Soon-to-be 60 hour resident work week limit?

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Panda Bear said:
Oh no, it's not. Suppose you finish your three-year plus one intern year medical school and decide you'd like to do emergency Medicine. While it's true that there are some minor things that you will be able to handle, depending on where you get a job, a significant number of patients will present with things you have either never seen or have no experience with. Even something as simple as intubation needs to be practiced under different circumstances, hopefully with some backup and advice for the difficult airways before we are thrown out on our own never having had to make the spit-second decision to cut open someone's trachea, not to mention never having actually been supervised doing it a couple of times. I shudder to think of what a botch I would have made of things if I was let loose on the public after just an intern year.

Surgery, as an another example, even more so than emergency medicine, needs extensive training "on the job." You can't fake your way through operations. That's why they have surgery residency programs.

Even if you are working under an experienced attending for an undetermined number of years without some structure you are going to be extremely unprepared. The practice of medicine is difficult. Eventually we are supposed to make it look easy but that's only because we work so hard at it. Are you going to get six months of absolutely necessary for an Emergency Physician ICU training in your informal residency? Probably not.

Now, if you mean that residency training has become too formal and regulated you may have a point but we have to have standards. Completing a residency, while an imperfect measure of competency, should be viewed as a minimum level of proficiency and is currently the best measure of quality we have.

Currently, mid-level providers fill the niche for low-acuity, booger-and-cough care. On the other hand, I had a young, fit, ostensibly healthy 25-year-old man as a patient yesterday who looked initially for all the world like just a bad case of the flu who turned out to be septic, deteriorated rapidly, and needed the whole nine-yards...intubation, ventilator, lines, fluids, pressors, and antibiotics. A NP or a PA, working in a Wal Mart clinic, would have sent the guy home, of this I have no doubt, because I almost did and was writing him up to go when his vitals headed south.

Kind of makes you step back and thank the Lord for being in a residency program where you can make the occasional mistake, receive the appropriate correction, and nobody but your attending knows that you almost ****ed up.
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Ok, I just want to clarify that I am not advocating getting rid of residency. I am advocating allowing people to practice some sorts of medicine without it. I'm also advocating making the training process a bit less formal. I am plenty aware that it is impossible to practice most subspecialties without more training. High acuity/highly technical fields also need more training. I'm not arguing that.

I'm not diminising the value of residency training, only questioning the system that makes it a defacto requirement to practice any type of medicine at all, which gives the individuals running the programs an incredible amount of power over their residents. I also questioned the environment where residents, who are often well trained in certain procedures as they move up the ranks, are often passed over for these procedures in favor of PAs/NPs/School nurse, etc... with less training but the right to direct bill for the same procedure.

I still maintain that there are plenty of types of jobs that a single year of internship makes one qualified to do, and that the miss rate at these jobs for a one year trained practicioner with 2 years on the job experience wouldn't be worse than someone with 3 years of formal training. These jobs are not surgery, EM, even complex outpatient care. However, I think that the MD is being devalued by the ever growing requirements of formalized training after its completion. As a newly minted MD, I have a background that really shouldn't be ignored. By allowing everyone to finish a TY as part of med school, it makes forgoing, or quitting residency a viable option, even if it's just to do some UC or fast track work for a while.
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I agree with Miami. There is a continuous trend with the devaluing of the physician degree due to continuous requirements and obstacles being held up. If these obstacles are supposed to stop naturopaths or chiropractors or other levels then fine but they are starting to catch too many residents who want to break out of residency or simply pause it. In the mean time these obstacles are not catching mid levels.

I think lowering license 3-year requirement will help primary care by boosting the number of resident physicians taking extra hours in it. Did the 1950 docs require also 3 years to get their permanent license? The problem is that this is a medical board issue and as we know most medical boards are just tyrannical dinosauric entities. (Except the ones in Florida, Maryland and New Jersey, please don't revoke my license! We are still anonymous here right? :scared:)
 
ClockworkDoc said:
The horrors of the night float system.
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Traditional call is a terrible system and does not eliminate handoffs.
I have actually noticed that services with night float have *fewer* handoffs and situations where patients are being cross-covered by someone with very little information (which is much worse than a handoff IMHO).

Call does not eliminate handoffs. First of all you always cap and the overflow person admits the rest and hands them off to the short call team in the AM. Second of all you have to leave eventually, and then all your patients are covered by the on-call person who doesn't know them at all.

With a night-float system, yeah, all the PM admits are handed off. However they are covered by the same person the next night and the next. With traditional q4 call they're covered by someone who doesn't know them 75% of the time, and a lot of them get handed off post admission anyway.
 
