Residency Hours

[Perrotfish]

There have been a lot of threads about how the maximum number of hours residents can work may soon be changing again and it got me wondering: what are the hours like in a military residency? Do they observe the current 80 hour rule? If so do they actually observe it or do people lie about their hours like on the civilian side? What's the call schedule normally like? How abusive would you say the residency system is compared to stories you all have heard from civilian colleagues? I realize that this can vary by service, specialty, and probably the year you went through it but if some people could just share their experiences I would really appreciate it.

 

[BigNavyPedsGuy]

There have been a lot of threads about how the maximum number of hours residents can work may soon be changing again and it got me wondering: what are the hours like in a military residency? Do they observe the current 80 hour rule? If so do they actually observe it or do people lie about their hours like on the civilian side? What's the call schedule normally like? How abusive would you say the residency system is compared to stories you all have heard from civilian colleagues? I realize that this can vary by service, specialty, and probably the year you went through it but if some people could just share their experiences I would really appreciate it.

In regard to hours: it's just the same as civilian programs. Same (or greater) frequency of call. I think the military actual tries to obey the 80hr week most of the time, because some programs have recieved RRC citations. Some programs still lie about it though.

All in all, it's remarkably similar. During residency you just happen to be at the military program/hospital when it comes to hours and attitude. Most of the complaints on this forum are about places outside the major training centers.

 

[RugbyJC]

There have been a lot of threads about how the maximum number of hours residents can work may soon be changing again and it got me wondering: what are the hours like in a military residency? Do they observe the current 80 hour rule? If so do they actually observe it or do people lie about their hours like on the civilian side? What's the call schedule normally like? How abusive would you say the residency system is compared to stories you all have heard from civilian colleagues? I realize that this can vary by service, specialty, and probably the year you went through it but if some people could just share their experiences I would really appreciate it.

This is just my anecdotal experience, but I have been in violation of these policies a number of times on internship. Most of my collegues lie about their hours regularly, but I feel weird doing that. I have been told that there is nothing good that come out of being honest if you go over your hours, so I decided not to fill out my hours until after I have forgotten what I actually worked--its just so i don't feel morally conflicted about it. Part of the reason I go over is because some of the senior residents are not good at managing their interns, as well as the fact that I would rather come in earlier than needed to make sure I get everything done because sometimes the unexpected can happen when you are prerounding.

Its really frustrating, but I do not think it is any worse or better than civilian according to my med school grads. Its been my observation that a lot of GMOs who come back do not completely understand the rules. Some seem to think that they are required to keep you their for 30 hours--not that this is only the max you can work, and I don't know what accounts for that. Its also very department specific. I've also heard a rumor that it depends where you train because some of the bases are busier than others, but I don't have anything to back that up.

 

[turkish]

When I was an intern at BAMC, I was constantly being pulled into work early or after hours for total bull sh** like drug testing, immunization profiling, accountability, or you name it that you wouldn't see in the civilian world. Maybe some places drug test, but they don't pull you in at 6 am on a random Tuesday morning to do it...after an all night shift.

So if you ask me, the Army is blind to the 80 hour rule. The company commanders think doctors are a joke, and they seem to revel in their ability to disrupt your fragile home life or ability to sleep between shifts. They think that if they are at work, you should be too...after all it's "duty hours"!

If I were you, I would run away from a military residency screaming like my pants were on fire.

 

[HackFuJones]

from my experience, its pretty similar to civilian residencies at least from the non surgical specialties, I cant really comment on surgical. Also it depends on how good or bad you are as an intern/resident. The good ones who have their **** together get done early and have their **** done correctly so they dont have to stay late patching up problems. The bad ones seem to always be running late and going over the work hours. I found that to be true during medical school at Civi institutions as well as Army ones. I cant totally comment on surgical in the Army but at least from what a buddy told me its pretty comparable.

 

[BlackFrancis33]

During 3.5 years of Army residency at a MEDCEN I have never been called in during off hours to do drug tests, admin etc. Yes, I do tons of this crap during business hours and it takes away from my other duties, but when I get pages about a urinalysis when post-call etc. I don't go in and take the urinalysis. The only authority the company has over any of us (at my hospital) is taking away leave. Which if you make ht. and wt. and pass your APFT they have no real power over you. And that is frankly the way it should be. The idea of being part of a company when the residency program and hospital is your real chain of command is stupid.

