Residency Hell

I believe there is legislation to limit the amount of hours for residents.

 

The problem with legislating the amount of hours that residents work, is that the legislation is being written by people who've never been residents or hospital administrators.

Residents are the workhorses of any hospital. They do the most work for the least pay (sorry RNs!). If hospitals are forced to cut back on the hours they assign to residents, who's going to do the work? Invisible medical fairies? While I support the idea that residents need to work fewer hours (and I'm dreading my turn, if I make it that far!), some logic needs to be applied to the solution.

As I've heard it, there are only two solutions currently being put forth.

1) Increase funding to hospitals so more residents can be hired (in this administration? fat chance)

2) Assign residents 12-hour shifts, 7 days a week.

So... maybe everyone needs to start writing to congressmen about option 1. Circulate a petition amongst your classmates. Get some professors and TAs in on it, too. It's all well and good to say "cut the hours" but that leaves a lot of slack that has to be taken up somewhere. And, be honest, would any of us really mind if more residency positions opened up? ;>

Nova

 

Are residency positions 100% funded by Medicare? Dont the hospitals contribute anything to their salaries, after all the residents are contributing greatly to their efficacy.

Can somebody give me a breakdown on the funding situation? How much is paid by Medicare and how much by the hospitals?

Our hospitals must absolutely be in the most dire financial straits if they cant even afford to contribute to the residents mediocre income.

 

Like sucks as an intern. I was at the hospital this morning at 3:30 A.M. and got home at 8:00 P.M. I didn't have time to eat breakfast or lunch. This is also a non-call day. When I am on call this Monday, I will be at the hosital at 3:30 A.M. to pre-round and then I don't get out until Tuesday at 8-9 P.M. That's a little over 41 hours straight. You will work OVER 100 hours during internship. The programs in NY are supposed to be limited to 80 hours, but I hear this is NOT followed.

 

Programs are roughly paid $100,000 per AMG (MD/DO) and less for a FMG. This is on top of the fact that you allow a hospital to see more patients and you take the load off the attendings to take call and do all the scutwork. You are basically SLAVE labor. By the way, for all our efforts, you get paid under $38,000 for your first year.

 

Hey!! Lets not paint a negative picture about residency!! I am really looking forward to that day when I will be a resident. I think it will be fun. If residents can do it then it IS possible to work so long shifts ( not that I am not against it!!). About falling asleep on the wheel....I experience that now itslef...I could never understand how people fell asleep on the wheel before starting med school but after working for a whole day and trying to drive back home late at night my eyes just want to shut !! The remedy to this is ofcourse to pull over and sleep in your car untill you feel fit to drive...PLEASE DON'T SLEEP and DRIVE!! You might kill somebody on the road and will regret that for the rest of your life. I know that the time is limited and I know we work like dogs in this profession but don't we all love this profession? We enjoy it!! Thats what we always wanted to be ( otherwise you need to get out of this career!!). Just relax, take it one step at a time and you will get through each hour of residency.

 

As a pre-med student the issue of resident/intern work hours is one that I follow vey closely. I support the actions of the AMSA and other organizations that are taking action to correct the situation. I have yet to even enter medical school, but it is obvious to see that interns/residents are the work horses of the medical community. My primary concern with this situation is the negative impact that the long hours, no sleep (no eating, bathing, or other basic human needs for that matter), and over all stress has on the intern/resident's health. I have some questions for current residents/interns: How has your residency/internship affected your mental, physical and social well-being? Would it be possible for you to gain the experience necessary to become a competent physician in your chosen specialty while working less hours per week? If so, how many? I pride myself on being a very healthy individual . . . no smoking, no drinking, no caffeinated or carbonated drinks, and I exercise for an hour per day. My passion for becoming a physician is unrivaled, however, it makes me very upset to think that I have to sacrifice my own good health to help others achieve theirs.

 

What ever happened to "The doctor is his/her own first patient"?

 

You won't have to wait for residency for hours like these. At certain times during your third year rotations you will easily do over 100 hours. My specialty surgery month in vascular was a nightmare. And, many times during medicine I was up all night on call and worked the next day until 5pm or later. So get ready. It is not healthy, but you do what you have to.

