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Revisiting the Residency Work Hours debate

Discussion in 'General Residency Issues' started by MBK2003, Sep 27, 2002.

  1. MBK2003

    MBK2003 Senior Member
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    I am a MS4 who is in the process of applying for residency and I wanted to know if others have noticed a similar phenomenon. Many of the clinical departments at our medical school of undertaking significant overhaul in order to comply with the upcoming RRC residency work hour requirements. Almost without exception, the residents that I talk with are not only in favor of the changes, but looking forward to having limits on the amount of work hours they must put in. However, the faculty for the most part are completely opposed to any change. My favorite arguements from the faculty are :

    1) "Back in my day, we used to do Q3 call and there was none of this leaving after noon conference $#&%!"
    - Nevermind that "back in my day" was a scant two years ago. I am always tempted to ask whether they had to walk to the hospital in the snow uphill both ways.

    2) "Well if they can only work 80 hours a week, then the residency needs to be made a year longer."
    - The arguement is often that the resident don't see enough pathology in 80 hours a week to be competent clinicians. However, one could argue that residents at a tertiary care facility (which is what we are) see significantly more zebras in 3-4 years than those at smaller community programs. Is this statement in fact then knocking community programs and smaller residencies?

    3) "If the residents are only going to work 80 hours a week and the hospital has to hire extra PA's and NP's to cover the rest of the work, then the residents need to be paying the hospital for their training."
    - This particular one irks me in so many ways. How many of us have seen the residents deliver the baby by C-section at 2am while the attending could not be roused from bed, only to know that he will cosign the operative note and still bill for the delivery?

    4) "Some of my interns and residents have been very slow, and that's why we don't finish morning rounds until 4pm. You can't expect me to let them go before rounds are finished."
    - Interns are slow the first month or so, after that everyone has reached a running pace. At the hospitals where I have rotated the interns have to deal with such a significant amount of scutwork that it can take up to 4 hours of their day everyday. This isn't putting in IV's - it's calling three departments to get the approval to order a swallow study, or waiting on hold for 20 minutes with the only home health care provider that the insurance will pay for. Certainly the interns need to know the logistics of getting these things arranged, but that requires doing it ONCE, not once a week. I would propose that 60% or more of the scutwork can be done by someone without an MD degree (and it shouldn't always be the medical students :) .
    - My other objection to this point is, "Dr. Attending, rounds wouldn't take so long if you weren't answering pages from your spouse and children Qhour." (Sorry, personal pet peeve)

    The reason that I am venting is that today I experienced a significant amount of hostility from an entire department of pediatric specialists over this issue. They have already decided that the group of incoming interns are "spoiled brats who are just too lazy to learn how to be doctors." This is certainly not the fellowship of medicine I was hoping to be joining. I would love to hear that others out there are having more positive experiences.

    Thanks for letting me vent!

    MBK2003
     
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  3. droliver

    Moderator Emeritus 10+ Year Member

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    As someone finishing general surgery this year, I can tell you that the strictly enforced 80 hr work week will have a signifigant impact on the quality of your training and quite possible patient care. I think if you polled most surgery residents, they would agree that an arbitrary # of hours before being mandated to leave patient care will cause some problems. The people leading the drumbeat on the new rules are ironically not the one most likely to be affected by them. A hidden consequence of these new rules will likely be much closer regulation of moonlighting activity if not outright prohibition by some programs
     
  4. fourthyear

    fourthyear Senior Member
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    Interesting that you are refering to people in pediatrics. From my very limited experience in 3rd year rotations, seems to me that peds is one of the specialties that takes a lot of call, but has a lot of down time while on call. Just b/c you are at the hospital 36 hours straight certainly does not mean you are awake and working 36 hours straight. At the hospital I was at, we had to take NICU call and guess what we did - watched about 6 movies a day b/c there was NOTHING to do unless an at-risk baby was delivered (about twice a day) or someone was really unstable, which was also surprisingly rare. yet these guys thought they worked so hard.

    I'm sure it varies from place to place and day to day. But I just thought this specialty was one of the kings of hanging out in the hospital trying to look like they are working and it's intersting that some of your peds faculty think they were so hardcore as residents b/c I just don't buy it.
     