 

[Perrotfish]

I have been told that there is nothing good that come out of being honest if you go over your hours,

I'm honestly surprised at this. I always figured that military might choose to completely ignore the civilian requirements, but that if they decided to observe them and had you fill out a form they'd be very anal that you filled it out correctly and honestly. Anyone else lie about their hours in a military residency?

 

[BigNavyPedsGuy]

I'm honestly surprised at this. I always figured that military might choose to completely ignore the civilian requirements, but that if they decided to observe them and had you fill out a form they'd be very anal that you filled it out correctly and honestly. Anyone else lie about their hours in a military residency?

That is the case at my program and in most of the programs at my hospital. They don't like when residents report being over, but they can't break that whole Honor Courage and Commitment thing and tell a bunch of officers to lie.

 

[crazybrancato]

That is the case at my program and in most of the programs at my hospital. They don't like when residents report being over, but they can't break that whole Honor Courage and Commitment thing and tell a bunch of officers to lie.

just out of curiosity, do you guys fill out time sheets, or is there some electronic way of checking in/out? I ask b/c the time sheets are easier to BS after the fact. You can BS an electronic system too of course (by not swiping in, say until an hour after you've really gotten there).

And if someone looks at your timesheet say for the year, and they see straight '80's for each week, does anybody question it?

 

[BigNavyPedsGuy]

just out of curiosity, do you guys fill out time sheets, or is there some electronic way of checking in/out? I ask b/c the time sheets are easier to BS after the fact. You can BS an electronic system too of course (by not swiping in, say until an hour after you've really gotten there).

Time sheets and there's also an ACGME site that people can fire off torpedoes if they really want to stir stuff up.
And if someone looks at your timesheet say for the year, and they see straight '80's for each week, does anybody question it?

Of course, but what are they going to do?[/QUOTE]

 

[crazybrancato]

just out of curiosity, do you guys fill out time sheets, or is there some electronic way of checking in/out? I ask b/c the time sheets are easier to BS after the fact. You can BS an electronic system too of course (by not swiping in, say until an hour after you've really gotten there).

Time sheets and there's also an ACGME site that people can fire off torpedoes if they really want to stir stuff up.
And if someone looks at your timesheet say for the year, and they see straight '80's for each week, does anybody question it?

Of course, but what are they going to do?[/QUOTE]

employ a random number generator, to come up with a sequence of numbers, 52 numbers long (one for each week of the year). Restrict the generator to produce numbers only in the range 78-82. Report this sequence, which will have no discernible pattern and thus appear to be truthful, as opposed to something made up. (i've been working for the government too long).

 

[VolatileNavyDoc]

That is the case at my program and in most of the programs at my hospital. They don't like when residents report being over, but they can't break that whole Honor Courage and Commitment thing and tell a bunch of officers to lie.

I have had the same experience. I have never worked for anyone in the Navy who told me to lie about my hours. Looking at the descriptions of anesthesia programs on SDN, I think our hours are about the same or maybe a little more than the average, but I have never gone over 80 hours. When guys have to come in at night when they are covering CT, they always get off the next day. All the malignant staff are gone from our program (one benefit of the military), so the staff are all very cool with helping out if someone is getting close to going over their hours.

Are they talking about making the hours more restrictive or allowing us to work more hours? It would be cool for future residents to work less hours just so I could say "When I was a resident, and we actually worked 80 hours a week..."

 

[Perrotfish]

Are they talking about making the hours more restrictive or allowing us to work more hours? It would be cool for future residents to work less hours just so I could say "When I was a resident, and we actually worked 80 hours a week..."

The new recomendation that they want implemented immediatly is to keep the cap the same, but with much stricter rules if for when you're on call (i.e. a 30 hour shift). I think the new rule is that you need to take a 5 hour unintirupted nap (which counts against your 80 hours), halfway through the shift, and also the last few hours of the shift can't be used for patient care, only teaching activities and paperwork.

