Resident duty hour protections on trial with iCOMPARE and FIRST Studies

[VisionaryTics]

Obviously not taking any call would be better than either system, but overall I found the get 4-ish hours of sleep in the hospital followed by a pseudo-day off Q4 call much nicer than 5-6 straight nights of 14-16 hour shifts followed by a pseudo-day off.

Even more fun, when the "day" between switching from night float to days is your only ACGME-mandated "24-hour duty free" period each week. Modern duty hour restrictions are like CrossFit: designed to confuse the body randomly and pointlessly.

Whoever came up with the ACGME duty hour restrictions should die of gonorrhea and rot in hell.

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[brownie]

Did the 2011 changes affect anyone besides surgeons?

 

[Gastrapathy]

Q2 36s sucked. The original rules got rid of that. Everything beyond that was a bridge too far.

 

[DoctwoB]

Don't forget: someone has to cover nights. If it's not a day resident on a q4 basis, it means you'll be taking night float. And I don't know about you, but I found being cut off from the world for a month at a time to be a pretty terrible experience.

Also, most night float systems will be much busier then if you took call. Our night float resident covers GI, vascular, thoracic, PB, liver, and endocrine at a very busy hospital, basically everything except trauma and cardiac. You don't sleep, you run around putting out fires on a huge list of patients you got 1 line of sign out about. Alternatively you can add another night float resident, but then you're doing 2 months of NF and not one.

In a call system usually you are covering fewer services, most of the patients are known to you, and it's a much less hectic experience.

 

[mvenus929]

Also, most night float systems will be much busier then if you took call. Our night float resident covers GI, vascular, thoracic, PB, liver, and endocrine at a very busy hospital, basically everything except trauma and cardiac. You don't sleep, you run around putting out fires on a huge list of patients you got 1 line of sign out about. Alternatively you can add another night float resident, but then you're doing 2 months of NF and not one.

Just to add a non-surgery perspective... our night float system (which apparently is not actually night float by ACGME criteria, but I can't remember exactly why) has us doing a week of nights on the service we're covering. So on the wards team I'm on now, we have 4 day interns and 1 night intern, and we rotate who does nights each week. And our hospital has four wards teams, so we have an intern each covering two of the services (which during the winter months is actually 3 services, since one of the teams splits in two and one intern covers both at night), a second year covering two combined services (for two weeks), and then two seniors to oversee everyone.

So while cumulatively, we do 1.5 months of nights as interns (9 months of inpatient, where 6 or so of them have nights), they're only done for a week at a time.

Duke Peds also takes an interesting take on nights and has the interns come in for their full 16 hour shift, but round with the team on the new admits in the morning before signing out and going home, but they only work every other night, so there are two teams that collectively cover two weeks. Seemed like an interesting system.

 

[mdfacs]

Since we are in season for finalizing our rank lists, does anyone have the "list" for programs that are in the experimental group of the icompare study. Thanks

 

[Law2Doc]

Having been an intern in the days of 30 hour shifts when places were starting to toy with night float (and thus had the "privilege" of trying both) I can say with certainty that the longer shifts were better for resident life. The 80 hour cap is hit faster, and you really don't feel much different working 24 or 30 hours so why not get an additional day off a week? With night float you never get enough sleep and are chronically tired. With post call days you can get a longer stretch of rest and are actually less tired, not going through life as much like a zombie. And no studies have shown an improvement in patient care, so might as well do the shift that is least painful. The only people who I know who prefer night float to longer calls have never worked both.

 

[Law2Doc]

I talked with several of our medicine residents. I think for them night float is a lot better.

I think this all comes down to a service burden to number of resident ratio:

Because medicine programs have approximately 40 residents (plus prelims) per class, and they only need a very small number of residents in house to make night float function, the call burden is very light. 2-4 weeks out of the entire year spent on nights. Whereas in the old system they would be on Q4 call, with the entire team there at night, just because that's the way it was always done.