  5. MBK2003

    MBK2003 Senior Member
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    I understand that with a strictly enforced 80 hour week, many surgery residents will have significantly reduced operative exposure and there are concerns about lack of continuity of care. I don't want to make any sweeping statements about the effect of the changes on the overall training of surgical residents. However, as I see it, the rule about not seeing new patients after 24 hours of duty has one significant benefit at the hospital where I did my surgery rotation. This hospital's general surgery service which routinely carried between 40 and 60 patients on a daily census, was set up so that the intern or 2nd year resident who was on call that evening was not in the OR that day, but spent the day doing all the team's scut - all the discharge summaries and dictations (regardless of who was following the patient) and making sure all the orders, labs, and TPN scripts were done for every patient on service. Then that person was up all night in the ER handling lacs and a million calls about post-op fever and pain management, and then finally they were in the operating room the entire next day. I routinely saw residents and interns fall asleep with the bovie in their hand. At least this work hour restriction will improve this potentially very dangerous situation.

    MBK2003
     
  6. dr.evil

    dr.evil Senior Member
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    Well, as we get closer to d-day and the changes that are taking place, I begin to feel more comfortable with it.

    I am a surgery resident and have to say I was really concerned with a set restriction on the number of hours that we work. Maybe surgery residents have a different mentality (no comments please:p ) but hours are less important to me compared to the amount of operative/patient care experience I'm getting. But we all must change so...

    Anyway, sticking to the changes, and if we go to a nightfloat system, I don't think our education will take that big of a hit and may actually improve as we will likely have more time to read.

    So here's the initial hour proposal from my institution: No night call. You can work 6 days per week at over 13 hours per day and be under 80. That means coming in around 5:30-6:00am and leaving at around 7:00pm (not bad and about average for most surgery residents if not on call). The nights would be covered by a 3rd year resident for 4 months who takes all the consults and does all the cases at night (except for Trauma) as well as an intern for 2 months to help out. All floor calls on patients on your team will be taken by you at home 24/7 (so no checkout). [We're not sure if this is within the regulations or not].

    Trauma is covered by a separate team who works 13 hours on, 13 hours off with some manipulation on the weekend to keep it under 80. You rotate each week on who works days and who works nights.

    I think the 6 months of nightfloat will suck, no doubt. BUT, no in house call will rock. You are actually in house overnight less days overall but you just miss out on the days, which sucks. So really, we kind of set it up as if we were attendings out in practice who took calls on their patients from home, went home at night, and had a resident in house at night to take care of you. All of this and we continue to operate >10 hours per day.

    I was intimately involved in coming up with all of this for our residency so it works for me. I think there is enough give in the system that if you went home at 5pm one day, you could stay until 9pm the next day. Anyway, the 80 hours/week has to be an average over 4 weeks from my understanding.

    I think it will be interesting to see the changes across the nation and how interviewees (4th year students) perceive all of the changes. I think it would be very, very difficult to choose a residency with all of the changes and instability going on.

    I'm too am surpised that the peds guys are moaning about it.

    Some of my attendings actually have made some common sense statements such as, "Well, the hours change would give you more reading time. In my day, we only had one imaging modality, two antibiotics, and one or two answers to a specific problem. You guys now have all of this biochemistry, PET scans, Nuclear imaging, CT scans, U/S, enough antibiotics/medications for a 3000 page book, and multiple ways to treat diseases. I think you need more time to read."

    We'll just wait and see.
     
  7. Neurogirl

    Neurogirl Resident Extraordinaire
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    What I want to know is, where does the money go? Supposedly, medicare pays approx $100,000 per resident, per year. Residents only get about 1/3 of that, so where does the rest go? I know it goes towards "education", but what does that actually mean? Does it go towards attending salaries, indigent care, equipment? I've heard that care provided by residents is more expensive because we supposedly run more tests, but I think that's bullsh#t! It might be true during the first month or two, but after that, most people get their act together and know what to order, or to ask when they aren't sure.