 

Lets say that instead of working 100 hours per week, that you had only worked 80. Would you have learned that much less? Do you really gain so much in those extra 20 hours per week in terms of new procedures and learning how to work under pressure that its worth risking your own health and indeed the health of patients? I understand there are some benefits under working in such a harsh system (residents learn to work under pressure, get to see unique cases) but is this benefit SO great that its worth risking your health and indeed the health of your patients? I just dont see that to be the case, but I'm not a resident so I defer to your judgment.

I understand that residents will always have to work long shifts and it will never be a 9-5 type job and neither should it be. But I just really cant comprehend being able to learn that much more in a 100 hour work week when you're exhausted for the most part and just barely pushing through than if you just work around 80-90 hours per week (which is still double the standard work week).

That way, the resident wouldn't have to push through 36 hour shifts on a regular basis.

I've talked to some residents who have gone through this and consensus seems to be that they really didnt learn that much more by working such long shifts than if they had worked less. But I'm curious about the residents' perspective on this forum. Sure, they were exposed to a couple of new situations, but they remarked that its still not worth the health risks it poses. They also felt that the care of patients with "routine" problems suffers greatly under such a system where the resident is struggling to stay awake on the job. After all, most residents can perk up temporarily to treat a critical case, but what about the routine case? Is their care any less important than a patient who is critical?

The bottom line is that patient care, in addition to resident health, suffers under hte current system. IMHO, from what I've seen and heard, any potential benefit of this system is mediocre at best in comparison to the possible risks, both to resident and patient.

It seems like alot of opponents to changing the current system argue that residents can't get trained properly in a standard work week. I agree with this, but I'm not talking about a standard work week. 80-90 hours a week is certainly not the norm for most Americans so thats not really a valid point. I can understand working 12 and 15 hour shifts routinely, and maybe even a 20 hour shift sprinkled in from time to time. But to work 36 hour shifts? Thats ridiculous and just doesnt make sense to me.

Despite the arguments of the establishment which insists that the current system needs to be maintained, I get the subtle impression that the real reason many people dont want to see the system change is due to the attitude of "I had to do it, so its only fair that you should have to do it also." I think its time we moved on from such childish arguments and frame the debate around the people who are the most important, the patients. Are they best served by a sleep starved resident in his 35th straight hour on the job?

 

"The physician will hardly be thought very careful of the health of his patients if he neglects his own."
-Galen

It's all well and good to talk about what the resident gets out of his or her experience in terms of education, but I think the health of residents' patients should come *far* before the benefit to residents' educations. I can't imagine not feeling guilty at the end of a marathon shift, when I would have a reasonable doubt as to the quality of care I am giving to my patients.

-Carl

 

That is so true. The late required conferences are just about the nastiest thing that is done to a student. You think I could go home and sleep, but no I get to go hear another lecture on diabetes. And, half the time the lecturer doesn't show up. Uhhhhh! And, your resident says and since you have to stay around anyway why don't you wheel Mr. Smith to xray and wait for the results.

 

I've been pretty interested in this issue ever since I spent a few years of undergrad working for a major sleep doctor/researcher who was extremely active in the legislative arena as well. It's sort of amazing when you think that all of these studies have been done showing that drowsy drivers are just as accident-prone as drunk drivers, and both sets lose about the same amount of reaction time and coordination, and then correlate it to the medical field. I can only imagine the public outcry if the residents were reeking of Jack Daniels or vodka...

 

And let's not forget that we legislate the number of hours that truckers can be on the road and driving before they have to stop (10 hours). As a country, we acknowledge that you're not competent to make safe driving decisions on little to no sleep. But it's perfectly ok if a resident starts cutting on a 12 year old after more than 24 sleepless hours?

And if it is just for the learning experience, someone should point out (I'll do it! ) that your ability to absorb, retain, and recall information is dramatically impaired by sleep-deprivation. Which is why it's always important to get a good night's sleep before a test ahem ahem ahem.

I think this is one of the more interesting tangles facing the medical-student community, and even though I won't be a resident for years yet (if at all), I'm paying close attention. I'd love for this to be resolved by the time I'm in the trenches. I predict that we'll someday be looking back on this era and will say, "Even as late as the early 21st century, residents were still required to work hours that the medical community knew compromised patient care." And everyone will shake their heads, wondering how we could have been so stupid.