But that's not the case for surgery residencies and other small programs with a heavy call burden to resident ratio. I know some surgery interns who spent 3 months out of intern year on night float - broken up into multiple chunks which means a lot of day/night transitions which are the worst part of it.

That much night float is miserable and like you, having experienced both traditional call and night float, I would definitely prefer to just take call.

I guess. But the IM folks I know around here also prefered the team call approach. Theres something more lingering and painful about float that you dont get in a call and post system. Sort of like peeling off a bandaid slowly. And there is nothing better than logging duty hours and realizing mid week that you are way past the hallway mark. And as mentioned each call night really doesn't hurt much worse than a float night.

As a resident, working two 40 hour shifts and having the rest of the week off might even be living the dream. Sounds bad to people not already in residency, but blocks of free time off are far more important to your quality of life than getting some sleep every night. Heck, lots of us have done night float, not been able to fall asleep during the day thanks to sun and noise from construction, etc, and ended up doing the next shift on none, which is more hours in a row than 40 but without a post call day to ever catch up. Rip that bandaid off fast, hurts for an instant and then you are sitting pretty.

 

[Cutie Dibbles]

Since we are in season for finalizing our rank lists, does anyone have the "list" for programs that are in the experimental group of the icompare study. Thanks

I can't for the life of me find a complete list online anywhere. I only know what PDs have told me directly during my interviews (I'm applying to neuro, but we usually talk to the IM PD at some point during interview day about what to expect from intern/prelim year), and it seems that's the only way the randomization results are being disseminated for now. Until an official list is published somewhere, maybe our best bet is to pool the information we've all gotten from our interviews? I'll start:

Wash U - Control
Yale - Experimental

That's all I know - all my other interviews were pre-randomization. Hopefully some more IM or prelim applicants can help out.

 

[mdfacs]

Have you tried contacting the study coordinators? They have an email up on the study website...

Thanks, didn't get a response yet, will let you know if I do.

 

[Law2Doc]

I will completely 100% agree with this in terms of which is better - just knocking out your duty hours and actually getting some time off vs. doing like 5 X 16 hour shifts. Now that I'm a second year I do some 24's (really 28's or 30's) on my off-service months, whereas I only did 16 hours max at a time as an intern. I actually get more days off this way and feel more rested. In fact just recently enjoyed a golden weekend

That said, they both completely blow, and I ultimately side with the basic premise set forth by PandaBearMD years ago which states that (brace yourselves here): Human beings need sleep. Everyone try not to faint from the shock of that profound statement.

As youve confimed, schedules that purport to give you a little sleep every day may be a LOT worse than those that make you go without sleep for a block of time in exchange for more time off. You will feel more rested an have a better life if you do shifts in 30 hour blocks (or even more) as opposed to a lot more in 16 hour stints. The 80 hour cap makes longer shifts great -- you hit that ceiling so much quicker.

Yes humans need sleep. But can you make it a few years with less? Sure. Will you be able to decrease your years of training by working more hours? You bet. So It's an easy trade off. Nobody is going to extend a 3 year residency to 5 to get a full 8 hours per Night of sleep every night. A lot of us would have been happy to compress it down a year and go back to Q3. Experience/learn more faster. Rip that bandaid, don't prolong the pain.

 

[Instatewaiter]

I have worked night float.
I have worked where you work 6- 12 hour days
I was an intern before the work hours changed at a place that did Q4 call for 8.5 months of the year and q3 call for 2 more months.

The overnight call (28hour shifts) was the best of these systems from a quality of life standpoint, from a learning and patient ownership perspective and for actually knowing patients. The 6 12/13 hour shifts were tiring and you never had time to actually get a haircut or go to the bank. Plus you never knew the patients because you kept handing them off.

