The latest on work hours

[eclcell]

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I know this has been discussed before, but my program director just got back from the association of program directors meeting, and he is saying that the future restriction on work hours will probably be 57 hours. He seemed to think that those who are in the know feel like this will be inevitable. I feel like that will make getting an adequate surgical education almost impossible. I actually think it's a little scary.

 

[StevenRF]

When is it supposed to take effect? Why 57? Well at least it's a defacto raise. This is gonna make surgical residencies so much more competitive though... it'll take even more resume padding to avoid the scourge of primary care specialties.

I wonder if they will still have the +8 carve out for neuro.

 

[opr8n]

ive heard the creation of an ACGSE instead of ACGME which may have different rules for surgical subspecialities

medicine and surgery just dont have similiar training platforms and shouldnt have the same (stupid) rules

I think anything less than 80 hours is rediculous

 

[mosfet]

I know this has been discussed before, but my program director just got back from the association of program directors meeting, and he is saying that the future restriction on work hours will probably be 57 hours. He seemed to think that those who are in the know feel like this will be inevitable. I feel like that will make getting an adequate surgical education almost impossible. I actually think it's a little scary.

It doesn't matter what they do!! It's not like programs are going to strictly enforce the "57-hour rule". Most programs haven't quite figured out how to enforce the 80-hour rule yet, so what makes you think they will actually enforce the 57-hour rule. It's all gonna be fine once they figure out how to fudge more numbers and avoid paying fines. 🙄

 

[Asdf77]

I hadn't heard much about this, but I think it would be interesting if they gave programs the choice. I think that a program that is 57 hours a week but maybe a year or two longer might be attractive to some folks (not me though). I know classmates with families who would love to enter Surgery if the residency hours were better able to accomodate their families. It'd be interesting to give programs the flexibility to choose how they would like to operate, and allow students to choose what kind of program they want. Just a thought.

 

[jubb]

All of this with an impending shortage of doctors? Train them to work less hours, train for more years? I just hope I finish before they put this crap in effect. Hopefully they will form a surgical specialty accreditation program.

 

[VoiceofReason]

I am nowhere near a resident, but this sounds reasonable to me. If we're to believe the popular press, then changes need to be made or there won't be any surgeons at all. And I think making surgery residency more attractive is a great place to start. Maybe the approach to residency needs to be altered slightly (please don't bite my head off, residents, it's just my inexperienced opinion), and instead of the number of cases logged being the determinant of your fitness for practice there should be a more active ongoing evaluation. Because lets face it, people come with different inherent talent, and some might actually be ready to practice with many fewer cases.

In other words, 57 hours max a week, but whether or not you complete training in 5 years or 7 depends on your performance and progress during those hours.

I'm gonna get reamed for this one lol

 

[Winged Scapula]

I am nowhere near a resident, but this sounds reasonable to me. If we're to believe the popular press, then changes need to be made or there won't be any surgeons at all.

True. You'll find that notion in the surgical press as well with the ACS predicting a shortage of 6,000 surgeons by 2050.

And I think making surgery residency more attractive is a great place to start.

I think some would argue that we still have enough good candidates without changing the curriculum at all. Hard core surgeons will say we don't want candidates who want to go into surgery for the lifestyle because there is a dedication needed that you cannot train for. So while change may be needed, it may be necessary for other reasons not necessarily to attract candidates.

Maybe the approach to residency needs to be altered slightly (please don't bite my head off, residents, it's just my inexperienced opinion), and instead of the number of cases logged being the determinant of your fitness for practice there should be a more active ongoing evaluation. Because lets face it, people come with different inherent talent, and some might actually be ready to practice with many fewer cases.

There are already discussions about a graduated level of responsibility wherein some residents move through training faster than others depending on skills, knowledge level, etc. Of course the fear is that this can be terrifically abused and you end up being a PGY-11 with no end in sight (I saw this exact scenario with Ortho in Australia, where advancing in training is not automatic and is rife with abuse).