Nova

 

first off, yes, kimberli, I would DEFINITELY go for a longer residency (or even the 12/7 schedule proposed earlier).

Changing the subject a little bit...

Im trying to find any legislation/whatever that deals with the sleep deprivation issue in residency for people with disabilities/diseases that NEED regular sleep patterns to function (i.e. bipolar disorder) Would this fall under ADA?? If anybody knows a website or journal I'd be FOREVER grateful.

thanks!
Star

 

As Nova mentioned, if resident work hours are cut back, someone will have to pick up this slack. I don't think the answer is to increase the number of residency positions, as this would eventually lead to a glut of physicians. I think the answer is to hire ancillary staff to do much of this scut work. However, I understand that the bottom line is, as it always is, about the $$$, and this is not an option for hosptial administrators.
What I want to know is - in this nation of ours where individual rights are placed above that of the common good of society (thanks to the media and extreme left wingers)and are exemplified by frivolous law suits resulting in large settlements for the plaintiff (i.e. patient's life is saved and then they sue the hospital, the DR., and anyone else invloved), WHAT HAPPENED TO MEDICAL STUDENT AND RESIDENT RIGHTS? I mean do you literally sign something when you accept your acceptance to a medical school that waves your basic human rights. I choose to become a competent physician. I think that in general a resident or medstudent should not have to work any longer than the most number of hours any attending has to work (i.e. if a IM physician works an average of 80 hours/week then that is what a resident should have to work.) 100-80= 20 hours. What in general goes into that 20 hours? For the most part I guess scut work (I assume as I have not actually been there). Now consider what the resident could do with that 20 hours if it was his/her own time. For me me that could mean 2 hours more sleep per night and 1 hour of exercise six days/week. That 20 hours would go a long way for the resident or medstudent's health and well-being, while not making much of a difference in his/her medical education.
I can't beleive that the work hours situation has gone on as long as it has, especially with the evidence looming of the detrimental effects it has on resident and patient health. If this was an issue affecting the lay person in the general public, it would have been addressed long ago. However, since it does not directly involve the general public, the issue has persisted to this day. The only reason that this issue is getting any coverage in the media is because it affects patients. If legislation does pass to limit resident work hours, it will be to protect patients not residents. I think the general public couldn't care less how many hours/week residents work, as long as it doen't affect them.
The only way resident work hours are ever going to be regulated is through legislation. As the "I went through it, so must you" mentality persists and the endoresement of the current system by the AMA (to keep costs down), resident work hours are never going to be regulated within. If the AMA and others endorsing the current system were wise they would find some neutral ground for all and regulate resident work hours internally to keep Washington from exerting control over medical issues, but that's not going to happen and Washington and legislation is the only hope for regulation of this situation.
Sorry this got SOOO long, I just had to vent! ERIC

 

Interesting letter. I wonder if steps like this are seriously ever going to do any good.

My only complaint was that I don't think they spent enough time going over the possible risk to patients. I think that if the training system is ever going to be changed, this aspect of it (the poor care of patients as a consequence of sleep deprived reisdents' mistakes) needs to emphasized to generate public outcry. People obviously wouldn't want to see a drunk doctor in the ER -- why do they want someone who hasn't slept in two days?? However, because of the obvious reticence of ever admitting mistakes or wrongdoing in the medical community, I'm not sure if enough information can ever really be collected about this problem.

 

atlas_shrugged - That petition from the link you listed was directed at OSHA. I read somewhere (I think the AMSA webstite) that although OSHA will take the petition into consideration and make a formal report, a spokes-person for OSHA made a preliminary statement that (basically) the issue of resident work hours does not fall under whatever jurisdiction OSHA has, in other words they can not (or will not) regulate this issue. (Again this was just a preliminary statement.) That's why I said in my previous post that the only hope for regulation of resident work hours is through Washington and legislation. Representative John Coniers of Michigan is introducing legislation this summer to Congress that would regulate resident work hours.

ERIC

 

If it comes down to needing longer residencies to compensate for the limited work hours, then I think its a sacrifice we need to make.

Patient care is compromised with the current system. Don't we owe it to our patients to give them the best quality care possible?

