Solution for allowing residents to file complaints - penalize the PD

[MedicineZ0Z]

So this whole notion of logging 80 hours when you really did 105 or ignoring all the malignant aspects of your program sucks. Why? Because as we know, it would have your residency shut down --> you don't become a licensed doctor.

It seems like the simple solution is to have the PD enforce the rules and face consequences for not doing so. I mean what other solution is there? Someone or something has to be held accountable. Right now, it's the program itself and hence the residents. Instead the PD should be held accountable through some form of action and should be penalized.

---

Members don't see this ad.

 

[gutonc]

So what do you suggest? I mean...it's such a simple solution after all. I'm surprised nobody has figured it out before.

 

[mk04447]

So this whole notion of logging 80 hours when you really did 105 or ignoring all the malignant aspects of your program sucks. Why? Because as we know, it would have your residency shut down --> you don't become a licensed doctor.

It seems like the simple solution is to have the PD enforce the rules and face consequences for not doing so. I mean what other solution is there? Someone or something has to be held accountable. Right now, it's the program itself and hence the residents. Instead the PD should be held accountable through some form of action and should be penalized.

That's why there is an anonymous complaint process, though they recommend using your name and they promise to protect you from retaliation; I doubt anyone would be that stupid though, the remainder of your time would probably be smooth sailin. If appropriate, I imagine there will be an investigation, a hearing, and a penalty; none of which is likely to close your residency down, not immediately anyway. If it's a first offense, they'd probably only get a stern bitch slapping. Regardless, seems like this is a completely reasonable mechanism, no?

 

[MedicineZ0Z]

That's why there is an anonymous complaint process, though they recommend using your name and they promise to protect you from retaliation; I doubt anyone would be that stupid though, the remainder of your time would probably be smooth sailin. If appropriate, I imagine there will be an investigation, a hearing, and a penalty; none of which is likely to close your residency down, not immediately anyway. If it's a first offense, they'd probably only get a stern bitch slapping. Regardless, seems like this is a completely reasonable mechanism, no?

Who wants their residency on probation? And if it was so straight forward, more residents in malignant programs would complain.
For a genuine first offence, you can suspend the PD's teaching. Second offence, you remove them. And lower the bar for what constitutes an offence.

 

[mk04447]

Who wants their residency on probation? And if it was so straight forward, more residents in malignant programs would complain.
For a genuine first offence, you can suspend the PD's teaching. Second offence, you remove them. And lower the bar for what constitutes an offence.

Nobody, that's the point. You are assuming the students experience greater harm, I'm arguing they'll correct the problem before that happens.

I'm not opposed to your idea, why don't you submit it. However, you have also assumed cutting the head off the dragon will solve the problem; I think you'd end up with a rudderless ship with a bunch poor policies and continued violation.

 

[Promethean]

I think you'd end up with a rudderless ship with a bunch poor policies and continued violation.

This.

Shooting the captain based on, what, an anonymous report? Seems like a situation rife for abuse and gamesmanship.

 

[NotAProgDirector]

Needless to say, there's no simple solution.

If everyone is working 100+ hours and forced to log <80, that's a huge problem. But how exactly do you plan to hold the PD responsible? If you fire the PD, whose going to want to do it? In a healthy system, a new PD works with the old PD for awhile so that the transition is relatively smooth. Simply firing someone and expecting someone else to step in and do a good job is naive. And even if you fired a PD for this, who do you expect to step in? Duty hour violations like this are usually a "system" problem and not a person problem, perhaps a new PD will fix the system, but you could end up with worse.

And if everyone else is actually working <80 and you're working 100+, then the problem is you. Not saying this applies to the OP.

But I agree that it can be a no-win situation. You can "suck it up" and suffer, and nothing ever gets better. Or you can complain via the ACGME resident survey, which is completely anonymous. But if your program gets poor marks on the survey, the program could make the residents miserable in trying to fix it. There should be a better system to deal with this, but I don't know what it is. If good people are running the show, it's not a problem at all.

 

[Waraba]

Perhaps this is a stupid question, but what happens when a program loses 25-30% of a residency class due to quitting/termination, etc? I'm guessing the program is not required to fill the empty slots, so if the other residents have to pick up the slack and exceed the duty maximums, I'm curious to know what the current protocols are to get out of such a mess, if any.

 

[NotAProgDirector]

There are no "protocols", each program can address it however they wish. They can hire new residents (although if you lose residents who are more senior in the program, those can be hard to replace). They can redo the schedule so that the remaining residents cover the hole -- if this create duty hour problems technically the GME office should be overseeing that and should address it. They can redistribute the work to someone else. Or any combination.