There are also rumblings that they might actually reduce the cap to 60 hours, of course, but that's an old rumor and the new 'you can't work 30 hours straight without sleeping' thing is the one that they seem to want implimented right away.

Also does anyone else notice that military docs seem more likely to favor shorter hours for residencies? I've noticed that when I talk to doctors that are ex military (not just military med, any part of the military) they seem a lot more likely to consider the traditional sleepless nights of residency an unnecessary tradition/form of hazing/money making scheme rather than a necessary part of training. Has anyone else noticed this? Am I getting a skewed sample?

 

[delicatefade]

I think the new rule is that you need to take a 5 hour unintirupted nap (which counts against your 80 hours), halfway through the shift,

I would kill to have this rule in effect during my 30 hour internal medicine shifts.

 

[Perrotfish]

I would kill to have this rule in effect during my 30 hour internal medicine shifts.

That's pretty much how we got the rule, yeah.

 

[Gastrapathy]

No work hours for attendings. The whole work hour argument has jumped the shark when the housestaff are working fewer hours than the staff.

 

[exPCM]

I find the argument that attendings are working longer hours than residents to be disingenuous. If an attending is working more than 80 hours it is by choice. As an attending physician, if I do not like my work hours then I am always free to change jobs. If I do not want to change jobs then it is my choice as well. I have found that many attending physicians at academic medical centers are more interested in having residents to do their bidding than they are interested in doing any teaching. Residents do not have the choice to just change residencies at will like attendings can change jobs. There are restrictions by the ABMS boards on transfers and finding an open position in another residency can be difficult. Unlike attending positions most residency positions do not pay for relocation expenses either.
I fully support the new work hour recommendations. The idea that the work won't get done if the work hours are restricted is another bogus argument. If a hospital or service wants to they can hire midlevels or part-time docs to fill in the gaps. The problem is that the hospital or service may say the can not afford to hire anyone - the reason being that the attendings and hospital executives do not want to take any cut in their salaries. Some programs are just overly dependent on cheap resident labor.

 

[Perrotfish]

No work hours for attendings. The whole work hour argument has jumped the shark when the housestaff are working fewer hours than the staff.

Don't you think this is sort of specific to the military in wartime? I know very few civilian attendings that work those kinds of hours, and those that do seem to be looking for that sort of thing. The key differences is that attendings can always set up shop for themselves, so that hospitals are always forced to negotiate contracts to maintain their attendings. When it comes to residencies, however, residents are legally bound to finish that phase of their training in the hospital and hospitals therefore can operate as a trust: they refuse to bargain individually so the only way force safe work hours on them is either through collective bargaining, legislation, and new safety requirements.

 

[Gastrapathy]

Not specific to military or wartime. I see lots of private practice physicians working more than 60 hours a week. It's also not that easy to just walk around the corner and get a new job as an attending in the civilian world (noncompete agreements, etc).


I'm not a university attending set on doing research and avoiding the wards. With the advent of the work hours, I routinely work as much and take as much or more call than the residents (BTW, I can't exactly quit either)


For all the housestaff who want to work fewer hours, are you prepared to lengthen your training to compensate? There is more to know now than ever and the consequence of a 60 hour work week is likely to be an extra year of training or worse.

I also don't think anyone should lie on their work hours. If you can't get it done, then it falls to your staff. Lying just because telling the truth is hard and will make people mad is wrong. If you are chronically over hours, look around and see if the other interns are too. If they aren't, then you need to think about ways to be more efficient. If they are, then the program had better find out sooner than later because nothing stays a secret forever. I tell my interns when I'm on the wards that baring unforseen circumstances, the only reason they will fail is going over hours or lying about whether they've done something.

 

[Perrotfish]

For all the housestaff who want to work fewer hours, are you prepared to lengthen your training to compensate? There is more to know now than ever and the consequence of a 60 hour work week is likely to be an extra year of training or worse.