 

[opr8n]

I am nowhere near a resident, but this sounds reasonable to me. If we're to believe the popular press, then changes need to be made or there won't be any surgeons at all. And I think making surgery residency more attractive is a great place to start.

i disagree
surgery residency needs to be tough for a reason
you cant traina surgeon on a 60 h work week in five years
I think the changes that need to be made to make surgeyr more attractive is the PAY for your time. Not less time, but reward me for the time that i give. GS dosent pay what it used to and will continue to plumet
And with medicaRE STARTING TO not reimburse for certain complications or nosocomial infection/conditions, it will mean more work for less money

I really wish I didnt like surgery, b/c i know i feel like all my hard work may not pay off in the end, the way I thought it would

my wife saysd everyday that I should have gone into radiology

 

[opr8n]

Hard core surgeons will say we don't want candidates who want to go into surgery for the lifestyle because there is a dedication needed that you cannot train for. So while change may be needed, it may be necessary for other reasons not necessarily to attract candidates.
).

i agreed completely

 

[SocialistMD]

If we're to believe the popular press, then changes need to be made or there won't be any surgeons at all.

General surgery has filled all open spots (after the scramble) the last several years. Cutting hours won't be a cure for the low numbers of surgeons because it has nothing to do with creating new spots and there is no shortage of people wanting to go into the field using the current hour regulations.

Hard core surgeons will say we don't want candidates who want to go into surgery for the lifestyle because there is a dedication needed that you cannot train for.

There must be a priority to the work and not to one's social life, and that is lacking in some people who want to do surgery and still make it to the bar by 6:30 with their non-surgery friends (ask Castro).

There are already discussions about a graduated level of responsibility wherein some residents move through training faster than others depending on skills, knowledge level, etc.

One of the interesting things I've heard (out of SIU) is that they will have their residents perform a procedure in a simulated environment prior to ever going to the OR. That way, they can demonstrate competency and avoid the PGY-11 who has been passed over as a way to keep the cheap labor.

you cant traina surgeon on a 60 h work week in five years

You don't know that. Many people said you can't train surgeons in 80 hours, but it looks like you actually can. While you and I may not be able to see how it can be possible, that doesn't mean it can't be done.

 

[Southpaw]

I am nowhere near a resident, but this sounds reasonable to me. If we're to believe the popular press, then changes need to be made or there won't be any surgeons at all. And I think making surgery residency more attractive is a great place to start.

Your point is well taken as far as the need to increase the number of surgeons, but surgery and its subspecialties fill completely every year. Changing the hours won't change that fact. If you want to increase the number of surgeons then you should advocate for increasing the number of training positions available.

Taking a big picture perspective, decreasing the number of work hours will increase the competitiveness of getting a residency position in surgery, further decrease the competitiveness of primary care, and beyond that....further allow for the infiltration of PAs and NPs into medicine. Doesn't really sound good for medicine if you ask me.

I can't speak to the feasibility of training of a surgeon in 57 hours a week in 5-6 years. I can say that increasing the length of training is not an attractive option at all if you ask me. I think medical training is way way too long as it is, and increasing the years while decreasing the hours per year would simply further piss me off with regards to the length of medical training.

I don't understand the goal here with decreasing the hours? Getting more people to go into medicine? Making it more attractive to those who choose to go to PA school instead of med school? Can anyone speak to the reason why hours are such a HOT topic in residency training these days?

 

[eclcell]

The goal for decreasing the hours has basically nothing to do with attracting more people to medicine or surgery. It is a result of pressure from the lay public and congress who think that people get tired from working a lot and as a consquence provide lower quality care. As far as I know this has never been shown to be true. There is at least one study showing that the work hour restrictions have not decreased medical errors. I think the real problem is that a lot of hospitals, especially county hospitals, rely heavily on residents for labor and patient care. If you decrease the hours that much then the labor isn't there and the patients lose. What are the hospitals going to do? Higher loads of PA's and NP's? That doesn't sound good for patient care either. The whole notion of lengthening training even more sounds absurd. No one could afford it. Apparently this work hour thing was one of the main topics at this big program directors meeting. Supossedly it is going tnto effect within the next few years.

 

[Castro Viejo]

What I find interesting about this whole work hours thing is that in spite of several papers already published showing NO change in patient morbidity or mortality as a result of a decrease in worked hours per week, there is still this push to decrease the number of hours further.

In an era where there's more to do and more to know for a surgeon, especially a General Surgeon as defined by the Board, how can they possibly expect to train someone to be good without eyeing that clock?