 

[Waraba]

IIRC I have heard of cases where the GME office does nothing. I'm assuming in these cases there is no one else to redistribute the workload to. If this scenario is possible, and no one in the program reports it "officially" then there would be no other oversight. Is that true?

 

[NotAProgDirector]

Oversight of residency programs includes:
1. The PD
2. The GME office / DIO (the person who leads the GME office)
3. The ACGME - which includes the annual resident survey, and anonymous reporting

Some institutions may have additional options (an ombudsperson, for example). And there's always the option of public shaming in the media.

The GME office will only do something if someone complains / reports. Same with the ACGME.

 

[operaman]

I’ve always thought a more straightforward solutions would be for the acgme to publish comparative rankings for QOL at different programs based on the annual survey. You could aggregate data from the last 2-3 years to prevent one angry resident from tanking things. Maybe that plus drop the highest and lowest scores.

People do love to rank things and this would be a nice data point for applicants to have when making their list. My sense is that most programs in a given field would cluster near a high mean score and the problematic programs would stick out. The PDs I know would be mortified to see their program ranking poorly compared to peer programs and would probably do whatever they could to make things better. While I’m sure there are bad apples out there who would try to coerce residents to game the system, they would still be faced with the reality that their own chairman and every other program can see them down at the bottom of the ranks.

 

[JustPlainBill]

Needless to say, there's no simple solution.

If everyone is working 100+ hours and forced to log <80, that's a huge problem. But how exactly do you plan to hold the PD responsible? If you fire the PD, whose going to want to do it? In a healthy system, a new PD works with the old PD for awhile so that the transition is relatively smooth. Simply firing someone and expecting someone else to step in and do a good job is naive. And even if you fired a PD for this, who do you expect to step in? Duty hour violations like this are usually a "system" problem and not a person problem, perhaps a new PD will fix the system, but you could end up with worse.

And if everyone else is actually working <80 and you're working 100+, then the problem is you. Not saying this applies to the OP.

But I agree that it can be a no-win situation. You can "suck it up" and suffer, and nothing ever gets better. Or you can complain via the ACGME resident survey, which is completely anonymous. But if your program gets poor marks on the survey, the program could make the residents miserable in trying to fix it. There should be a better system to deal with this, but I don't know what it is. If good people are running the show, it's not a problem at all.

I really wish I had known you during my residency -- at least I would have had an unbiased source --

At my program, we were told by our seniors to log only 80 hours no matter how much we put in -- otherwise, we would be seen as incompetent and unable to complete the work. I declined to do that and got called on the carpet for it. I figured, if there's a problem, they need to know -- naïve as hell, I know but that was my thinking at the time. And since all the residents logged 80 hours and refused to fess up, I got hammered -- it was well known that our PD picked a resident out of the incoming class that he didn't like for whatever reason, or no reason at all, and rode them hard, trying to get them to quit or transfer. He had been passed over for PD about 5 times and finally when there was no one else, he was selected. The University system closed ranks to protect him and when I went to see the GME office about a being put on probation, it was obvious the GME officer had already read my file and made up his mind for I was told, "Shut up, do your job, cooperate and graduate".....

The department was one of the most sued departments in the entire system I was in-- thankfully an attending who thought I was being treated unfairly let me know that the PD was openly stating at the end of my intern year that I would never get a PGY2 contract and he was going to fire me....

groupthink is a wonderful thing....

 

[LucidSplash]

I’ve always thought a more straightforward solutions would be for the acgme to publish comparative rankings for QOL at different programs based on the annual survey. You could aggregate data from the last 2-3 years to prevent one angry resident from tanking things. Maybe that plus drop the highest and lowest scores.

People do love to rank things and this would be a nice data point for applicants to have when making their list. My sense is that most programs in a given field would cluster near a high mean score and the problematic programs would stick out. The PDs I know would be mortified to see their program ranking poorly compared to peer programs and would probably do whatever they could to make things better. While I’m sure there are bad apples out there who would try to coerce residents to game the system, they would still be faced with the reality that their own chairman and every other program can see them down at the bottom of the ranks.

But who is going to submit data for the rankings? If you rank QOL for your program low, you then risk getting decreased quality of applicants. And nothing makes life ****tier than crappy juniors/coresidents.

 

[NotAProgDirector]

I’ve always thought a more straightforward solutions would be for the acgme to publish comparative rankings for QOL at different programs based on the annual survey. You could aggregate data from the last 2-3 years to prevent one angry resident from tanking things. Maybe that plus drop the highest and lowest scores.