See, I'm all for this solution. I just believe it needs to be paired with adequate pay for the residents rather than the current minimum wage arrangment. The idea that residents wouldn't sleep or be paid much of anything during residency was created at a time when residency was basically an apprenticeship lasting 1 year or maybe 2 if you were a specialist. Now we are transitioning into something more like what you see in engineering fields: a half decade or even decade long 'training' period where you need to be supervised, taught, and regularly tested before you can be trusted to work on your own. That's fine, but just like the engineers we need to realize that that 5-10 years is too long to consider it a little bit of hazing that happens before our careers start. It's has to be part of our careers. Therefore it should involve reasonable hours and adequate pay.

This is basically what they've done in a lot of European medicine, BTW, and it seems to work just fine.

 

[notdeadyet]

See, I'm all for this solution. I just believe it needs to be paired with adequate pay for the residents rather than the current minimum wage arrangment.

Ugh, you can have it. Give me three years of hell followed by the freedom to carve out my own wage. But I can see the logic of both paths.

I'd rather have a few short years of slavery followed by freedom rather than a whole lot of years of servitude.

 

[Gastrapathy]

This is basically what they've done in a lot of European medicine, BTW, and it seems to work just fine.

So you'd like to make what European doctors make? Really?

I've seen a real change for the worse in trainees over the past few years. Patient ownership was a badge of honor in the past, now so many approach medicine as shiftwork ("I'm just covering, I don't know anything about the patient but would you come see him", etc). I think the workhours are to blame. I agree that some balance is necessary but we've lost something with the work hour restrictions that I don't know how to get back.

 

[notdeadyet]

I've seen a real change for the worse in trainees over the past few years. Patient ownership was a badge of honor in the past, now so many approach medicine as shiftwork ("I'm just covering, I don't know anything about the patient but would you come see him", etc). I think the workhours are to blame.

I disagree. I think it's more cultural and generational than a work hours issue. Most medical students I know have "lifestyle" as their #1 consideration for choice of medical specialty. The number of folks willing to martyr their personal life for the sake of their career is much less than in years past.

 

[BigNavyPedsGuy]

I disagree. I think it's more cultural and generational than a work hours issue. Most medical students I know have "lifestyle" as their #1 consideration for choice of medical specialty. The number of folks willing to martyr their personal life for the sake of their career is much less than in years past.

These things aren't mutually exclusive. We are just put in a tough place. We get yelled at (by admirals) if we go over our hours. We get yelled at (by senior officers) if we leave on time meaning we don't stay late to follow-up every lab and every consult.

We can't do both, but we still get rebuked no matter what we do. Senior staff act like "this generation" of trainees is lazy when all we're trying to do is keep our programs accredited.

It's ridiculous. The message I come away with: lie about your hours or attendings will B*tch and moan about you being lazy.

 

[Gastrapathy]

These things aren't mutually exclusive. We are just put in a tough place. We get yelled at (by admirals) if we go over our hours. We get yelled at (by senior officers) if we leave on time meaning we don't stay late to follow-up every lab and every consult.

We can't do both, but we still get rebuked no matter what we do. Senior staff act like "this generation" of trainees is lazy when all we're trying to do is keep our programs accredited.

It's ridiculous. The message I come away with: lie about your hours or attendings will B*tch and moan about you being lazy.

I hear what you're saying. I try to never roll my eyes or complain when I have to do "intern work" (there is no such thing, attendings write H&Ps, do narratives and daily notes everywhere but training hospitals) even though most of the time its because of inefficiency not work load.

But, what drives me nuts is when I get the impression (or am told flat out) that the patient in question is not a priority to that trainee because the patient isn't really theirs. I hardly ever saw that before the work hours. So, maybe it is a generational thing and maybe it isn't. Regardless, its bad for patients and I think its bad for physician education. I don't want martyrs but at least pretending to care a little would go a long way.

I started to write about a specific example that lead to a bad outcome, but I couldn't write it in a way that didn't have too much information in the post. There is a real cost to the shiftwork/signout culture we seem to have embraced.

 

[Perrotfish]

I disagree. I think it's more cultural and generational than a work hours issue. Most medical students I know have "lifestyle" as their #1 consideration for choice of medical specialty. The number of folks willing to martyr their personal life for the sake of their career is much less than in years past.