I'm curious to see what happens when the 80-hour crop of people finally graduate to the real world and take on jobs that demand well over 80 hours per week in dedication. Who are they going to cry to then? Can Congress pass legislation limiting the number of hours worked by a physician or surgeon? Are they going to compensate us for those hours lost to "rest" as attendings?

If the ACGME goes ahead with reducing the work hours to 57 per week, I'd be more than happy to see surgery split off and form the ACGSE and bring the number of hours back up to the traditional 120. 🙂

 

[swoop]

When this topic is discussed it is usually brought up that work hours could be shortened and residency kept at five year if the ancillary services provided by the resident were done by ancillary staff and the resident then spent more time operating. Then someone replies that that is all well and good but what about continuity of care of the patient and the fact that a major part of surgical training is learning when to operate and how to take care of the patient post op. Seeing as how I am not a resident yet I don't know quite what I think, but it seems from what I have experienced I fall in with the latter. What do some of you more experienced individuals think?

I think this comes down to economics. The us health care system is hemorrhaging green blood and if the residents worked less, others would have to do the work; unless of course services just weren't provided. Those others requiring being fully paid. (Attendings and PA's make more than residents) Therefore, before any of this could become law, there would be people fighting it kicking and screaming the entire way.

 

[Winged Scapula]

When this topic is discussed it is usually brought up that work hours could be shortened and residency kept at five year if the ancillary services provided by the resident were done by ancillary staff and the resident then spent more time operating. Then someone replies that that is all well and good but what about continuity of care of the patient and the fact that a major part of surgical training is learning when to operate and how to take care of the patient post op. Seeing as how I am not a resident yet I don't know quite what I think, but it seems from what I have experienced I fall in with the latter. What do some of you more experienced individuals think?

I think there is a breaking point at which 5 years at X number of hours is not enough to learn surgery and perioperative care. Surgeons could become technicians whereby they do the procedures and the hospitalists take care of all peri-operative care, but I doubt anyone is really interested in returning to the days of the barber surgeon.

Obviously there is a lot of fat and gristle in surgical residency in most places and it is possible to train a good surgeon in 80 hrs per week (although it remains to be seen if there is any decline in perceived surgical skill). But 57 hours per week? That's hard to imagine unless call and weekends were eliminated and I cannot imagine even with all perioperative care given away. There is value in seeing things over and over again; not much time for that at 57 hours per week, 5 years.

 

[balaguru]

Have any residents out there sat down and calculated the min, max, mean and stddev of how many hours they actually log per week? When I was on the interview trail one of the programs that I interviewed at said that they tracked resident hours by badge access to facilities and found that they averaged around 60 hrs.

 

[Winged Scapula]

Have any residents out there sat down and calculated the min, max, mean and stddev of how many hours they actually log per week? When I was on the interview trail one of the programs that I interviewed at said that they tracked resident hours by badge access to facilities and found that they averaged around 60 hrs.

We could easily see how many we worked each week once we had the electronic system and were required to use it (not tell the truth necessarily) although it did not calculate mean or STD.

Although I realize that there are programs out there that adhere to the 80 hrs, I find it hard to believe that a surgical program truly only averages 60 hrs, unless they are:

* counting lab residents
* residents don't swipe in and out all the time
* have loads of midlevels, night float, no in house call, lots of no call rotations

 

[balaguru]

...
Although I realize that there are programs out there that adhere to the 80 hrs, I find it hard to believe that a surgical program truly only averages 60 hrs, unless they are:

* counting lab residents

Possibly, but the PD seemed pretty straight up about things.

* residents don't swipe in and out all the time

The also used logon and possibly parking access, too.

* have loads of midlevels, night float, no in house call, lots of no call rotations

Midlevels may have been the most significant reason as they have tons of money. I wanted to ask more about this not because I was looking for this quality in a residency program, but more because I found it so unbelievable after having been on this forum. However, I didn't want to create the wrong impression about my work ethic. This was Mayo Rochester, BTW.

 

[Pilot Doc]

This was Mayo Rochester, BTW.

That explains things.

No trauma
No indigent care
Primarily elective cases on insured patients who have been medically managed well prior to operation

I don't think they're a model for how to run a program in the real world.