I am now a consultant, I can't tell you how many times I get consulted and it's someone "who's just covering." Don't ever utter these words. Handoffs are dangerous to patients and the new work hours make handoffs a necessity. It takes forever to properly signout and this is rarely done. What is left is a system where quite frankly I think there is an issue with patient safety and resident happiness.

 

[KnuxNole]

I wonder what people do to keep themselves functional during a 24 hour shift....every time I'm on one, I haven't made it through without making errors due to dozing off :/

Plus, during late night admits, I usually am so tired I feel I learn nothing at all, or that I forget material...

 

[KnuxNole]

I have worked night float.
I have worked where you work 6- 12 hour days
I was an intern before the work hours changed at a place that did Q4 call for 8.5 months of the year and q3 call for 2 more months.

The overnight call (28hour shifts) was the best of these systems from a quality of life standpoint, from a learning and patient ownership perspective and for actually knowing patients. The 6 12/13 hour shifts were tiring and you never had time to actually get a haircut or go to the bank. Plus you never knew the patients because you kept handing them off.

I am now a consultant, I can't tell you how many times I get consulted and it's someone "who's just covering." Don't ever utter these words. Handoffs are dangerous to patients and the new work hours make handoffs a necessity. It takes forever to properly signout and this is rarely done. What is left is a system where quite frankly I think there is an issue with patient safety and resident happiness.

What should I say instead? Because more than half the time, it is me covering for someone. I mean, if they ask if I've been seeing this patient for a while, I feel bad lying, or if they ask if I know their history in depth...

 

[Instatewaiter]

What should I say instead? Because more than half the time, it is me covering for someone. I mean, if they ask if I've been seeing this patient for a while, I feel bad lying, or if they ask if I know their history in depth...

I expect you to know exactly what you should when calling the consult. Or don't call the cosult. The "I'm just covering" line only gets thrown out there when they know essentially nothing about the patient.

 

[VisionaryTics]

I expect you to know exactly what you should when calling the consult. Or don't call the cosult. The "I'm just covering" line only gets thrown out there when they know essentially nothing about the patient.

Also a favorite from the ED:

"Oh thanks for coming down so quick. I haven't had a chance to even look at the patient!"

[then why the **** are you consulting my service]

 

[KnuxNole]

I expect you to know exactly what you should when calling the consult. Or don't call the cosult. The "I'm just covering" line only gets thrown out there when they know essentially nothing about the patient.

Fair enough, I won't say that when I call for cards for troponin levels

 

[Instatewaiter]

Also a favorite from the ED:

"Oh thanks for coming down so quick. I haven't had a chance to even look at the patient!"

[then why the **** are you consulting my service]

Truth.

 

[Instatewaiter]

Fair enough, I won't say that when I call for cards for troponin levels

Please don't. You should also have an idea where that troponin is coming from ... Like from that mule kick to the chest he took when he came in with rib pain or the hypotension on 3 pressors

 

[DoctwoB]

Because you're not "just covering"

For whatever period of time - whether that is twelve hours or twelve years - the patient is under your care, and they are your responsibility.

That's a little sanctimonious. When the number of patients I'm covering on night float is getting near 3 digits to expect one intern to know every detail is unreasonable. They're "under my care", but unless there is an acute issue I'm not making changes to management. I'm too busy putting out fires.

That being said I'm also not calling consults, that should be done by the primary day team. If someone is sick enough I'm calling an emergent consult, you can bet I'll have brought myself up to speed on him/her.

 

[DigStim22]

I can't for the life of me find a complete list online anywhere. I only know what PDs have told me directly during my interviews (I'm applying to neuro, but we usually talk to the IM PD at some point during interview day about what to expect from intern/prelim year), and it seems that's the only way the randomization results are being disseminated for now. Until an official list is published somewhere, maybe our best bet is to pool the information we've all gotten from our interviews? I'll start:

Wash U - Control
Yale - Experimental

That's all I know - all my other interviews were pre-randomization. Hopefully some more IM or prelim applicants can help out.