People do love to rank things and this would be a nice data point for applicants to have when making their list. My sense is that most programs in a given field would cluster near a high mean score and the problematic programs would stick out. The PDs I know would be mortified to see their program ranking poorly compared to peer programs and would probably do whatever they could to make things better. While I’m sure there are bad apples out there who would try to coerce residents to game the system, they would still be faced with the reality that their own chairman and every other program can see them down at the bottom of the ranks.

I think this is a reasonable option. The ACGME (via the resident survey) already collects this data. As mentioned already, if it becomes publically available, programs will work to improve their standing. This could be good or bad, it depends on how it plays out. If I had an unhappy resident whom I thought was giving us bad scores, it might bias me to terminate them rather than try to remediate them.

I really wish I had known you during my residency -- at least I would have had an unbiased source --

At my program, we were told by our seniors to log only 80 hours no matter how much we put in -- otherwise, we would be seen as incompetent and unable to complete the work. I declined to do that and got called on the carpet for it. I figured, if there's a problem, they need to know -- naïve as hell, I know but that was my thinking at the time. And since all the residents logged 80 hours and refused to fess up, I got hammered -- it was well known that our PD picked a resident out of the incoming class that he didn't like for whatever reason, or no reason at all, and rode them hard, trying to get them to quit or transfer. He had been passed over for PD about 5 times and finally when there was no one else, he was selected. The University system closed ranks to protect him and when I went to see the GME office about a being put on probation, it was obvious the GME officer had already read my file and made up his mind for I was told, "Shut up, do your job, cooperate and graduate".....

The department was one of the most sued departments in the entire system I was in-- thankfully an attending who thought I was being treated unfairly let me know that the PD was openly stating at the end of my intern year that I would never get a PGY2 contract and he was going to fire me....

groupthink is a wonderful thing....

This is really unfortunate. We build our busiest rotations so that they average out to 70-72 hours a week, that way there's room for the occasional busier than expected day. I'd like to think that my residents don't lie on their logging.

To be fair, if everyone else is really getting their work done in 80 hours and you're taking 110, then the problem is you. I'm not saying that's what happened in your case, but I can tell you that I've had inefficient residents in the past, and their usual "explanation" is that everyone else lies on their time sheets.

 

[JustPlainBill]

<snip>
To be fair, if everyone else is really getting their work done in 80 hours and you're taking 110, then the problem is you. I'm not saying that's what happened in your case, but I can tell you that I've had inefficient residents in the past, and their usual "explanation" is that everyone else lies on their time sheets.

Totally agree -- however, on our inpatient service (FM residency) I was sitting right beside the other intern and we usually got there within 5 minutes of each other in the morning and we'd leave together at night -- the senior on service would be there with us and advised us to log 80 hours -- we both complained that the administration needed to know how long it took but the senior argued that they didn't want to take the heat for our "team" taking longer to do the work -- even though everyone knew all the residents were sandbagging.

it was a screwed up place -- I personally witnessed an attending try to do a therapeutic tap with the Safe-T-Centesis kit (where you have to use a scalpel for the initial incision), not be able to figure it out and wind up using an 18ga draw needle into the abdomen and reversing the tubing/kit to effect a 2L drain....I was physically slapped in the head by an attending on Ob (FM attending) down a blind hallway with no cameras and then threatened with non-professional conduct when I brought it to my chiefs who gossiped it around the entire residency. My advisor was so junior they didn't know what to do....I had passed an ICU rotation but had 2 or 3 areas of "needs improvement" and it was considered a failure by the program and used to put me on probation....when the prior resident (who just happened to be the same religion as the PD and several of the attendings) received a worse evaluation on their ICU rotation (they went off service as I was coming on) evaluated by the same ICU attending but it was regarded as a pass.....we had a Chief who didn't complete their required inpatient rotations and did enough "academic studies" electives to qualify for a special recognition (he was basically home sleeping but well liked since he would tell everyone it was the best residency around and NEVER, EVER fought for the residents)....I had more than one case of where I didn't know how to treat a particular disease process as an intern and was verbally chastised in front of my peers. 2 months later on the same inpatient rotation with another intern and they didn't know how to treat the disease process either and they were calmly instructed on how to do it by the same attending that chewed me out (PD).

It was 3 years of a living hell and I just tried to survive -- I did graduate, am BC and now practicing but I can't say that it was a good learning experience....My most common phrase when asked about my program, "Those idiots couldn't teach a bunch of horny Boy Scouts what to do inside a Vegas cathouse".....