 

[Faebinder]

Castro + Winged.

Seriously.. you guys are clinging so much to the old mentality of General Surgeon wants to do everything. You are trained that way but yet you know that as a general surgeon you need to be able to do 15 surgeries very well to make it. That's it.

Seriously... FIFTEEN.

Lets look at a colorectal surgeon for example.

1) Right/Left Hemicolectomy (Extended or not, lap or not)
2) Mediport Insertion
3) Subtotal Colectomy (lap or not or NOTES)
4) Transverse Colectomy
5) Low anterior resection (lap or not, Kraske or not)
6) Anterior peroneal resection (lap or not, flap or not)
7) Transanal excision
8) Rectopexy
9) Fistulotomy / Fissure closure (plug or not, flap or not)
10) Hemorrhoidectomy
11) Ostomy reversals (lap or not)
12) Proctocolectomy (lap or not)
13) Small Bowel Resection
14) Liver Wedge resection
15) Salpingo-oopherectomy

Do you need more to be a successful colorectal surgeon? Why are you also doing breast removal, gastroectomies, Heller myotomies, thyroidectomies, Whipples, gastric bypass, kidney transplant, skin graft, etc etc in your residency? It is inefficient.

I applaud itemizing surgery training and shrinking it. It's better for the patient and better for the surgeon. As a trauma surgeon or oncall surgeon you might think you are an expert in a region of the body (e.g. neck wound) because you operated on the neck 40 times in your training in residency but the fact is, you are not the best and you need to consult ENT and we had a big case about it in MM this week. The problem is, everyone has a huge chip on their shoulders and dont wanna show that they dont know what they are doing or are not the best at it. Gotta protect that reputation.

I just feel it's time surgery was more specific in its training, rather than trying to make someone who can do everything but not so well as the high volumes doing that same surgery.

I agree with people above that stated, the first step is to drop separate Trauma surgery.

 

[SocialistMD]

Have any residents out there sat down and calculated the min, max, mean and stddev of how many hours they actually log per week? When I was on the interview trail one of the programs that I interviewed at said that they tracked resident hours by badge access to facilities and found that they averaged around 60 hrs.

Mayo may be the only residency in the country that can honestly claim 60 hours for the reasons Pilot Doc delineated. We have night float, weekend cross-cover, etc... and we still average around 79.5 hours at each PGY level. I struggle to think where the cuts in hours could be made (NPs/PAs covering the weekends/night call), and I think taking those times away from the interns will only further dilute their patient management skills.

Think about it from the perspective of hours in a day. Let's say everyone gets to work at 6am to round (most would agree that is about as late as it can happen). If we work Monday-Friday, we would have to leave everyday by 5pm to make 55 hours. How many times can senior residents recall still being in the OR at that time? Also, what happens from 5pm to 6am or from Friday night to Monday morning? No resident coverage at all? That is a serious blow to resident education. I don't consider myself the "the bad thing about q2 call is you miss half of the interesting cases" type of person, but I just don't see how it can be done.

 

[opr8n]

i think the other thing not being discussed here is that the rules also include max length shift of 16 hours, which basically means NO call without night float

I seriously hope none of this come to fruition
We have a hard enough time with continuity of care with 80 hours and q3-4 call

I just think its rediculous that we may be cut to 60 hours
its a joke
like capping on medicine
Surgery dosent cap

 

[SocialistMD]

i think the other thing not being discussed here is that the rules also include max length shift of 16 hours, which basically means NO call without night float

Ha! That means that you would only be able to work 10 hours the other four weekdays or you would be over hours. Also, how happy will the attendings be covering those 4 hours/day where there is no resident coverage? Most went into academic medicine with the mindset that they would always have a resident to assist them in the workup/management of their patients.

The more we talk about this, the more I can see an ACGSE forming. I can see the hour cuts working in medicine and pediatrics, but not surgery.

 

[Winged Scapula]

Castro + Winged.

Seriously.. you guys are clinging so much to the old mentality of General Surgeon wants to do everything. You are trained that way but yet you know that as a general surgeon you need to be able to do 15 surgeries very well to make it. That's it.