Can anyone verify this? I was told at Was U they were in the experimental arm (pre 2011 rules)?? That was for surgery if that makes a difference..

 

[Armadillos]

One thing that slightly confuses me about these discussions- why is there an automatic assumption that every service needs a resident covering it 24/7? If a department really cared about resident well being they could hypothetically provide coverage in other ways.

For example in psych a lot of programs will pay moonlighters or attendings to cover certain services on weekends and allow the on call resident to focus soley on ER and consults.

 

[Armadillos]

Because money...

But seriously -

We have a ton of midlevel support. They are there 5 days a week during the day on our elective services. We have them for nights/weekends on trauma.

But all of our services are "resident run" - so a senior resident/chief is always on call and the first contact for the intern or PA.

And there is an educational aspect to call as well. I think it's disingenuous to say that if programs really cared about their residents they would just pay someone else to do all the call. I think a part of "caring" about residents is ensuring they get adequate clinical exposure and see enough emergent/overnight operations.

You also just can't compare the burden of call for psych to something like internal medicine or general surgery which have order of magnitudes more inpatients.

I agree about the educational aspect in general and I'm not claiming all the call should be covered by other people. But folks in here are making it sound like going back to the old system is the only way a resident will ever get a real day off, on the other hand you could easily work in the occasional internal or external moonlighter to assure interns and residents get atleast 1 real weekend a month or whatever, which I imagine wouldn't destroy their educational experience

 

[Armadillos]

Because everything is a tradeoff.

You can't "easily" moonlight when all of your residents are working close to the limits. Moonlighting counts against the 80 hour workweek. It's feasible in psych because the average hours are much, much lower.

This is why several people have posited that there need to be entirely different set of regulations for different specialties.

And...why should our senior residents learning experience (since they've already taken their share of call and the priority for them needs to be operating as much as possible) be compromised by moonlighting to give interns extra days off?

We could give our interns more days off if we had our lab residents moonlight to cover the intern shifts. But I don't think our lab residents are particularly interested in having mandatory intern call shifts (a couple of programs do this, but they do it just to get the interns the bare minimum days off, not "extra" days).

Bottom line - I don't think you have any appreciation for how thinly stretched many residency programs are to meet the coverage requirements. You can't just manufacture extra hours when all of your deployable work force is up against the limit already.

I might have used the wrong term, I don't mean seniors to moonlight, I meant having occasional in house attending coverage with no resident. For example one VA I rotated through had a partially retired community surgeon who worked like 10-25hrs/week depending on what was needed covering random nights/weekends. she would hang out in the hospital, take calls/consults and occasionally do an emergent operation

 

[Armadillos]

I don't think you have an accurate understanding of how busy a major hospital is.

On any given night at my hospital there are about 10 residents in house covering the various surgical services. For trauma and emergency general surgery consults, we average 15 or so consults per night.

So to actually supplement that workforce with either locums or midlevels to the degree needed to meaningfully impact the residents' quality of life/time off - would be a tremendous expense. And most surgery departments are not bursting at the seams with profits.

I don't think my department would be comfortable with the quality of care that a "partially retired" community surgeon would provide in those circumstances. And I don't think our faculty, who are pretty damn busy themselves, have the time or inclination to cover the intern call burden.

And this is all within the setting of an academic program where people actually are pretty dedicated to teaching. The incentives to do this would be even lower in a community program where much/most of your teaching faculty are private practice surgeons.

In short - (a) the incentive just isn't there from any practical sense, (b) the expense of providing any meaningful degree of coverage would be major, (c) it's a largely imaginary workforce you're talking about - there isn't a ready supply of semi-retired surgeons interested in taking intern call, and the quality of the care they might provide would probably not be up to the level needed.