 

[Goro]

Totally agree -- however, on our inpatient service (FM residency) I was sitting right beside the other intern and we usually got there within 5 minutes of each other in the morning and we'd leave together at night -- the senior on service would be there with us and advised us to log 80 hours -- we both complained that the administration needed to know how long it took but the senior argued that they didn't want to take the heat for our "team" taking longer to do the work -- even though everyone knew all the residents were sandbagging.

it was a screwed up place -- I personally witnessed an attending try to do a therapeutic tap with the Safe-T-Centesis kit (where you have to use a scalpel for the initial incision), not be able to figure it out and wind up using an 18ga draw needle into the abdomen and reversing the tubing/kit to effect a 2L drain....I was physically slapped in the head by an attending on Ob (FM attending) down a blind hallway with no cameras and then threatened with non-professional conduct when I brought it to my chiefs who gossiped it around the entire residency. My advisor was so junior they didn't know what to do....I had passed an ICU rotation but had 2 or 3 areas of "needs improvement" and it was considered a failure by the program and used to put me on probation....when the prior resident (who just happened to be the same religion as the PD and several of the attendings) received a worse evaluation on their ICU rotation (they went off service as I was coming on) evaluated by the same ICU attending but it was regarded as a pass.....we had a Chief who didn't complete their required inpatient rotations and did enough "academic studies" electives to qualify for a special recognition (he was basically home sleeping but well liked since he would tell everyone it was the best residency around and NEVER, EVER fought for the residents)....I had more than one case of where I didn't know how to treat a particular disease process as an intern and was verbally chastised in front of my peers. 2 months later on the same inpatient rotation with another intern and they didn't know how to treat the disease process either and they were calmly instructed on how to do it by the same attending that chewed me out (PD).

It was 3 years of a living hell and I just tried to survive -- I did graduate, am BC and now practicing but I can't say that it was a good learning experience....My most common phrase when asked about my program, "Those idiots couldn't teach a bunch of horny Boy Scouts what to do inside a Vegas cathouse".....

Gawd Bill, first TCOM and then this...how did you ever survive!!!!????

 

[Perrotfish]

To be fair, if everyone else is really getting their work done in 80 hours and you're taking 110, then the problem is you. I'm not saying that's what happened in your case, but I can tell you that I've had inefficient residents in the past, and their usual "explanation" is that everyone else lies on their time sheets.

My friends from medical school ended up in a lot of different residencies, and everyone was lying on their time sheets. No one was even kind of close to 80 hours per week.

One of the odd things is that, having sat next to residents who were right there with me for all 100+ hours of our work week, the majority actually had convinced themselves that they really were working less than 80 hours. Some had elaborate and not too closely examined mental formulas to get them under 80 hours (one told me that he subtracted any time he used the bathroom, looked down at his phone, etc). Others just relied on flat out denial. They really did see five lights. My group of friends did seem to be unique in that they all knew that they were lying about how much they worked.

I do remember one of the funnier things I saw in medical school was a surgery resident getting berated for going over hours. He was so deliriously tired from his (completely standard) 120 hour week that he screwed up his time sheet and filled it out so that it said 81 hours. The attendings spent the first part of the weekly case conference calling him out for inefficiency.

 

[VA Hopeful Dr]

They really did see five lights.

Nice

 

[VA Hopeful Dr]

On topic, the only time I ever lied about hours and residency was when I was Moonlighting too much.

 

[JustPlainBill]

Gawd Bill, first TCOM and then this...how did you ever survive!!!!????

Why do you think I go batzoid, chew the carpet crazy every time I hear some twit NP make a statement along the lines of being my peer? No, sweetheart, until you 1) earn the grades necessary to be selected for medical school 2) make the MCAT scores necessary to be selected 3) have the extra-curricular activities and appropriate clinical experience plus that certain something that all successful applications require 4) Survive the onslaught of information to sufficient detail and breadth to make it through MS1/MS2 5) Recall sufficient detail and be able to put it into a cohesive useable block of information sufficient to pass Step 1 (or COMLEX Level 1) 6) Survive each rotation with attending physicians and residents continually function checking your ability to be a physician and attempting to mold you into such 7) Study sufficiently to pass shelf exams in each subject rotation 8) successfully complete all of your clinic rotations in MS3/MS4 9) Retain said information previously required in sufficient quantity/quality to pass Step 2 (or COMLEX level 2) 10) Have a complete medical school package and personality such that you successfully get called for interviews for potential residency positions 11) Successfully match into said residency position vying against all the other candidates 12) Successfully pass all required rotations of intern year which includes but is not limited to -- understanding interactions between all medications in sufficient detail so as to not kill/injure your patients, understand/retain and demonstrate mastery of societal recommendations regarding all aspects of patient care in your assigned patients, be able to determine "sick/no sick, emergent/can wait" in your clinic patients, be able to understand why certain medications are appropriate in certain patients and not in others, plus a host of other things too numerous to mention 13) Study during intern year to successfully pass Step 3 (COMLEX Level 3) 14) Demonstrate sufficient knowledge during PGY2 to be able to supervise interns so that they don't kill patients 15) Successfully be given a new contract each year during your entire residency which includes but is not limited to: demonstrating increasing medical knowledge as witnessed by passing in training exams, play the residency politics successfully while maintaining some semblance of sanity 16) Successfully graduate residency 17) Demonstrate mastery of all previous material by successfully passing your specialty board exams 18) apply and demonstrate success in getting an unrestricted license to practice medicine --- you are not my peer......

