

[45408]

sometimes you have to keep many old patients in the ward doing basically nothing because they don't have the support they need at home.
What do you do in those cases (89 year-old Alzheimer patient with family living far away and so on...)? And about the very-long recovered? Sorry if i go OT but i'm madly curious!

We almost never keep them. They'll go to a skilled nursing facility (nursing home), and we replace them with someone who is much sicker.

 

[Winged Scapula]

We almost never keep them. They'll go to a skilled nursing facility (nursing home), and we replace them with someone who is much sicker.

Or sometimes family suddenly becomes interested in taking grandpa home when they realize that insurance benefits will not longer cover his "luxury suite" in the hospital and they'll be responsible for the medical bills.

In the US, we have case managers who work on such things and chart reviewers who troll the wards looking for people who are overstaying their welcome (although in some cases, they don't understand the issues which might make it reasonable to stay).

Patients who don't need acute care are transferred to skilled nursing facilities, rehab facilities, etc. or to home with visiting nurses.

 

[Doctor Bagel]

We almost never keep them. They'll go to a skilled nursing facility (nursing home), and we replace them with someone who is much sicker.

But sometimes finding a SNF for patients can be hard, especially for people with things like dementia with behavioral issues, so treating people needing placement isn't that abnormal for most residents, I think. I've been on medicine, psychiatry and neurology teams composed of a good numbers of folks waiting around for placement. Maybe surgeons escape this more than the rest of us. From a work perspective, it's not the end of the world if you're on a team that's always going to be capped anyway because it spares you admits. It sucks when you don't have a cap or when you never reach the cap anyway.

Of course these placement guys are also the ones who fall all night, get hyper (or hypo) glycemic and get agitated and all sorts of other cr@p that results in me being called. Patients quietly sleeping -- what a thought. In the psych world, we also get called when pts aren't sleeping with demands to write for a sleeper even though it's 4 am. Then we called about docusate, cpaps and CBGs of 201. I hate call!

 

[ele190]

Oh i understand...in here nurses are a lot more autonomous, they usually call the doctor is something is very wrong
It's very good you can dispose of lots of nursing homes and rehab facilities, it's much more cost-effective! In here it's the doctors' and chief nurses' job to find accomodation for the patient who can't stay home and it takes veeery long

 

[Law2Doc]

Oh i understand...in here nurses are a lot more autonomous, they usually call the doctor is something is very wrong...

So from your posts I think we can summarize that residents here do a lot of the job functions attendings plus nursing do in your country, with a much greater volume of much sicker patients, and much higher turnover. Plus we continue to get radiology and laboratory information all night, requiring our attention, and have legal reasons to not sit on things until the morning. Not too much of a mystery why the hours are longer and nights are busier.

 

[Winged Scapula]

But sometimes finding a SNF for patients can be hard, especially for people with things like dementia with behavioral issues, so treating people needing placement isn't that abnormal for most residents, I think. I've been on medicine, psychiatry and neurology teams composed of a good numbers of folks waiting around for placement. Maybe surgeons escape this more than the rest of us. From a work perspective, it's not the end of the world if you're on a team that's always going to be capped anyway because it spares you admits. It sucks when you don't have a cap or when you never reach the cap anyway.

Yes, we've all had to deal with patients with placement issues. But I do think that there may be a specialty difference. If patients are too ill to undergo surgery because of major medical/psychiatric problems, they are generally not on the surgical service; IMHO these are typically the patients who are often placement problems.

Surgery also doesn't have caps on admissions. I can honestly say that having more than 1 or 2 patients waiting for placement was unusual during my training and waiting more than a few days was very unusual. Perhaps we just had good case managers.

 

[ele190]

In here people with major medical/psych problems are operated anyways if it's an urgent surgery, and if you try to send them to the IM department they will never ever accept (the department doesn't accept).
Patient often stay 3-4 weeks waiting for a location, even in surgical departments...

 

[belle54321]

of course, pt who needs urgent surgery will get it. For the most part, in the US, rarely do patients stay in hospitals before "elective" surgeries. You come in the day of surgery. Things like bowel preps, etc are done at home. People who wait around usually came in on medicine service (or getting medical treatmet on the gyn service) and ended up needing a procedure.

I think it is very interesting to know how differences between the Italian and US health systems, but you are comparing an apple to an orange. So, the residency system here will prepare us to function as attendings in our system. As someone who is an obgyn attending, I can tell you life as an attending can be even more stressful and demanding than that of a resident.

 

[45408]

But sometimes finding a SNF for patients can be hard, especially for people with things like dementia with behavioral issues, so treating people needing placement isn't that abnormal for most residents, I think. I've been on medicine, psychiatry and neurology teams composed of a good numbers of folks waiting around for placement. Maybe surgeons escape this more than the rest of us. From a work perspective, it's not the end of the world if you're on a team that's always going to be capped anyway because it spares you admits. It sucks when you don't have a cap or when you never reach the cap anyway.

We rarely have patients who can't be placed within 3 days or so, once they're ready to go. We still get patients who are post-op day #20 who aren't ready to go though. People are almost never able to get into a nursing home between Friday at noon and Monday morning though.

The downside is that our surgery services never cap, ever. The only thing that might happen is that an attending would refuse a transfer for a cold leg because we already had a ruptured AAA on the way.

 

[LucidSplash]

We rarely have patients who can't be placed within 3 days or so, once they're ready to go. We still get patients who are post-op day #20 who aren't ready to go though. People are almost never able to get into a nursing home between Friday at noon and Monday morning though.

The downside is that our surgery services never cap, ever. The only thing that might happen is that an attending would refuse a transfer for a cold leg because we already had a ruptured AAA on the way.

Same here. Except every once in a while we have a trauma patient that is just almost impossible to place. Typically this is due to the combination of lack of insurance, relative paucity of available inpatient psych facilities in our region, and general refusal of our existing psych facilities to take patients with basically anything more serious than a papercut... and they'd think long and hard about the implications of having a patient with a papercut. They once refused to take one of my discharges on a Friday because the patient had superficially stabbed himself in the neck a week prior and the patient's hematocrit dropped two points from the day prior to the planned discharge. First, a pox on my co-intern who ordered the unnecessary crit and second a pox on the accepting psychiatrist who claimed he was concerned about "occult internal bleeding from the recent injury." By Monday and a weekend of daily hematocrits which were totally unnecessary, they grudgingly accepted that he didn't have an occult neck hemtoma. I've had a few patients with psych issues sit around for months before they left the hospital. Also a couple uninsured severe TBI patients with considerable deficits - skilled nursing wouldn't take them because of "history of aggressive or violent behavior" before their trauma, which had rendered them unable to feed or clean themselves let alone take a real swing at someone.

 

[SouthernSurgeon]

and general refusal of our existing psych facilities to take patients with basically anything more serious than a papercut... and they'd think long and hard about the implications of having a patient with a papercut.

Glad its not just our hospital that has these issues...

I had a trauma patient sitting around waiting for dispo...we finally got them accepted to psych...until the psych unit charge nurse came to evaluate the patient and saw that they had a JP DRAIN and told the psych attending that the patient was too complex for them to medically manage.

This then led to me talking to the charge nurse about the fact that we send patients home on POD#0 with JP drains and they seem to manage them just fine...

 

[ele190]

I think it's a global issue, just every health professional in the world will try not to take a patient from another department if he can