What do I have to do with this? 😕

Although I think there is still room for a general surgeon, I never said that I didn't think that training shouldn't change. You have mistaken my comments that I thought that there was something to be learned from every operation to assume that I think that everyone needs to spend years doing procedures they will never do. And while I understand your argument about being the "best" and I agree with it, I don't think that your argument that general surgery doesn't prepare one for fellowship training/practice is true. While the way surgical residency is designed may not fit modern day needs, there is no doubt (in my mind at least) that it has been effective for decades in producing good quality general surgeons/colorectal surgeons, etc.

Only time will tell if the changes produce the same.

 

[Castro Viejo]

Castro + Winged.

Seriously.. you guys are clinging so much to the old mentality of General Surgeon wants to do everything. You are trained that way but yet you know that as a general surgeon you need to be able to do 15 surgeries very well to make it. That's it.

Uhm, I think you misinterpreted my beliefs as well.

My issue with regard to work hours is the mentality of trainees as it relates to continuity of care, responsibility for one's patients, and taking care of a large General Surgery service.

This almost has nothing to do with the technical aspects of surgical training.

You're right. The marketplace doesn't currently support a General Surgeon who wants to do more than fifteen operations well and without too many adverse outcomes. And this is an argument I made in another thread regarding the need to change surgical training and the continued hyper-specialization of surgeons in this country.

But being a surgeon is more than just learning where to throw a stitch, how to expose, and getting your left hand to do more than rest on the Mayo stand. Patient care perioperatively and outside of the operating room is way more important than any of this other stuff.

Remember, you can teach a monkey how to operate.

 

[Amgen1]

I applaud itemizing surgery training and shrinking it. It's better for the patient and better for the surgeon. As a trauma surgeon or oncall surgeon you might think you are an expert in a region of the body (e.g. neck wound) because you operated on the neck 40 times in your training in residency but the fact is, you are not the best and you need to consult ENT and we had a big case about it in MM this week. The problem is, everyone has a huge chip on their shoulders and dont wanna show that they dont know what they are doing or are not the best at it. Gotta protect that reputation.

I just feel it's time surgery was more specific in its training, rather than trying to make someone who can do everything but not so well as the high volumes doing that same surgery.

Do you really think this is the best thing for the patient and the healthcare system?
Once you open this "only the 'expert' should do the case" can of worms you are sliding down a slippery slope.

Do you want ENT to be called for every penetrating neck wound? Should vascular also be called in because of the high likely hood of vascular injury? Can you name a single hospital in this country that has in house ENT faculty on call every night? Can you name a single ENT that wants to be called for every penetrating neck wound?

Should the liver transplant/HPB team be called in for any pancreatic/liver trauma? Should they also be required to be in house?

It is hard enough getting face coverage between ENT, PRS, and OMFS for the cases that really do require their expertise.

I do agree that for major airway traumas ie tracheal transections, the appropriate consultants should be called. But the minute you start saying "only X should work in that region" you are taking all the work that comes in that area, not just the relevant cases.

WHere do you draw the line?

 

[DrDre311]

While I was on the PRS interview trail I remember a resident at Mt. Sinai mentioning that it's possible to teach a monkey to operate...hmmm.

I feel compelled to comment on this thread because it was a hot topic on the plastics trail when I was interviewing and it kind of ties in with the whole argument for the existence of the integrated/combined residency model for plastic surgery.

So, as a future plastic surgeon, I know I won't need to resect bowel or perform a radical pancreaticoduodenectomy. But as Winged said, there is something to be learned from every operation and every surgeon. I love being exposed to a wide variety of surgeries and learning different ways to do things--I think it makes you a better, more complete surgeon with more techniques in your arsenal. Also, exposure to different patient populations is critical in the development of good patient management skills no matter who you are or what you do. I don't really like the ICU, but it's nice to know I can take care of sick patients if I have to.

We need to be able to strike a balance between broad exposure/broad knowledge and knowing when we're in over our heads. In an ideal situation, of course you'd want a head and neck surgeon to operate in the head and neck, but I'd like to think that a general surgeon could explore a neck wound if that were the best option for the patient at the time.