    Also, limiting hours might compromise training for some specialties (like surgery), but for most fields, I don't think it has to be an issue. During internship, I averaged 70-80 hrs a week and think that was more than sufficient. I've yet to feel unprepared or lacking in any way. Of course, we had nurse case managers, who handled ALOT of the scut, so maybe that made the difference. Now that I'm in specialty training, my hours haven't really changed all that much, except that some (rare) months I only work 50-60 hrs/wk. I don't know how unique that is...maybe my program just really has it's act together. I think the programs that are having major problems with the new system, are the ones that have much bigger issues to deal with.
     
  8. MustafaMond

    MustafaMond K-Diddy M.D.
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    I think the Hour-Cap is a great idea.

    It will force a lot of programs to rethink their schedules and include a lot of "night-float" and extra coverage, as an above poster mentioned.

    I think the federal rules are going in NEXT YEAR, so as of now, there is no mandate. But a lot of programs are trying to shape up, esp. before ACGME rolls in and inspects. :laugh:

    Well, NEwayz..80 hours sounds good to me.
     
  9. surg

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    Here are the rules: (you can check them up at http://www.acgme.org/new/dutyHoursLanguage.pdf

    3.d.

    At-home call (pager call) is defined as call taken from outside the assigned institution.
    1.) The frequency of at-home call is not subject to the every third night limitation. However, at-home call must not be so frequent as to preclude rest and reasonable personal time for each resident. Residents taking at-home call must be provided with 1 day in 7 completely free from all educational and clinical responsibilities, averaged over a 4-week period.
    2.) When residents are called into the hospital from home, the hours residents spend in-house are counted toward the 80-hour limit.
    3.) The program director and the faculty must monitor the demands of at-home call in their programs and make
    scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue.


    2.b. Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities.



    So yes: the schedule proposed by Dr. E. appears to be in compliance.
     
  10. droliver

    Moderator Emeritus 10+ Year Member

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    thanks for the link! however, I think the 24/7 beeper coverage (assuming its the same person carrying the beeper) would violate the intent of 3d sec 1 "at-home call must not be so frequent as to preclude rest and reasonable personal time for each resident".
     
  11. surg

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    Having spent literally about 100 hours debating this topic at the national level over the last 1.5 years, it only now has come to my attention that the published ACGME rules no long specify the number of hours one has to be one before you are considered to be on call. As I recall, the last draft (before the published one) had a section stating that days that lasted beyond 14 hours were considered "on call days" subject to the q3 rule, however, I admit that the final draft does not have this rule so it is open to interpretation. I can tell you that ACGME had night float type systems (night shift/day shift) such as Dr.E proposes as a specific type of schedule that would allow programs to be compliant.

    Just for completeness, the AMA policy asks for averaging over 2 weeks and defines anything over 12 hours as being "on call"

    http://www.ama-assn.org/ama1/pub/upload/mm/377/report9.doc
     
  12. Future GI Guy

    Future GI Guy Hoo Hoo....
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    Hey dr.evil

    Can you clear up something for me?

    You're talking about 6 months of night float per year, though it was my understanding that the max number of night float months in a 3 year residency is 3 months for the entire length of the residency. I realize Surgery is 5 years, but are these night float restrictions different for longer residencies?

    GI Guy
     
  13. MacGyver

    MacGyver Membership Revoked
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    The short answer to your question is that hospitals make a PROFIT off of resident payments by Medicare.

    They use those profits to pay for indigent care mostly. Thats why the number of residency positions in the US has exploded over the last 20 years; hospitals quickly caught on that residency positions were a cash cow that they could use to pay down the costs of indigent care.

    It does cost some money to train the resident, but its far below what the hospitals take in as profit from the 100k per year per resident that they train.
     
  14. dr.evil

    dr.evil Senior Member
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    I must have wrote that a little cooky. It would be 6 months of the entire 5 years of residency. I'm not sure if that fits under the auspices of ACGME regulations or not. We may have to change it to 4 months or something.

    Sorry about the confusion.

    Oh and BTW, 12 hours= "on call". Holy crap. I've been on call every single day of my 3 months of residency.
     

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