On another note, someone stated that each residency position in the U.S. is funded at $100,000 per year by Medicare. Assuming thats accurate, what is this I keep hearing about a funding shortfall? When the only pay residents between 30-40k per year what are they doing with the other 60-70k per year per resident position? I know the hospital has some costs to bear for teaching residents (insurance comes to mind) but are the costs THAT great to where the hospitals arent coming out ahead in the process?

I also agree that we should not fund additional residency positions. In some cities, we have too many already.

It will probably take a few more high profile accident cases (like the one in New York) before something is done about this issue. Its sad that the government won't act on this problem and the general public wont get upset about it until there is some scandalous case where a patient needing routine care ends up dead because of the poor judgment executed by an exhausted resident.

I think the long resident hours and 36 hour stretches perhaps SLIGHTLY help the resident learn to work under pressure, but at what cost? Is that extra training worth jeapordizing the health of patients? Clearly to most attending doctors they feel that it is. A 36 hour shift maybe once a month or so might be OK, but to do it on a regular basis defies common sense.

Do the attending doctors/supervisors in New York realize that they are breaking the law by forcing their residents to stay longer hours? If they dont agree with the law, then they should try to change it, not break it outright. If I worked as a resident in one of these hospitals, I would outright question the integrity of any attending who would openly break the law like this. If they are going to take shortcuts to get around the law this way, are those the kind of doctors we want training residents and working with patients?

 

Recently on the news- airline pilots are working too many hours even with the limits imposed, and that is putting lives into danger. Hmmm, if they only realized.

And, in the nahnah nahnah boo boo catagory, I've never spent more than 50 hours in the hospital!

 

I'm at the other end of the tunnel - just ready to leave my 5 year residency in medicine and psychiatry.

A few points (okay - many), some of them playing the devil's advocate:

1) Many hospitals have come to depend on the cheap labor that resident's provide. The long hours are not usually because of interest in "educational" opportunity, but more out of requirements for clinical service.

2) I would guess that part of that money going to the residency program is used to write off losses for caring for uninsured patients. I just know that many hospitals are struggling financially, and the last thing they would be excited about would be having to hire more staff to take on the role of residents working less hours, even if it obviously needs to be done. The government would then have to come up with the money to help out these institutions to keep them going - politicians won't be excited about more taxes.

2.5) Longer residency with less hours - would you also take less pay? Who would pay for this extra training time? The taxpayers. I do know people who modified their residency to work every other month so they could spend time with their family. I don't know the details of the financial arrangement though.

3) There are the restrictions in New York, and I did hear that they were mostly ignored. I know the ABIM/ACGME has requirements for medicine residency programs which are being somewhat enforced, as programs are evaluated every few years and can lose accredidation for too many violations.

4) Something to keep in mind is that no one is forced to become a doctor. No one is forced to become a surgery resident, let alone one at a program with a (proud) reputation of a 110% divorce rate. There are options for residency programs that are not so malignant. Each person has to make a choice for their own personality and life-style. You'd be surprised that there are actually people who would hate to only work 70 hours a week.

5) The long hours don't end after residency (for many people). Private practice docs usually see more patients, and often work longer hours than some residents - they make this choice because they like it (or like the money / need it to pay off debt)

6) I have found a lot of my time in residency is now spent on paperwork that was not part of my job 5 years ago. Same is true for the staff. Much of the new medicare billing guidelines are killing medical education. More time on paperwork, less time with patients, teaching, and learning. And now records are less useful to read through than ever.

7) You'd be amazed that even with all of the complaining of being overworked, how many residents manage to find time to moonlight.

8) Good question about someone with needs for regular sleep patterns and whether that would fit under the ADA - I don't know. I have heard of a resident with bipolar disorder and the program allowed him/her to not take night call. I don't know what reasons went into making the decision.

I personally think more resources should be invested into finding economical ways of delivering care that allow for physicians to work more normal hours. Some of this is already being done with physician assistants and nurse practioners. It is not so simple as making a law saying residents can only work an average 80 hours per week and expect the rest of the system to handle it.

Rick
Medical Jokes and Cartoons

 

Believe it or not, there are worse working conditions and more life challenging situations than medical residency. For example, military combat in Viet Nam, Korea, WWII, WWI, and the Civil War comes to mind. Some of those battles lasted for days (Hamburger Hill, Pork Chop Hill, Battle of the Bulge). Those folks did not get much sleep either. Neither was the pay anything to brag about.