I don't think this issue can be solved with unilateral curriculum change, and definitely would not be served by itemized surgical training focused exclusively on bread and butter operations. In keeping with the theme of balance, I think the current work hour limit is OK--not ideal, but OK. I think further reduction in work hours would certainly be detrimental to some aspect of resident education: either patient care, OR time, or medical knowledge would have to suffer if every week was just 6a-6p Mon-Fri. On the other hand, I have had 100+ hour weeks and I know that I am sharper if I get 5-6 hours of sleep and have a day off every once in a while. I can do that, but I don't really like it and I think there is a temporal point of diminishing returns with regard to time spent in the hospital.

So I don't think returning to 120 hours is the answer either, but 60 hours just seems a little ridiculous.

 

[DrDre311]

As an addendum, I think a 60 hour week would actually necessitate additional primary care residency spots which would mean more and more IMG's and less qualified U.S. grads taking up the slack in medicine and pediatrics, because I think most teaching hospitals would rather pay 3-4 residents than 1 PA. Of course, the alternative would be to give PA's and NP's even more turf/money/power for half the work and less than half the training--not to mention medicolegal liability. That is a bad, bad idea.

I don't actually have a good solution for this problem, it's just something that pisses me off. If the 60 hour week comes to fruition there should definitely be a separate ACGSE.

 

[Faebinder]

Do you really think this is the best thing for the patient and the healthcare system?

YES! You don't know what you don't know what you don't know.

Do you want ENT to be called for every penetrating neck wound?

YES!

Should vascular also be called in because of the high likely hood of vascular injury?

Why not? You still have not told me a reasonable reason against it other than "the vascular service will be busy". Well either general surgery will be busy or vascular. If you dont do the surgery nearly as often then let the expert at it be busy.

Can you name a single hospital in this country that has in house ENT faculty on call every night? Can you name a single ENT that wants to be called for every penetrating neck wound?

No, but they can come see them in the morning and give a solid opinion, maybe even take the patient. You arent the expert in the area, let the expert do it. It's better for the patient, hospital, and you (cause you hope you know what you are doing and not the dont know cubed case).

 

[DrDawg]

The ABS Surgical Council on Resident Education posted this earlier this month

http://home.absurgery.org/default.jsp?news_score408

 

[Myempire1]

The ABNS and Society of Neurological Surgeons were allowed to give a presentation at one of the more recent Institute of Medicine meetings about this issue. They obviously urged against additional regulations.

See a related article:
http://www.aans.org/young_neurosurgeons/spring_08.asp
Batjer's power point:
http://www.iom.edu/Object.File/Master/52/255/Batjer%20Presentation.pdf
The IOM has media from everyone who gave presentations at the 1st two meetings. Find them here:
http://www.iom.edu/CMS/3809/48553/53782.aspx

 

[psipsina]

ive heard the creation of an ACGSE instead of ACGME which may have different rules for surgical subspecialities

medicine and surgery just dont have similiar training platforms and shouldnt have the same (stupid) rules

I think anything less than 80 hours is rediculous

This is what I heard too.

 

[pseudoknot]

The ABNS and Society of Neurological Surgeons were allowed to give a presentation at one of the more recent Institute of Medicine meetings about this issue. They obviously urged against additional regulations.

See a related article:
http://www.aans.org/young_neurosurgeons/spring_08.asp
And the power point:
http://www.iom.edu/Object.File/Master/52/255/Batjer Presentation.pdf

I would like to thank you for being the first person in these threads to post a URL leading to any kind of substantiation of these claims...interesting stuff.

 

[mmu]

Common stereotypes hummered in to your brain.
one of them: you cannot make a surgeon in less than
100+h/week (older version), less than 80h/week (newer version).
answer: if a resident does at least one case a day for 5 years, he/she will be a perfect surgeon. Oh yes, there will be time for post op/ICU/etc management. They try to get residents on their side by saying less hours=less OR time.
How about hiring more PAs to do the scut work for us and we will go to OR. Expensive? yes, very expensive. They'd rather spend money convincing you you have to work long hours and forget about your personal life.