Miami_med said:
I still maintain that there are plenty of types of jobs that a single year of internship makes one qualified to do, and that the miss rate at these jobs for a one year trained practicioner with 2 years on the job experience wouldn't be worse than someone with 3 years of formal training. These jobs are not surgery, EM, even complex outpatient care. However, I think that the MD is being devalued by the ever growing requirements of formalized training after its completion. As a newly minted MD, I have a background that really shouldn't be ignored. By allowing everyone to finish a TY as part of med school, it makes forgoing, or quitting residency a viable option, even if it's just to do some UC or fast track work for a while.
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Faebinder said:
I think lowering license 3-year requirement will help primary care by boosting the number of resident physicians taking extra hours in it. Did the 1950 docs require also 3 years to get their permanent license? The problem is that this is a medical board issue and as we know most medical boards are just tyrannical dinosauric entities. (Except the ones in Florida, Maryland and New Jersey, please don't revoke my license! We are still anonymous here right? :scared:)
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in some states, you do not need to complete 3 years of residency in order to get a permanent license. in california, there is no training/trainee license. you get your license after your intern year and that's it.

i spoke with an attending about it, and he stated that if you really didn't like residency, you could quit after your intern year with license in hand, and just go work for someone. you wouldn't be board certified (nor be board eligibile), but there wouldn't be anything stopping you from working in urgent care clinic or a walk-in/primary care clinic. and you'd probably be able to get on staff/hospital privileges at very small community hospitals that need the help. again, this is specific to california since there is no training/trainee license, but i'm sure there are other states that don't have it either.
 
tr said:
Traditional call is a terrible system and does not eliminate handoffs.
I have actually noticed that services with night float have *fewer* handoffs and situations where patients are being cross-covered by someone with very little information (which is much worse than a handoff IMHO).

Call does not eliminate handoffs. First of all you always cap and the overflow person admits the rest and hands them off to the short call team in the AM. Second of all you have to leave eventually, and then all your patients are covered by the on-call person who doesn't know them at all.

With a night-float system, yeah, all the PM admits are handed off. However they are covered by the same person the next night and the next. With traditional q4 call they're covered by someone who doesn't know them 75% of the time, and a lot of them get handed off post admission anyway.
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I agree with you completely. Most places that still maintian a call system generally say that its for "continuity of care," but this never really seems to be the case. I think most places that have not gone into a nightfloat system generally are larger/heavier load county hospitals where it is more difficult to implement change.

I personally am not a fan of the call system at all. But then again, I am definitely biased :-D
 
saanjana said:
I agree with you completely. Most places that still maintian a call system generally say that its for "continuity of care," but this never really seems to be the case. I think most places that have not gone into a nightfloat system generally are larger/heavier load county hospitals where it is more difficult to implement change.

I personally am not a fan of the call system at all. But then again, I am definitely biased :-D
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The day you try to get a nightfloat person to do anything for your patients, I suspect you'll change your tune.
 
Good God, this has to be one of the best damn posts I have ever read on SDN. :thumbup:
Haemulon said:
Agreed. But then again, isn't there currently a recommendation for an increase in physician training of 15%-20%?

I am not actually for a 60 hour rule (but wouldn't actively campaign against it either probably), but I think the 80 hour rule was certainly warranted and seems to be working out well enough. For me it comes down to the absurdity of a system that basically forces interns/residents to work more than double the average person's working hours for ridiculously low pay (we obviously have no choice, we HAVE to complete a credentialling year just to get a license, plus the rest of a residency if we want hospital privilages anywhere). Even at 80 hours a week, what does it come out to .... something like $9.60/hour, assuming 40k salary? And like you said, many residents still have to work more than this.

It is easy to lose perspective that even an intern almost always has at least 8 years of college/med school training and is dealing with some pretty advanced, high-pressure, high-stress work. Not to mention that interns and residents are in many ways considered to provide the the backbone of medical decision making for our entire hospital system. For less than 10 bucks an hour? The lawnmower guy at Home Depot makes more than that! (I think it was like 11-12 bucks/hour in my town). And the lawnmower guy didn't have to take out 200k+ in loans to get there. Granted, the idea is that it all pays off in the end in both professional/personal satisfaction and monitary returns. But for many, the cost/benefit of the process is becoming less and less appealing in an era where the future path of American health care is in question and the typical conception of what it means to be a "success" is changing, for better or for worse.

Now I knew what I was getting into and still chose to go into this profession of course. But things still are kinda screwy. Why arn't regular worker protections that apply to virtually every other job classification in the country applicable to residents as well? Practival reasons? I am sure. But it wold surely be less costly and more lucrative for all other professions to be exempt from worker protections as well, right?
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Tired said:
The day you try to get a nightfloat person to do anything for your patients, I suspect you'll change your tune.
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Actually it's the uninformed cross-covers who do the most damage. Don't you love coming in in the morning to find your brittle diabetic got 10U Lispro and tanked to a fingerstick of 42? How about when they slam your pleasant elderly patient with Ativan so it takes him 36 hours to wake up and then he falls out of bed and breaks a hip?