 

First of all, groundhog, a lot of those troops ended up making mistakes too. Also, there were more amphetamines in all those wars than there were bullets!


Second, if anyone really thinks that making a residency longer would help, they are fooling themselves. Our 'tradition' is too deep rooted to change now. All I see happening in that situation is hospitals getting slave labor for twice as long!

 

When you say the regulations are being ignored, lets be clear: THEY ARE BREAKING THE LAW. Do we just allow people to break laws as they see fit if they dont agree with it? New York needs to do a better job of enforcing those laws, or else they should have never enacted them in the first place.

I dont understand why everyone in NY is just content to tolerate that. If they dont comply, their accreditation should be cut. I think residents have a moral obligation to speak up against this. Everybody seems to think that its within the attendings discretion to follow the law or not. Attendings are subject to the law, just like everyone else. If you were a patient, would you trust an attending that routinely breaks the law as he/she sees fit?

Hospitals are in dire financial problems, but I think it has much more to do with the care of patients who cant pay and government's lack of financial compensation for these cases, than it does with their ability to pay residents. That should be a separate issue from residency funding. Using the residency funding to care for indigent patients is a form of financial mismanagement in my opinion. They should allocate a separate fund for that issue instead of linking it to residency positions.

A funding level of $100,000 per position should be adequate to fund more than 1 single residency position. If the hospitals are allocating that money to other resources not directly linked to residency training, then Medicare needs to rethink the funding scheme so that the finances are kept separate.

I think the poster above was accurate in stating that we cant just expect the system to adjust automatically to a change like this. But that doesnt mean that we should just not investigate the issue at all. There is a direct correlation between 1) resident health and working hours; and 2) patient health and working hours. I realize that it will take time and serious thought to change this system, but we need to start somewhere. I dont understand why everybody is just willing to accept the system the way that it is, even when we know we can do better.

I just can't have respect for the attitude of 'well there are some tricky issues to resolve with this issue so its better not to try anything new at all.' I realize that there are difficulties associated with any new method of doing things, but honestly how many hospitals around the country do you think have really considered the alternative? I have a gut feeling hospitals and Medicare have not really considered this issue at all.

 

The issue raised by this thread reminds me of a movie. Do any of you recall the scene in Godfather II where Michael visits Myron in Florida right after the assasination attempt on Michael? Michael complains about the attempt on his life which prompts Myron to counter with some of the unpleasant things that happened to him. Then Myron directs a barb at Michael by finishing with "I remind myself that this is the business I have chosen."

Well, that was a good scene. But you residents keep striving for better conditions just the same. One should never stop pressing for improvements.

 

My question is more along the lines of ...

How the hell are we going to make it through these shifts???

I understand that people have done it before, and people will do it now ... But, I really don't think my body or mind could handle it. Seriously. Will I fail Surgery because I'm falling asleep all the time? I don't want to hurt any patients either. And that driving thing, geez, I'm a lousy driver as is, after 30 hours of work, they'd better clear the roads for me.

I just don't get it: After pulling all-nighters for tests (30 hours or so), I am ready to die for like 8-10 hours ... I don't know how I could work 36 hours, sleep for 7 or 8 and then do another 12 hour shift. My body will be ruined ... How do you have time to work out or eat nutritiously or talk to your friends or go for a run or read a book?

I just don't like the idea of getting fat, depending on stimulants, losing contact with my dawgs, and looking like a mess constantly. I can't do that. I am too pretty of a guy to have to deal with all that.

And, Kimberly and other residents, how am supposed to take advantage of the fact that I'm a doctor and mad chicks will want me? If they work me like a rented mule for 3 years, I am going to come out a shell of a man, and even the doctor thing won't work with women. This sucks, man.

Funny thing is, my parents think I am a lazy SOB (I am) ... and I bet they are looking forward to seeing me work my tail off... Actually, I know they are, they kind of laugh about the whole residency thing...

Well, good luck Doctors!!! You guys rule! I'll sleep for you this summer, okay?