Fair enough, I won't pretend to have an understanding of the financial realities of running an academic program. I think I was lead astray because massive, high volume hospitals exist with no residents (or the 100s of thousands of gme dollars they come with) and manage to cover with attendings and mid levels. Granted they probably have better insured patients that academia

 

[KnuxNole]

I'm not being sanctimonious. I've done plenty of call and plenty of night float and cross covered more patients than you can count.

What I'm telling you is the expectation we impart on our interns starting day one. Patient ownership is extremely important and a challenge in the current environment

I never said I expect the intern to know "every little detail". It's the attitude that's an issue, not the knowledge

The attitude is there....however, I'll be honest, it's HIGHLY, HIGHLY challenging to know any covering patients in the same depth if they were mine from the start. Every time they call, I NEED my sheet of info. I NEED to tell the nurse to give me a few secs as I scurry through the EMR at home. I always panic, and freak out...it's hard

Especially if it's after midnight, where my brain is shut down, and I've given someone morphine Q12 hours by accident :X

 

[Cutie Dibbles]

That poster was talking about icompare

Yup. I believe the Internal Medicine department at Wash U is in the control arm of the icompare study. I don't know anything about the surgery study.

 

[Gastrapathy]

If you start a call with "your patient" or "I'm just covering" expect rage. We know what time it is but if you are doing anything other than calling a code, own it. Get good at figuring it out fast. Then call. It's basic roundsmanship in a culture where you are shift workers and we were and are not.

When you don't know a detail, say I didn't catch that in my chart review before I called but I see why you want to know. Just try. So many interns don't.

 

[Kaustikos]

Bottom line - I don't think you have any appreciation for how thinly stretched many residency programs are to meet the coverage requirements. You can't just manufacture extra hours when all of your deployable work force is up against the limit already.

True. Very true.
At this point: I sympathize with interns so much. Sympathize and not empathize because I'm not there. But because I feel bad for them. I honestly try harder to do more for interns because I just know their lives are so ****ty already. When I'm doing vascular surgery and the intern is doing overnight call... I damn well will have everything ready that morning so he/she can go home asap.

 

[Kaustikos]

If you start a call with "your patient" or "I'm just covering" expect rage. We know what time it is but if you are doing anything other than calling a code, own it. Get good at figuring it out fast. Then call. It's basic roundsmanship in a culture where you are shift workers and we were and are not.

When you don't know a detail, say I didn't catch that in my chart review before I called but I see why you want to know. Just try. So many interns don't.

I'm sorry, but can you clarify the first part? I'm not disagreeing but trying to get an idea of how to "cut to the chase" without being rude. I'm only beginning to get an idea of how to consult, so any advice is appreciated

 

[Gastrapathy]

Unless he's my outpt admitted from my clinic, ifyou are covering for the primary, take ownership. If you are calling a new consult, brief hx and a question. I like the BLUF (bottom line up front) approach.


Ie ("hi G, I have a crohns pt id like your help with...then a quick presentation leading to a question."). You won't get the why are you calling me q halfway through the presentation that way.

Works great when calling surgeons. "Hey surgeon, I have a pt on my service who I'm concerned has an sbo. He's an 85 yo demented guy admitted for failure to thrive ... Etc. if you lead with the second sentence and get to the sbo later, it doesn't work as well.

 

[KnuxNole]

I usually try to read to h and p first, since I barely get info during a 15 sec checkout haha...

 

[Kaustikos]

Unless he's my outpt admitted from my clinic, ifyou are covering for the primary, take ownership. If you are calling a new consult, brief hx and a question. I like the BLUF (bottom line up front) approach.


Ie ("hi G, I have a crohns pt id like your help with...then a quick presentation leading to a question."). You won't get the why are you calling me q halfway through the presentation that way.

Works great when calling surgeons. "Hey surgeon, I have a pt on my service who I'm concerned has an sbo. He's an 85 yo demented guy admitted for failure to thrive ... Etc. if you lead with the second sentence and get to the sbo later, it doesn't work as well.

Ok,
Makes sense. It's pretty much what I do. Just be sure to take ownership. .. got it.