I'm on a service with a night float right now and it's great. The night float knows the patients just like the day team knows the patients. Obviously most of the action takes place during the day but night float does any procedures that need urgent attention and most importantly, she knows all the patients and their plans so you don't get any nasty surprises when you walk in in the morning.

It's *cross-cover* that will never do a thing for your patients. Not night float.
 
tr said:
It's *cross-cover* that will never do a thing for your patients. Not night float.
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Cross cover means you cover each others' patients. I scratch your back, you scratch mine. You want your head scan done over night? Then you damn well better check my post-CT pull chest xray.

Night float, on the other hand, sits around killing time. They don't care because they don't have to; they don't answer to the attending on rounds, they don't do notes, they sleep. They are worthless. It's no accident that night float is considered a "cruise" month.

We have night floats on medicine, and cross covers on surgery. Guess who codes more often?
 
New Zealand Resident Doctors' Association (NZRDA), is NZ's resident doctor union. They are holding a strike to demand better conditions and better pay.

http://tvnz.co.nz/view/page/411749/1728526

http://www.newstalkzb.co.nz/newsdetail1.asp?storyID=136030


It could be a reality in the United States too maybe if things don't get better. Maybe if residents instead of reporting their annual stipend/salary.. wrote it in terms of how much they get paid per hour of work.. the public would be more understanding.

Thoughts.
 
I just read those articles. Six weeks vacation, two paid weeks of study time. And they are going to strike. We are all chumps.
 
Tired said:
Cross cover means you cover each others' patients. I scratch your back, you scratch mine. You want your head scan done over night? Then you damn well better check my post-CT pull chest xray.

Night float, on the other hand, sits around killing time. They don't care because they don't have to; they don't answer to the attending on rounds, they don't do notes, they sleep. They are worthless.
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Must depend on the structure of your night float then. Ours sticks around to present overnight admits on AM rounds.
 
Apollyon said:
More than 80 percent of EM programs are 3 years. There are 1-4 programs, and then the dying breed of 2-4 programs.

People trained in EM make more money than any other 3 year residency. That's why there's the debate of the 4th year of EM at those programs that have a 4th year being the "$150,000 mistake".
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Unless you can more than make that up moonlighting...
 
DebDynamite said:
I just read those articles. Six weeks vacation, two paid weeks of study time. And they are going to strike. We are all chumps.
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Every time I catch myself thinking that, I ask myself which doctor I would rather have.
 
EM_Rebuilder said:
Unless you can more than make that up moonlighting...
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You know, at my program whenever you complain about a mandatory fee for something, say paying for a PALS course, the reply is always, "Well, it's just one moonlighting shift."

The point is that I don't want to moonlight. I'm signing a contract early with a stipend for the rest of my time in residency for many reasons (good offer, nice hospital, etc.) but also because I don't want to moonlight. Moonlighting sucks as a resident. Sure, you make some extra money (but lose about a third of it in taxes) but the only shifts we can get are the crappy ones in our urgent care side that the PAs don't want. Maybe if I got payed to moonlight in the ICU or on the acute care side I'd be more enthusiastic but seeing runny noses and vague back pain in the wee hours of the morning? It just ain't worth it. (We aren't allowed to moonlight outside of our program.)

Not to mention that it wears me out for my regular, minimum wage shifts.
 
Panda Bear said:
You know, at my program whenever you complain about a mandatory fee for something, say paying for a PALS course, the reply is always, "Well, it's just one moonlighting shift."

The point is that I don't want to moonlight. I'm signing a contract early with a stipend for the rest of my time in residency for many reasons (good offer, nice hospital, etc.) but also because I don't want to moonlight. Moonlighting sucks as a resident. Sure, you make some extra money (but lose about a third of it in taxes) but the only shifts we can get are the crappy ones in our urgent care side that the PAs don't want. Maybe if I got payed to moonlight in the ICU or on the acute care side I'd be more enthusiastic but seeing runny noses and vague back pain in the wee hours of the morning? It just ain't worth it. (We aren't allowed to moonlight outside of our program.)

Not to mention that it wears me out for my regular, minimum wage shifts.
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wow, is this really pandabear writing this? What happened to "I got a family to feed"? :cool:
 
Panda, here is an easy fix to your moonlighting tiring you out for your min. wage shifts. I know many EM residents who will moonlight at an outside hospital for 150-200/hr, DURING scheduled min wage shifts. How? They pay other residents 30/hr to cover their regularly scheduled residency shifts while they rake in the moonlighting. That 30 changes based on the internal market within the residency program.