 

[siliso]

Real solution: RFID tags. My residency would be fine, topped out at 72 hrs on the worst month. Only violations were rare instances of not getting out at exactly 28 hrs...so things were rearranged to have people come in later on call day. Not every place is trying to game the system.

 

[NotAProgDirector]

It would be easier to track EMR access, or cell phones connecting to work IP addresses.

 

[siliso]

The janitors in a couple places I’ve worked are already on the rfid. Even the nurses on a couple units. We have the technology!

I would actually hate such an imposition but if 100 hr workweeks are still a real frequent issue and people are reallly scared to report accurately, well. I don’t know. I never tried to sell anyone on our program as easy or cushy, the residents work hard and get well trained, and there is still really no issue with going over 80 hours, at all. Our people do report work hours violations when they happen and they are treated as a systems issue the program needs to fix. I find it hard to believe this is so rare a condition, but if so then I’m going to start selling it harder in recruiting. Come on to Midwest U, we follow the rules and don’t even try to push them to their limits.

 

[siliso]

Perrotfish I’m perplexed. People are working 6a to 10p, 6 days a week, in residency, routinely? What area of the country in what specialties? I’ll advise people to stay away.

 

[FutureInternist]

Plug for Lubbock IM program where the attendings would see new pts on floor or ICU by themselves if the intern that admitted them was scheduled to go home at noon.

Very rare that all pts don’t get seen by then but on the few occasions it happened, it was a “Dr Smith, are you not post-call?, you should go home now and I will see your pts”

 

[mimelim]

Plug for Lubbock IM program where the attendings would see new pts on floor or ICU by themselves if the intern that admitted them was scheduled to go home at noon.

Very rare that all pts don’t get seen by then but on the few occasions it happened, it was a “Dr Smith, are you not post-call?, you should go home now and I will see your pts”

I tried writing several responses to this thread over the last couple days and couldn't, given the complex emotions and opinions that I have on this topic. However, I can respond to this pretty easily...

I never had a senior resident or fellow do this for me as I went through my program. However, since my PGY4 year and beyond, I have routinely done this with all residents, both below me and at my same level. If you were taking a bunch of calls overnight as a junior or operating all night as a senior, I'm going to make your life easier in the morning. To me, it is beyond stupid for someone who has been working for 24+ hours to take care of stuff if there are others available, even if it is "their work". Virtually everyone below me tries to fight it and I tell them every single time, "This has no educational value to you and I can do this quickly, get the **** out." Virtually all the seniors just say, "Thanks, see ya." and while initially they didn't do it, within a month or two, it is the culture of our program that the residents unequivocally look out for each other's hours and help cover the left over AM stuff. Now, of course if there is a case that is going to go at 5:30am and the night guy wants to do it (interesting, unique, rare, high level of personal investment on the part of the resident), then the case is all theirs.

Our attendings don't know our call schedule and don't keep track of us very well. Also, half of them probably don't actually know what the hour rules are. They have some vague notions, but that is about it. But, as long as the work gets done, patients are well taken care of, all is good on their front. And, if all is good on the attending front, all is good on my front.

 

[FutureInternist]

I tried writing several responses to this thread over the last couple days and couldn't, given the complex emotions and opinions that I have on this topic. However, I can respond to this pretty easily...

I never had a senior resident or fellow do this for me as I went through my program. However, since my PGY4 year and beyond, I have routinely done this with all residents, both below me and at my same level. If you were taking a bunch of calls overnight as a junior or operating all night as a senior, I'm going to make your life easier in the morning. To me, it is beyond stupid for someone who has been working for 24+ hours to take care of stuff if there are others available, even if it is "their work". Virtually everyone below me tries to fight it and I tell them every single time, "This has no educational value to you and I can do this quickly, get the **** out." Virtually all the seniors just say, "Thanks, see ya." and while initially they didn't do it, within a month or two, it is the culture of our program that the residents unequivocally look out for each other's hours and help cover the left over AM stuff. Now, of course if there is a case that is going to go at 5:30am and the night guy wants to do it (interesting, unique, rare, high level of personal investment on the part of the resident), then the case is all theirs.