Simul

 

I am sure that there is some fat to be cut in all hospitals. Maybe the Emergency Wards should really consider who they turf upstairs, so the hospital may be able to free up some of it's resources. Health care is just way too abused by the public, and I think, that many interns/residents/privates just want these people out of their faces, so they send them somewhere else. I just think that hospitals should keep an eye on admissions. A good percentage of patients are little old ladies in NO APPEARANT DISTRESS, requiring care that could be spent where it may really be needed, or for personal time for interns. I'm sorry, this is just what I observed from my volunteer work in medicine. Too much abuse of the health care system which would just result in increased demand for resident's services. Once some of these resouces may be liberated, there would also be more help for some of the other specialties, such as surgery.
Also, if there was some way to get this lazy country on it's feet and moving/exercising, and eating better, there would be much less incidence of various preventable disease. I think that the outrageous fuel prices are a good thing. Maybe we need to see prices around 6$-7$ like in the UK, maybe that would get more people walking/riding bikes. Maybe that is the reason that UK residents work 40 hours a week. This country is just so damn unhealthy. These are just some of my ideas to improve our health care system and make residents life more easy. I think that the only solution is revolutionize the current system, and find a way to promote more healthy lifestyles among Americans. Russ

 

On a side note,

Whats a typical attending workload? I've heard arguments made by them that the hospital would not be able to function without residents (i.e. too many patients would go untreated). If they feel so strongly about this issue, why havent they volunteered to share the workload in a more equitable fashion instead of forcing everything on the residents?

I question their true motives. I still think its worth fighting against the current system because its the right thing to do. I think deep down everybody senses this. It will be hard to revamp the current system, but lets face it, most doctors are pretty smart people and I'm sure they could come up with a viable alternative if they would just admit there's a problem and try to work together to find a good solution. My impression for the most part is that they have refused to even look at the issue.

I seem to remember that the laws in NY were enacted only because the journalist (whose daughter died) raised hell in the media. Unless a similar situation unfolds with a legislator's loved one, there probably won't be any new laws on this issue. I certainly dont expect the situation to change from within the system, especially since most residents are too scared to speak up.

Unfortunatley, it seems that most residents are afraid to step up to the plate, even though I sense alot of them feel there are problems with the current system. Until they speak out with a larger, more unified voice, I guess we cant expect anything to change.

 

Flatblues
"Little old ladies in no apparent distress."

I hope you didn't seriously mean this very ageist comment and if you did I hope you aren't going into medicine. Anybody else sensing a lack of compassion?

 

star23
Anybody else sensing a lack of a sense of humor. It is from the book called "House of God". Why are so many people so "up tight" about everything. Chill. If you believe that doctors/nurses/PA's are in some way more than human, you've got another thing coming. Do you think that medical school and graduate training are suppossed to suck the life out of the student? Your attitude is typical of someone with little or NO clinical experience. This is not intended to be a flame, but I find it just ridiculous when people like you just look for anything to start a fight over. I suggest you try and find something better to do than pick apart what others do and say. That attitude wont get anyone anywhere, regardless of what career and life paths they decide to take.
Russ

 

Ageist? Come on.

I agree that the poster has yet to experience the realities of clinical medicine...

 

Hey, in case you missed my previous posts, this very topic will be disscussed on CNN tonight at 8:30pm EDT!!! AMSA, who has been advocating for restrictions on residents' hours, will be disscussing their fight with Gretta VanSustern. Tune in, and post what you thought after it's over!

 

Hmmmm?
Russ

 

Despite the fact that I work (depending on the rotation) 100+ hours per week.. I love being a resident.

When you first start it sucks….When I did my medicine, surgery, and neuro rotation there were nights that I never saw the call room that meant I worked about 40 hours straight without any sleep….