I don't think doctors were ever willing to martyr themselves for their profession more than they are now. I think that doctors just always expected the quality of life/pay for their profession to approximately match the careers of their non medical peers at the time. However the increasing quality of medical school applicants, the extension of our training from a 1 year Internship to a 3-7 year residency (not mentioning fellowships), increasing debt loads from education, a predatory legal enviornment, and ever increasing QOL/pay for other top professions has made modern medical students and young doctors feel that they are getting shafted. This isn't even mentioning the issue of patient care (you can't think when you're hardly awake, or at least I can't). There's nothing different than the last generation here, other than the circumstances we face.
.

 

[Gastrapathy]

However the increasing quality of medical school applicants, the extension of our training from a 1 year Internship to a 3-7 year residency (not mentioning fellowships), increasing debt loads from education, a predatory legal enviornment, and ever increasing QOL/pay for other top professions has made modern medical students and young doctors feel that they are getting shafted. This isn't even mentioning the issue of patient care (you can't think when you're hardly awake, or at least I can't). There's nothing different than the last generation here, other than the circumstances we face.
.

The transition from a 1 year internship into longer training happened way before I got into medicine. Yet, the shift-work mentality seems like a new phenomenon to me. Maybe the other factors are worse now than before.

\
As far as quality of patient care, that is the issue. At some point, the constant signout and crosscover care starts to harm inpatient care. I personally believe we have crossed the threshold at which work hour rules are a detriment to good patient care. I have no evidence for this, the studies on this topic are horribly designed and inconclusive, but this is my anecdotal experience.

 

[Perrotfish]

As far as quality of patient care, that is the issue. At some point, the constant signout and crosscover care starts to harm inpatient care. I personally believe we have crossed the threshold at which work hour rules are a detriment to good patient care. I have no evidence for this, the studies on this topic are horribly designed and inconclusive, but this is my anecdotal experience

I see the point here. The question is, why do you think this isn't an issue in community hospitals that don't have residents on long shifts?

Also, part of the reason I'm hoping for the change in work hours is personal. I seem to do significantly worse than my peers with sleep deprivation. I know no one does well, but I've been in rooms full of people that have stayed up all night studying and they would always comment on how out of it I was. No idea why, but it's always been that way. I feel like fear of sleep deprivation related errors would essentially keep me out of fields I might otherwise enjoy.

 

[exPCM]

Not specific to military or wartime. I see lots of private practice physicians working more than 60 hours a week. It's also not that easy to just walk around the corner and get a new job as an attending in the civilian world (noncompete agreements, etc).


I'm not a university attending set on doing research and avoiding the wards. With the advent of the work hours, I routinely work as much and take as much or more call than the residents (BTW, I can't exactly quit either)

I must respectfully disagree. No one can force you to sign a noncompete clause. If you sign one then it is your choice. Also if you can't get a job around the corner you can get one in another city. The only attending physicians I see work very long hours are those that choose to, those that are workaholics, and those that are just trying to make gobs of money. And yes you can quit if you want to (except of course if you are in the military). I think the concept that since I am working more than 80 hours then my residents should too is a fundamentally flawed concept.

 

[Gastrapathy]

Thanks.

I definitely can't quit. I don't think residents should work more than 80 hrs. I objected to a forced 60 hr workweek and kindergarten-style naptime. The best learning happens in the 5 hours they would be sleeping. No staff in the hospital, sick patients, and the chance to learn to make some decisions.

Also, I guess its not the work hour restrictions that bother me, its the culture of shift work that the seem to have created. I'm sure its not that simple but thats how it seems to me.

 

[exPCM]

so you put that picture in a post and then write that you "respectfully disagree". Stay classy San Diego.

Yes, good point.

 

[HackFuJones]

You guys are all wrong!!! Apparently according to nurses, I can be a fully competant doctor in a 1 year online course after nurse practitioner school so I dont know what all the fuss is about these long work weeks when all we really need is just 1 good year online and its Boom goes the Dynamite, solo practice!!!