Our attendings don't know our call schedule and don't keep track of us very well. Also, half of them probably don't actually know what the hour rules are. They have some vague notions, but that is about it. But, as long as the work gets done, patients are well taken care of, all is good on their front. And, if all is good on the attending front, all is good on my front.

It helps when the attendings themselves are doing it since there is less guilt from the intern who is leaving about dumping their work on a other intern or resident.

If we had a pt that was just awaiting placement, waiting for CABG on Monday, waiting for PICC etc, the resident would just see them since there is no learning potential in those cases.

Just remember how you felt as interns and try NOT to perpetuate the cycle.

 

[Psai]

The janitors in a couple places I’ve worked are already on the rfid. Even the nurses on a couple units. We have the technology!

I would actually hate such an imposition but if 100 hr workweeks are still a real frequent issue and people are reallly scared to report accurately, well. I don’t know. I never tried to sell anyone on our program as easy or cushy, the residents work hard and get well trained, and there is still really no issue with going over 80 hours, at all. Our people do report work hours violations when they happen and they are treated as a systems issue the program needs to fix. I find it hard to believe this is so rare a condition, but if so then I’m going to start selling it harder in recruiting. Come on to Midwest U, we follow the rules and don’t even try to push them to their limits.

I'd rather work 100 hour weeks than wear a tag to be tracked like an animal

 

[WingedOx]

Real solution: RFID tags. My residency would be fine, topped out at 72 hrs on the worst month. Only violations were rare instances of not getting out at exactly 28 hrs...so things were rearranged to have people come in later on call day. Not every place is trying to game the system.

I'm only ok with this if we implant the microchip into the residents' skulls.

 

[siliso]

Don’t be dramatic it goes on your badge lol. I too would decline the mark of the beast.

I still have my secondary question about the actual prevalence of the 120h work week. I know in my parent’s day they would hit that by doing q2 icu calls, 40 h on and 8 off x3 and you’re there. Is that what people are still doing today? Is this really happening? “80+ hours is normal” seems to be a trope of the forum but I’m skeptical based on my own eyes. And the ACGME surveys which unlike your hours logs are anonymous.

 

[Perrotfish]

Don’t be dramatic it goes on your badge lol. I too would decline the mark of the beast.

I still have my secondary question about the actual prevalence of the 120h work week. I know in my parent’s day they would hit that by doing q2 icu calls, 40 h on and 8 off x3 and you’re there. Is that what people are still doing today? Is this really happening? “80+ hours is normal” seems to be a trope of the forum but I’m skeptical based on my own eyes. And the ACGME surveys which unlike your hours logs are anonymous.

Everywhere I have worked the scheduled work week was 78 hours long: 6 shifts, each 12 hours long, with a 30 minute sign out on each end. Since there was a scheduled sign out with the off going team there was never a way to start late or to leave early. Even if there wasn't anyone in the hospital 78 hours was the minimum.

The problem is charting. At the end of the day no one is ever, ever done, so there are hours of work to be done after the official close of business unless the service is bizarrely light. That's also the problem with asking about work hours. First PDs are very rarely aware that their learners are breaking hours because they're not in the hospital seeing patients, they're either at home or in a resident office charting on patients. It also allows learners to lie to themselves about how much time they're really spending at work: because their final 2-3 hours of work are done on the couch, with a glass of wine and the TV on they can pretend that they're really just being wildly inefficient, and could have stayed within hours if they had just concentrated for 15 minutes rather than making themselves comfortable and charting for 2-3 continuous hours.

Everyone lies on those suverys. As others have said (this is the whole point of this thread), the only thing that can happen is that the ACGME closes your program and throws you out into the street while your attendings suffer no meaningful consequences. If a failed survey resulted in docked attending pay, rather than a closed program, you might see more meaningful responses.

 

[siliso]

It doesn’t auto close the program though. If systemic problems are revealed then a remediation plan is required. High motivation for the program and school GME office to keep a bad survey from turning into a serious probation/closure threat already exists. There are lots of stakeholders invested in continuing to have residents. Which is the leverage we have as a program if it becomes apparent that a certain service is abusing/overworking the residents: you’re going to have to fix this/cut caps/keep toxic people off the teaching service/add fellow or attending support or sadly we won’t be able to keep sending you our people. This actually works in my observation.

I had one rotation in residency that was 12 hours 6 days a week, yes brutal and closing in on max hours but not actually violating. That was one MICU with no night call. Other MICU months were q4 call and still not hitting more than 70h on average, regular ward months with q4-q5 call more in the 60-65 average range. What fields/places are having the 12x6 as a normal usual month?