Here is a typical intern call night:

You get a call in middle of the night, as your head is about to hit the pillow, on someone who is crashing that you have never seen before and no one has checked out to you…but since you are the intern on call …its your responsibility to deal with it....You run to the floor. you examine the patient quickly and go through the chart trying to figure out what could be causing this patients demise, while the RNs are getting nervous and yelling that the pts vital signs are dropping….You quickly change your scrub pants (usually for the second time) and then call your senior resident and he/she will ask you questions about this patient that you don't know the answers to…then the senior resident proceeds to tell you to do stuff that you have not done before….and tells you that as soon as you are finished with this there is new admission for you to do in the ER and there is a direct admit that will be here in an hour….. By this time (about 2-3 mins) the RNs are getting very nervous and are hovering around you saying "so what should we do, what should we do….pt doesn't look good…need some orders"… then your pager goes off again and it's another patient with a crushing chest pain… (again you don't know the patient)… You get the vitals over the phone and order the STAT EKG, CIEs, ASA, Nitro and tell them that you will see the pt as soon as you are done with the current pt..) ....then you start looking for the closest window to jump out of, and that's when you see the best possible thing you can see as an intern...yep its your senior resident walking down the hall to help you out with your patient….Just when you thought things were getting under control and while trying frantically to describe to your senior resident all the different problems this pt is having and all your pending patients.. you hear overhead "Adult Blue Alert" and your code pager (one among the three pagers you carry) goes off.. .You quickly yell out some orders on your current patient and you and your senior resident begin to run to the other side of the hospital while all of your pocket books/pens/ID badge are falling out of your pockets as you run…(Blue Alerts are always at the furthest point possible from where you are)…After doing the code…you return to your first pt and finish up the work up…then you proceed to see the chest pain… all these while your pager keeps going off about the two new admissions that the floor needs admission orders and H&P on…..After doing the two new admissions and .calling the attending physicians to staff the new admissions with (they usually take 30 mins to answer your pages), you realize hey its time to start rounding since its 6am an you are already running behind…..

However, after few calls like this…you will get the confidence to deal with these situations….and you don't have to change your scrub pants as often.. When you get to that point (by middle of your intern year)..it will feel great to know that you were able to handle all these problems on your own…and these patients are doing better because of your interventions… It is a great feeling (I think) to be able to take care of a truly sick patient and have the confidence to be able to handle most problems that could possibly arise…and that is the whole purpose of the residency training…They cant give you the knowledge, you have to read and obtain the knowledge yourself, but they can give you the experience to use that knowledge so that you can gain the confidence you need to put the knowledge into practice.

 

From my peds ER volunteer days, the firecrackers either took off a hand -turf to plastics/hand, or ended up taking out an eye- turf to optho.

And a fanny pack will keep things from falling away as you run down the hall . . . (is that Chariots of Fire playing in the background?)

 

Well I'm doing my internship right now and I'm in the ER. I've been seing my other fellow interns who are on the medicine services running like chickens with their heads cut off so it's quite disconcerting to me considering I'll be on those services later on. We are trying to be as selective as possible in the ER as to who we admit but frankly it seems a lot of admissions seem to be covering out legal a**es. You just say CP and that seems to be an automatic admission even though tests seem fine. Frankly I don't see any way around this current situation. It seems like the attendings are never to be found except if you catch them for a quick 10 minutes. Mind you we have no senior resident. So it's the immersion method

 

That has been my observation also, many times an admission is to R/O something more serious. Have you guys seen the ambulance chaser commercial with the LOL who says "my husband went to the ER b/c he thought he was having a heart attack and the Dr. sent him home. He WAS having a heart attack! That doctor didn't know the difference between indigestion and a heart attack! He should pay!"....1800sueadoc

Because our hospital has a CDU (staffed by ER docs), many of these R/O go there unless there is a concrete diagnosis. 23:59's are being requested more and more by insurance companies because a 23:59 is not TECHNICALLY an inpt. stay, no DRG needs to be paid, just the ER charges which are often less than for a stay. Also, this reduces the hospitals ALOS (admission starts after the 23:59), which is a big deal to the government.

Financially, a 23:59 hospital stay is SOOOO much less expensive to R/O than to send a pt home and open self/hospital up to lawsuits & settlements. I think perhaps a lot of the "frivilous admissions" you guys see are attempts to control risk.

Perhaps also, it is the staff in your ER/hospital who have set up the process this way that you perceive as inefficient. Our ER staff/residents/MS do most of the procedures and care management instead of turfing off the patient on the medicine residents. Unless it is an ICU admission, they are sent to the floor prior to IM workup.