 

[notdeadyet]

Well let's be clear. There are a few vocal NPs who sit around telling each other how great they are, and how their education is more than adequate, and nobody needs doctors anymore now that they printed their completion certificate from their "school" website.

Then there are the millions of real nurses who are rolling their eyes and ignoring their new "doctor" colleagues . . .

I'm glad you made this point. Folks seem to pull out the few annoying vocal ones and seem to think that they're the majority, which rarely seems to be the case.

Truth be told, if you wanted to compare the percentage of nurses with a way overinflated sense of worth with the percentage of doctors with a way overinflated sense of worth, we'd probably "win" hands down.

 

[HackFuJones]

Although I agree with you that it is a small % of nurses, those "few" nurses that are causing all the controversy have been intruding on our turf for a while and getting more autonomy every year since we sit and do nothing because we are not taking them seriously.

Look at Anesthesia, I guarantee you that specialty goes into the toilet in 10-15 years as more and more nurse programs sprout up which they will, and completely take over most of the work, leaving just extremely high risk cases and supervisor spots for the MDs which most likely will make it difficult to find work and have major pay decreases since the argument will be why should we pay you a lot of money when a nurse can do 98% of your job for 1/3 the pay.

Anyway, just something to think about because although at THIS moment in time, many nurses may roll their eyes and not much has happened yet, in the future this might not be the case and by then there will be nothing we can do.

 

[BigNavyPedsGuy]

Anyway, just something to think about because although at THIS moment in time, many nurses may roll their eyes and not much has happened yet, in the future this might not be the case and by then there will be nothing we can do.

Then you'd better store up the canned goods and keep your money in a safe in the matress. That's we survived the Y2K end-of-the-world scare.

You do actually raise some interesting points, but I couldn't resist poking fun at the bunker mentality

 

[HackFuJones]

Then you'd better store up the canned goods and keep your money in a safe in the matress. That's we survived the Y2K end-of-the-world scare.

You do actually raise some interesting points, but I couldn't resist poking fun at the bunker mentality

haha yah I can do that sometimes with the doomsday scenarios BUT if more people would actually look into what the future might hold for certain things and not just how good it is today, then many of the worst problems probably wouldnt have happened if more people stepped in early to solve them. For example, go watch a movie called "Maxxed out" . It pretty much exactly predicted our current mortage/credit crises 3-4 years ago when it was filmed yet many dismissed it like it was a few fanatics making stuff up like a Michael Moore movie and that they were full of ****.

 

[notdeadyet]

You're absolutely right and this is the primary reason that I never even considered it. I think that as more students catch on to what's really going on in the field, they're going to see fewer and fewer top-level applicants. I hoenstly see Anes slipping back into the times they had a few years ago, where they were positively hurting for applicants.

Interestingly, I hear this concern about the death spiral that anesthesia is on much more from folks outside the field than folks in it.

Ditto for radiology, which many folks outside the field are convinced is on the path to being outsourced/offshored. Ditto for primary care, which many folks outside the field are convinced is going to be taken over by NPs.

For anesthesia, if this trend is really the case, why is it more competitive as a specialty now than it has been for more than a decade? Radiology doesn't seem hurting for applicants either.

 

[docbrown76]

Interesting NYT article:
http://www.nytimes.com/2008/12/05/health/05chen.html?scp=1&sq=%2b%22American+Medical+Association%22&st=nyt

 

[Perrotfish]

Interesting NYT article:
http://www.nytimes.com/2008/12/05/he...tion%22&st=nyt

I was in a fraternity during a 4 year period when we finally got around to eliminating the little bit of hazing that we had left in our pledge process (apparently this had been a 20 year process that I got to see the tail end of). This article sounds remarkably like guys I remember who were trying to justify keeping those 'traditions'.

The amazing thing about the article is that it doesn't even focus on the only even slightly reasonable argument for denying residents sleep: continutity of care and the dangers of handoffs. Instead it's focusing on the confidence that being abused builds, the bonds that you forge with your colleages by being abused collectively, the fact that not sleeping means you have more time to be educated (which is, of course, why not sleeping during college is such a good strategy for improving your GPA), and most tellingly that it would cost a lot of money to allow residents to sleep (she estimates 1.7 billion dollars). This is stockholm syndrome, pure and simple.