 

[Perrotfish]

It doesn’t auto close the program though. If systemic problems are revealed then a remediation plan is required. High motivation for the program and school GME office to keep a bad survey from turning into a serious probation/closure threat already exists. There are lots of stakeholders invested in continuing to have residents. Which is the leverage we have as a program if it becomes apparent that a certain service is abusing/overworking the residents: you’re going to have to fix this/cut caps/keep toxic people off the teaching service/add fellow or attending support or sadly we won’t be able to keep sending you our people. This actually works in my observation.

I had one rotation in residency that was 12 hours 6 days a week, yes brutal and closing in on max hours but not actually violating. That was one MICU with no night call. Other MICU months were q4 call and still not hitting more than 70h on average, regular ward months with q4-q5 call more in the 60-65 average range. What fields/places are having the 12x6 as a normal usual month?

At my program it was Wards, PICU, and NICU, which was 7-8 blocks/year. Outpatient blocks were a more humane 62 hours per week (really) with 5 10 hour days (1.5 hour didactics + 8.5 hours clinic) and a 12 hour ward cross cover day on the weekends. eDitto all of the Children's hospitals we rotated through except for one ICU rotation that used a Q4 call system. It's a side effect of the night float system: you were either day team or night team for an entire rotation, which meant the only way for both teams to stay within hours was 13 hour shifts. I guess you could cut it to 12.5 if you did a faster handoff, but honestly that's not the corner I would choose to cut.

 

[operaman]

Whatever the ACGME does to better address work hours, I hope they do it after I'm done. We in the surgical subs land don't usually run afoul of the 80 hour week, but often run into trouble with the 28 hour rule. Like many, we're a "home call" program but we tend to do our scheduling as though we assume the call person isn't getting called in. Of course the reality is that you're getting called quite a bit and then still have to work a full day afterward. This leads to some rough days but the infrequency of call means our lives are pretty freakin' awesome overall. I think we all fudge the numbers a tad to ensure nobody does anything stupid like institute in house call or split us into multiple call pools; I'll take my q14 home call and 43 golden weekends for the year, thank you very much! Our staff pretty much leave us alone when it comes to call and scheduling provided the work gets done and people aren't reporting flagrant violations. Our chiefs have been pretty good about scheduling daytime responsibilities such that the overnight person is done fairly early too.

 

[mimelim]

Don’t be dramatic it goes on your badge lol. I too would decline the mark of the beast.

I still have my secondary question about the actual prevalence of the 120h work week. I know in my parent’s day they would hit that by doing q2 icu calls, 40 h on and 8 off x3 and you’re there. Is that what people are still doing today? Is this really happening? “80+ hours is normal” seems to be a trope of the forum but I’m skeptical based on my own eyes. And the ACGME surveys which unlike your hours logs are anonymous.

I have been in facilities that use RFID, it is easily fooled and worked around as residents for a long time have proven.

It is rare that I work 120 hours a week, but it certainly has happened. Usually there is something unusual going on like multiple people out of town or a disaster weekend where I'm literally at the hospital for 50+ hours straight. The issue isn't what the schedule is planned on paper, the issue is what happens when bad things happen in a system already stretched thin.

Whatever the ACGME does to better address work hours, I hope they do it after I'm done. We in the surgical subs land don't usually run afoul of the 80 hour week, but often run into trouble with the 28 hour rule. Like many, we're a "home call" program but we tend to do our scheduling as though we assume the call person isn't getting called in. Of course the reality is that you're getting called quite a bit and then still have to work a full day afterward. This leads to some rough days but the infrequency of call means our lives are pretty freakin' awesome overall. I think we all fudge the numbers a tad to ensure nobody does anything stupid like institute in house call or split us into multiple call pools; I'll take my q14 home call and 43 golden weekends for the year, thank you very much! Our staff pretty much leave us alone when it comes to call and scheduling provided the work gets done and people aren't reporting flagrant violations. Our chiefs have been pretty good about scheduling daytime responsibilities such that the overnight person is done fairly early too.

This works as long as you don't have any dinguses in your program and you have enough residents. We do that, except that we are somewhere between q2 and q4 home call at any given point. I'm not sure how you can have enough residents to be q14.

Honestly, when we finally got rid of the dinguses things went from impossible to tolerable because you always have 2-3 different people that are happy to tag you out if you would rather sleep than do whatever you are supposed to be doing the next day mainly because they know that you will do it for them if necessary down the line. Once you have even one dingus that you know either won't pull their weight or help cover when someone has a ****ty call, everything falls apart.

 

[operaman]

I have been in facilities that use RFID, it is easily fooled and worked around as residents for a long time have proven.