Problem solved.
 
Residents will undercut one another for top residency slots, leaving unionizing to only work at places where the bottom of the barrel resides. The market will always have a trade off..Did I mention the bottom of the barrel will be undercut by FMG's and other desperados?

In the end, unions will never work on a large scale within residency programs. There is too much demand for the intangibles, namely, the ability to practice medicine within the US as a bc'd physician, to allow for it.
 
As much as I hate looking forward to residency and the long hours, the idea of capping the hours to 60 is a scarier idea to me for the long-term health of the medical profession. Reducing the hours to 60 will simply open the hospital doors to more DNP's and PA's, because the scutwork has to be done either way. Hospitals had to hire more NP's and PA's after the hours were reduced initially to 80. The solution is to find a way to increase the number of residency slots, but that probably won't happen. If you increase the demand for midlevels like DNP's, then there will more of them. If there are more of them, it will strengthen nursing which will lobby for further scope expansion. It's an ugly, vicious cycle. This is why it's so important to support PA's and AA's and stay away from "advanced" nursing.

That's the problem when you try to design an artificial system like GME. Supply and demand becomes totally out of whack after a while. It should be replaced with a free-market system.
 
Taurus said:
the idea of capping the hours to 60 is a scarier idea to me for the long-term health of the medical profession.
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Again, the hours aren't capped at 60 in Australia and Nz (they aren't capped at all really). They simply base your salary/stipend on a 60hr work week, and pay you MORE when you work over that. :thumbup:

Is there anyway to set up a system like that in the states? Where you can continue to work 80-90 hrs/wk.. but just get paid better like in Aus/Nz?
 
Since patient care is slowly being replaced by documentation and lawyer-dodging, if the work week were cut to 60 hours...I'd only be able to see patients for about 10 of those.

So, if hours are restricted any further, I'm gonna just get trained as a "paperworkist". I'll do transfer/dsch summaries, op reports, clinic chart notes from 8-4 every day and then go home. Sure, it won't be exactly what I expected when I got in the rat race...but it will be a niiice, stable job with lots of family time.
 
I'm sure the 60hr week would work well, but it would absolutely require an increase in spots for those long-houred programs. Perhaps even medical could take over more basic surgical floor care and allow the cutters more OR hours.
 
There would just be more years of training. Personally, I'd stick with fewer years of longer hours than more and more years of shorter hours. The only way hospitals will go for shorter hours is if they get residents for more years.

Faustian bargain.
 
yeah, it's probably best to ramp it up for fewer years and get that attendingship.
 
Coastie said:
Panda, here is an easy fix to your moonlighting tiring you out for your min. wage shifts. I know many EM residents who will moonlight at an outside hospital for 150-200/hr, DURING scheduled min wage shifts. How? They pay other residents 30/hr to cover their regularly scheduled residency shifts while they rake in the moonlighting. That 30 changes based on the internal market within the residency program.

Problem solved.
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We are not allowed to moonlight outside of our program. Some of the moonlighting outright blows...like doing weekend call for an extremely busy medicine service (I once admitted 18 patients in one night) and the rest is doing the crappy shifts in urgent care that the midlevels don't want.
 
My husband is a German citizen who went to med school in Germany. He did part of his residency in Germany and the UK before we came to the US (my native country).

In Germany, the work hours were much kinder. Night float generally worked well to replace 'call' and IM training was 5 years instead of 3. During that time, he was paid more than a resident in the US, and worked fewer hours/week. He felt like the longer exposure in time over years in a teaching environment was more conducive to learning clinical skills (as opposed to the baptism-by-fire, shorter, sleep-deprived states that are almost celebrated here).

I think a 60 hour week could work here...but the length of residency training would have to be extended and resident pay would have to go up.
 
Panda Bear said:
We are not allowed to moonlight outside of our program. Some of the moonlighting outright blows...like doing weekend call for an extremely busy medicine service (I once admitted 18 patients in one night) and the rest is doing the crappy shifts in urgent care that the midlevels don't want.
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If you're just covering one night, I don't think admitting medicine patients is that bad. Since you're there only one shift you don't have to follow them day after day; they're going to someone else. If there's a closed ICU it's even nicer, since the majority are stable (how many of those 18 were rule out chest pains or COPD exacerbation etc?). You can write your admit orders and forget about them for the rest of the night, for the most part.

Now, if you're going to be following them long term it's a different story. With each successive admit you have to worry about disposition, social issues etc. In the back of your mind you're thinking (how am I going to get this patient back home before I start admitting again?)

Maybe you have a different perspective coming from the ER.

-The Trifling Jester
 
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