 

[Perrotfish]

I was speaking more about military anesthesia than civilian. Talk to the military residents about how things are going. The last CABG I did before leaving internship, a CRNA was running it. Think the residents didn't need/want that case?

Has anyone seen any studies for morbidity and mortality of gas cases handled by CRNAs vs. Docs? When I googled I found studies that showed either very small statistical differences or no statistical differences between the two levels of training. I mean, it seems like this should be a very easy field to track that kind of data, and if it's not showing a significant difference then why do we need the speciality? It is reasonable for nurses to take over a profession if doctors can't show a statistically better outcome, particularly when the outcomes are so easy to study. And if there are studies out there showing a significant difference in quality of care why don't the malpractice lawyers take care of it?

 

[notdeadyet]

I was speaking more about military anesthesia than civilian. Talk to the military residents about how things are going. The last CABG I did before leaving internship, a CRNA was running it. Think the residents didn't need/want that case?

Ah. Got it. I have heard that case volume can be a problem with military surgical residencies, it makes sense that that would carry over to anesthesia as well, particularly if you have CRNA's competing for the cases that are there.

 

[Perrotfish]

1) CRNAs still mainly practice under Anes supervision. Hard to account for the "bailout" effect.

'Mainly' is not always, and it's very simple to study CRNAs that practice without supervision (especially in other countries where that's much more common) to see if they have different outcomes. In fact both of the studies I linked reference unsupervised CRNA care. The study that found no statistical difference in results also found no difference for unsupervised CRNAs vs Docs.

2) Anesthesia encompasses a much wider range than just "passing gas".

Fair enough, but CRNAs are claiming that their training encompasses that field, so that doesn't really change the argument.

3) When someone claims "I provide equivalent care with less education and training" the impetus is on them to demonstrate that this is true, not vice versa. I have no data that a high-school huffer provides inferior care than an Anesthesiologist, but I'm not waiting for the malpractice lawyers to "take care of it" either.

Well, I think that they are generally arguing that they have, in fact, proven that. Also they might also argue that when you present a more expensive alternative (docs) that the burden of proof in a free market tends to fall on that more expensive option. After all, even though it's very imprtant to me that the 22 story building I am in not fall down, I think a constuction firm would be well within their rights to argue that they do not need to prove that their HS educated construction workers should not need to prove that they provide a lower probability of building colapse than someone with a BS in building construction to be allowed to do their jobs.

I personally hate the idea of NPs/Doctors of Nursing taking over primary care because I think their training is insufficient for that and that the evidence supports my opinion. For gas... I'm just not so sure.

 

[notdeadyet]

I personally hate the idea of NPs/Doctors of Nursing taking over primary care because I think their training is insufficient for that and that the evidence supports my opinion. For gas... I'm just not so sure.

I'm curious why they haven't made in-roads into surgery. Seems analagous to anesthesia in that the simple procedures wouldn't be too hard to conduct with physician supervision. I'd think the lack of four years of medical education would be more of a hinderence in something like gas than in surgery.

Is it a matter of proportion (that there are more simple/bread-and-butter anesthesia cases than simple/bread-and-butter surgery cases) or just culture. I find it interesting that nursing has made in-roads into the fields of medicine in which practitioners seem to be the least confrontational. I'd be curious to see your average department of surgery's reaction to nurses trying to take turf.

 

[Perrotfish]

Wait, didn't you preface this discussion by saying that the studies were small and there were only very few of them?

Um, no. The studies were quite large in scale, I have no idea how many others are out there (I'm not exactly writing a research paper here)

They're claiming it, but they're still not praciticing it. That makes it difficult to study.

There are a significant number of CRNAs practicing in settings where their 'supervising' anesthesiologist isn't on the premesis when they're handeling everything. It seems like that means that they're handling everything that comes up, which seems like it means the entire field

I don't know enough about Anes to really get too deep into this argument.