 

[Geographer]

So have we found a list of iCompare trial participant programs? I've been unable to locate a list, which is pretty frightening.

 

[redpanda]

So have we found a list of iCompare trial participant programs? I've been unable to locate a list, which is pretty frightening.

Dude, the list is the first thing that comes up for the trial if you google it!

 

[Geographer]

Nevermind- I found it finally through a helpful news article, but numerous Google searches kept taking me to a page with details on the setup and how to get involved.

For those who also had trouble:
http://www.jhcct.org/icompare/showassignments.asp

 

[justvisiting2016]

This thread shows what’s wrong with physicians and why they have lost your status, position and respect.


You are right, it takes a lot of time and effort to express your thoughts intelligently so why not just call a person stupid (including patients who you can’t seem to ‘educate’)


Especially if that person doesn’t happen to agree with your opinion and arguments (which is always the only truth) - that’s an outrageous stupidity!


At the risk of causing another burst of outrage, the author of the original post is right in many regards:


1. Residents are vulnerable population as there is an asymmetry and hierarchy in authority and position between those who are conducting and have consented to the study and those who are recruited. This is exactly why students are considered to be vulnerable population. For example, if I recruit my students or any students from my institution, or consent for them to be recruited in a study they will be absolutely viewed (at least should be) as VP.


2. Informed consent is necessary for every human subject except: when 1) it is not possible to obtain individuals’ consent to participate (e.g. mentally compromised, which you don’ seem to be), 2) it is not desirable to obtain consent as it may pose a risk to subjects, or obtaining informed consent may diminish the scientific merit of the research, which neither of these applied to iCOMPARE.


Therefore, your consent was needed (there is a debate ongoing started by JHU bioethicists whether consent always necessary but a) it is not applicable to this study, b) still a debate with valid arguments on both sides.


In addition, as an ethical position, you are happy to waive the right to be consented if it benefits you (at least according to your hypothesis) but you cry rivers about not having a voice in a policy debate (remember ACA?)


There is so much more that can be discussed in terms of iCOMPARE ethics and research merits but I’m concerned about your time and effort to go through all that

 

[PL198]

This thread shows what’s wrong with physicians and why they have lost your status, position and respect.


You are right, it takes a lot of time and effort to express your thoughts intelligently so why not just call a person stupid (including patients who you can’t seem to ‘educate’)


Especially if that person doesn’t happen to agree with your opinion and arguments (which is always the only truth) - that’s an outrageous stupidity!


At the risk of causing another burst of outrage, the author of the original post is right in many regards:


1. Residents are vulnerable population as there is an asymmetry and hierarchy in authority and position between those who are conducting and have consented to the study and those who are recruited. This is exactly why students are considered to be vulnerable population. For example, if I recruit my students or any students from my institution, or consent for them to be recruited in a study they will be absolutely viewed (at least should be) as VP.


2. Informed consent is necessary for every human subject except: when 1) it is not possible to obtain individuals’ consent to participate (e.g. mentally compromised, which you don’ seem to be), 2) it is not desirable to obtain consent as it may pose a risk to subjects, or obtaining informed consent may diminish the scientific merit of the research, which neither of these applied to iCOMPARE.


Therefore, your consent was needed (there is a debate ongoing started by JHU bioethicists whether consent always necessary but a) it is not applicable to this study, b) still a debate with valid arguments on both sides.


In addition, as an ethical position, you are happy to waive the right to be consented if it benefits you (at least according to your hypothesis) but you cry rivers about not having a voice in a policy debate (remember ACA?)


There is so much more that can be discussed in terms of iCOMPARE ethics and research merits but I’m concerned about your time and effort to go through all that

DO/PHD? isn't that kinda an oxymoron

 

[AlteredScale]

DO/PHD? isn't that kinda an oxymoron

Not if you do your thesis in holistic bench research. You consider the whole acrylamide gel as a whole.


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