And Baylor21: lets not add more buerocracy to the medical education funding nightmare by trying to seperate costs out by payor/patient type. It is VERY expensive to be a teaching/research facility. There is still waste, but it's getting harder to cut it out as it turns out that the most "wasteful" programs are the ones that seem most rooted in the teaching hospital mission. By teaching, you reduce efficiency of the senior staff, you have higher liability, you often have more advanced equipment available and higher indigent patient load. Hospitals are just getting used to APC's, HIPAA compliance is right around the corner, tjhey have to be super careful about upcoding, and the BBA is still cutting reimbursement for IME expenses. Lobby for restricting hours, yes. Adding more complexity in GME regulations and how the money is spent, NO!

Just random thoughts. I'm not so mentally organized today.

 

I agree with you that increased bureaucracy is extremely undesirable. But I'm not referring to adding new guidelines or hiring more people to ensure that hospitals are complying with anything. Separating out the funds would make it easier to analyze the current state of affairs in hospitals. The way it stands currently, its some sort of black magic that only a few accountants working in the hospital basement know about. Operating in such an atmosphere leads to financial mismanagement and invites poor planning.

Residents are clearly making sacrifices, which they should. My question is, why dont attendings need to make any sacrifices? Is medicine not a lifelong commitment to accepting some sacrifice? It just seems to me that the full burden is placed on residents. Of course the majority should be placed on the residents' shoulders, but to force all the burden to them endangers patient care needlessly.

In the end, I still come back to the patient point of view. I think we should come up with some kind of MINIMAL intervention that could easily improve patient care. From the New York example, its clear that hospitals are unwilling to take the initiative, and many will outright break the law. When you get to the point that hospitals are breaking the law (and the law directly affects patient care) then I'm sorry but we need to have some kind of intervention.

If it was possible for a resident to work 130 hours a week and make no detrimental impact on patient care, then I would accept it because being a resident involves sacrifice. Unfortunately, that just cant be done, as much as we would like it to be so.

 

After I wrote that post, I felt a little bad because I know I am very crabby about the level of hospital finance I am being required to learn these days. I know I am incredibly sensitized to financal issues right now b/c I am working on a really stressful project based on finance. It's taking 17 different costs (indirect, direct, variable and fixed) and the expected payment amount associated with each patient charge (i.e. central line placement might be one charge, x-ray might be one charge, inpt. stay is one charge) and trying to figure out the profitability or loss by payor of different programs. This information will be used to try to determine future negotiations/ contract stuff with insurance companies. (i.e. if you lose your shirt on one payor, renegotiate for higher capitation or add an additional rider to cover the costs associated with very expensive procedures. ) There were 47,000 charges associated with 9 patients over 4 years, so the volume of data is immense. Yes, I am crabby and I apologize if my post came off as snippy.

Allocated costs are based on charges, reimbursement is based on payor. There are formulas for everything. five people could all code a record differently based on thier skills and experience. I can't imagine trying to make the accounting any more of a nightmare, especially as residents rotate through different cost centers and see all pateints, not just the government paid & indigent ones. I don't see a way to easily seperate out costs of care as a patient doesn't just see one doctor. They might have a consult, lab or radiology studies, preop and post op outpatient visits... get admitted to one unit and sent to another (i.e. ICU to stepdown to GPU) The list goes on. I don't think you can just add regulations without adding people checking to see if systems are complying. HIPAA hasn't been finalized yet, but it is close, and we still have people arguing about how todesign systems as if it isn't a very near future reality.

As to your question about attendings not sacrificing, the attendings I know are making sacrifices. They work 60-80 hours a week. They spend weekends at the hospital. They have mandated 10 hours off between shifts, but I see many of them here after working the night shift, finishing up paperwork, attending meetings, making sure someone was put to bed until 10 in the morning and being back at 4p. Maybe it's not like that everywhere, this is just my observation. Maybe it's only the few I know who are dedicated to teacihng and research who are making these sacrifices. Maybe they aren't taking as much call. (Although people like OB's do!)Yes, the SYSTEMS are screwed up. Unfortunately, we have two choices. Live with them, or change them. As people here have mentioned, trying to make changes solo can be extremely hazardous to your career. I would love to see regulations similar to truckers or airline pilots imosed, but as we have discussed before, this will make cost of care go up. We are going into a business where everyone wants top of the line care at the economy price or free and it just can't continue to work that way.