Ditto, of course

For me personally, I can't imagine asking for a CRNA if an Anesthesiologist was available for a case I was doing. I suspect a lot of surgeons would prefer the MD in the room the whole time,

Of course, but this is a straw man argument. No one is claiming that an MD is worse than a CRNA, and if your hospital has already paid for an MD there would be no reason to settle for less, on the general principle that the extra training can't hurt. However, the money we spend on Anes docs could easily be directed to other things (better facilities, more time allotted per patient with other docs, fewer patients per nurse, or even just plain lower costs or better physician pay) so the question is whether there is enough of a difference in quality to justify paying for the doctor over the CRNA.

Again, I lack the research/experience to make a really strong argument here, I just think physicians need to be open minded to the idea that there might be some fields where you don't necessarily need a doctor's expertise.

 

[notdeadyet]

As far as I can tell, it's either that (1) the surgeons don't notice a difference, or (2) the Anesthesiologists are telling them it's fine, don't worry about it.

I know a couple of private practice anesthesiologists who are quite happy with the CRNAs they have on stafff. They have a much smaller overhead so your profit margin is very attractive. The CRNAs get the more simple cases with the anesthesiologists doing more pain management and complex procedures.

I'd imagine it's a different sentiment at a training hospital, though...

 

[DrMetal]

I commend you all for this discussion. At least you recognize that the MD isn't the holier-than-thou degree and some jobs can be done by other medical staff.

I think the problem with the MD community is that there's this vicious cycle . . . medical education costs you a ton of money (up to $50k/year), and the training is lengthy and sometimes hazing-like. So you come out the other end demanding a decent-sized paycheck. And so you become a very expensive commodity for Institution X, who now must pay you an exorbitant salary, so you can pay your insurance, pay back your ungodly student loans, and live the nice lifestyle that you're entitled (or feel entitled) to.

So if Institution X sees a cheaper solution--such as hiring a CRNA, who say doesn't require as great of a salary, b/c he got his credentials via a junior college nursing program or some other cheaper means--then Institution X will sway that way.

I guess Anes and primary care are heading down this road, it'll be interesting to see what other medical fields follow suit. It's no wonder then that medical students are moving towards more invasive specialized medical fields (things that only MDs can do, at least today!)

 

[notdeadyet]

I guess Anes and primary care are heading down this road, it'll be interesting to see what other medical fields follow suit. It's no wonder then that medical students are moving towards more invasive specialized medical fields (things that only MDs can do, at least today!)

I wouldn't extrapolate too far down that road. Primary care was a field that was hard to fill long before the NP movement. Radiology has been having the doom-and-gloom of your-job-is-going-overseas, but that hasn't hurt applications any.

Anesthesia has been under fire for the CRNA thing, but their applications are up and the field is still competitive. General surgery, on the other hand, a "invasive specialized medical field" has been less competitive for a while now.

I think the encroached medical fields alarm is more shared by folks not actually involved in those fields. Folks who are in them don't seem particularly troubled. I've yet to meet an anesthesiologist, PCP or radiologist who is particularly worried about their future job prospects.

 

[Perrotfish]

I wouldn't extrapolate too far down that road. Primary care was a field that was hard to fill long before the NP movement. Radiology has been having the doom-and-gloom of your-job-is-going-overseas, but that hasn't hurt applications any.

Anesthesia has been under fire for the CRNA thing, but their applications are up and the field is still competitive. General surgery, on the other hand, a "invasive specialized medical field" has been less competitive for a while now.

I think that this is less a sign that doctors are confident about the future of Rads, Anes, and Primary Care than that medical students would prefer to take the risk rather than subject themselves to a GS residency. Which brings us back to the residency hours thing that started this thread.

 

[BigNavyPedsGuy]

I think that this is less a sign that doctors are confident about the future of Rads, Anes, and Primary Care than that medical students would prefer to take the risk rather than subject themselves to a GS residency. Which brings us back to the residency hours thing that started this thread.

Way to bring it back around!

 

[notdeadyet]

I think that this is less a sign that doctors are confident about the future of Rads, Anes, and Primary Care than that medical students would prefer to take the risk rather than subject themselves to a GS residency. Which brings us back to the residency hours thing that started this thread.

Nicely done. Tied that one up with a bow!