It is rare that I work 120 hours a week, but it certainly has happened. Usually there is something unusual going on like multiple people out of town or a disaster weekend where I'm literally at the hospital for 50+ hours straight. The issue isn't what the schedule is planned on paper, the issue is what happens when bad things happen in a system already stretched thin.



This works as long as you don't have any dinguses in your program and you have enough residents. We do that, except that we are somewhere between q2 and q4 home call at any given point. I'm not sure how you can have enough residents to be q14.

Honestly, when we finally got rid of the dinguses things went from impossible to tolerable because you always have 2-3 different people that are happy to tag you out if you would rather sleep than do whatever you are supposed to be doing the next day mainly because they know that you will do it for them if necessary down the line. Once you have even one dingus that you know either won't pull their weight or help cover when someone has a ****ty call, everything falls apart.

Yup. It’s given me a newfound appreciation for why people are so cautious about applicants and why even the slightest hint of laziness or asholery is grounds for dropping someone.

We get the q14 because it’s a single call pool as all the hospitals we cover are adjacent to each other, we are a large program, and call is only a junior 2/3 on primary and a senior 4/5 on backup. Weekends are the previous night junior, oncoming junior, an intern for rounds/floor, and the senior who is on Fri-sun. Saturday rounds can be a bit brutal sometimes but that’s a small price to pay for all the golden weekends.

We also frontload the calls a bit on the 2s and 4s so they take all the holidays and some extra weekend calls. Even so I think I averaged q8 or so last year so still pretty cushy compared to most surgical sub pgy2s.

But yes you are spot on about how this all hinges on people pulling their weight and helping each other out. Our staff essentially let us manage the whole call schedule, vacation schedules, etc, on our own and don’t really micromanage other than a few broad guidelines that are very reasonable. Obviously this would all go away if work stopped getting done or clinics and cases weren’t covered adequately. So far we’ve been fairly lucky and everyone seems to “get it” and pull their weight most of the time.

 

[Psai]

Yup. It’s given me a newfound appreciation for why people are so cautious about applicants and why even the slightest hint of laziness or asholery is grounds for dropping someone.

We get the q14 because it’s a single call pool as all the hospitals we cover are adjacent to each other, we are a large program, and call is only a junior 2/3 on primary and a senior 4/5 on backup. Weekends are the previous night junior, oncoming junior, an intern for rounds/floor, and the senior who is on Fri-sun. Saturday rounds can be a bit brutal sometimes but that’s a small price to pay for all the golden weekends.

We also frontload the calls a bit on the 2s and 4s so they take all the holidays and some extra weekend calls. Even so I think I averaged q8 or so last year so still pretty cushy compared to most surgical sub pgy2s.

But yes you are spot on about how this all hinges on people pulling their weight and helping each other out. Our staff essentially let us manage the whole call schedule, vacation schedules, etc, on our own and don’t really micromanage other than a few broad guidelines that are very reasonable. Obviously this would all go away if work stopped getting done or clinics and cases weren’t covered adequately. So far we’ve been fairly lucky and everyone seems to “get it” and pull their weight most of the time.

Also you are ENT so most of you are awesome by default

 

[MediCane2006]

Yup. It’s given me a newfound appreciation for why people are so cautious about applicants and why even the slightest hint of laziness or asholery is grounds for dropping someone.

We get the q14 because it’s a single call pool as all the hospitals we cover are adjacent to each other, we are a large program, and call is only a junior 2/3 on primary and a senior 4/5 on backup. Weekends are the previous night junior, oncoming junior, an intern for rounds/floor, and the senior who is on Fri-sun. Saturday rounds can be a bit brutal sometimes but that’s a small price to pay for all the golden weekends.

We also frontload the calls a bit on the 2s and 4s so they take all the holidays and some extra weekend calls. Even so I think I averaged q8 or so last year so still pretty cushy compared to most surgical sub pgy2s.

But yes you are spot on about how this all hinges on people pulling their weight and helping each other out. Our staff essentially let us manage the whole call schedule, vacation schedules, etc, on our own and don’t really micromanage other than a few broad guidelines that are very reasonable. Obviously this would all go away if work stopped getting done or clinics and cases weren’t covered adequately. So far we’ve been fairly lucky and everyone seems to “get it” and pull their weight most of the time.

God isn’t this the truth. In my 3-year (I guess technically it was a residency but we called it) fellowship, the first two years were just a procession of work hour violations, complaints, threats of an ACGME investigation, etc. My third year, we had three people who had decent work ethic, liked each other (as in, we were not only friends outside of work but we respected and cared about each other), and had some pride in their performance. And the schedule ran like a well oiled machine that year.

And I would echo the fact that it’s given me a newfound zeal for detecting laziness in applicants....