 

[jubb]

See a related article:
http://www.aans.org/young_neurosurgeons/spring_08.asp

Point #2 in that article is awesome.
And I love the quote in response to why people fail the oral boards:

You assumed that a wrong answer would give rise to a warm and nurturing response by the attending surgeon who asked a question. Your errors of thought and action were met with gentle kindness and the softest of educational caresses. This approach, I am sure you now agree, turned out to be a lethal educational mistake. Surgical pathology is unforgiving. It can hurt your patient (and you) in ways you cannot imagine. You should fear making errors and should steel yourself to the harsh realities of a life in surgery…Many surgical programs are trying to provide a nurturing educational atmosphere delivered in a non-threatening manner taking into account your psychosocial and ethno-cultural background. Because of this philosophy, the attending surgeon who holds you to an objectively high standard through rigorous demands is accused of eroding your self-esteem. Please remember that a shielded surgical graduate who has been protected from the vicissitudes of surgical life is a weak graduate and ultimately a weak surgeon…the product of prioritizing self-esteem over basic surgical knowledge is a graduate who feels great about knowing nothing.

 

[pseudoknot]

Point #2 in that article is awesome.
And I love the quote in response to why people fail the oral boards:

I highly recommend that article he cited ("So You've Failed Your Oral Board Exam. Here's Why..."). It's available here although you have to register:

http://www.generalsurgerynews.com/index.asp?section_id=66&show=dept&article_id=3912

 

[BlondeDocteur]

Common stereotypes hummered in to your brain.
one of them: you cannot make a surgeon in less than
100+h/week (older version), less than 80h/week (newer version).
answer: if a resident does at least one case a day for 5 years, he/she will be a perfect surgeon. Oh yes, there will be time for post op/ICU/etc management. They try to get residents on their side by saying less hours=less OR time.
How about hiring more PAs to do the scut work for us and we will go to OR. Expensive? yes, very expensive. They'd rather spend money convincing you you have to work long hours and forget about your personal life.

I couldn't agree more. Bottom line, you can't do it all. The skills which are the protected domain of the MD'd surgeon are the most essential; things which *could* be done by someone else, and are done by someone else, do not compromise patient care nearly to the degree some old-schoolers appear to think.

Reading the surgery threads pre-80 hours rules-- including some august forum members who still post prolifically today-- it's rather hilarious to hear what people predicted would happen if surgery residents got a good night's sleep every now and again. I do recommend it on a slow afternoon.

 

[DeadCactus]

I hope you all don't mind a pre-med popping in to ask a question (well questions).

Why is the focus on hours worked during residency? It's seems like the bigger issue would be the hours you work for the decades after residency. Is it because of the low pay during residency? Because you can't legislate working hours? Because you have more say in your career as an attending than in your training as a resident?

 

[jubb]

I hope you all don't mind a pre-med popping in to ask a question (well questions).

Why is the focus on hours worked during residency? It's seems like the bigger issue would be the hours you work for the decades after residency. Is it because of the low pay during residency? Because you can't legislate working hours? Because you have more say in your career as an attending than in your training as a resident?

I think a lot has to do with feeling scutted out. It's very easy to feel like you are slave labor. You are covering the grunt work of a number of surgeons, you aren't in control or in charge in this situation, and your pay isn't dependent on how hard you work. I don't think people mind working so hard when they feel in charge and responsible and then there is that part about financial reward for their hard work.

Later on if you don't like your hours you can join a group that is a little more lifestyle focused and take a hit financially to actually be allowed to sleep at night every once in a while.

 

[Cheisu]

Wow. The idea of limiting a resident's work hours is just ignorant IMHO.

You don't tell a surgeon "you have to stop working now".

They'll either just ignore you, laugh at you, or work more just to regain their pride from even being asked to limit their work hours.

My guess, they'll do all three.

 

[SocialistMD]

Wow. The idea of limiting a resident's work hours is just ignorant IMHO.

You don't tell a surgeon "you have to stop working now".

They'll either just ignore you, laugh at you, or work more just to regain their pride from even being asked to limit their work hours.

My guess, they'll do all three.

Must...bite...tongue...too angry...right now...to say...anything...productive......🙄

I'm glad you have such idealistic views of the profession. However, you should research the reasoning behind the work hour limitations and see why they were inacted. Even if you don't buy the patient safety issue (which really hasn't been shown, depending on how you look at the data), I know a great many surgeons who were (unnecessarily) involved in single-car accidents on their way home post-call as residents. Safety first!

 

[Myempire1]

Must...bite...tongue...too angry...right now...to say...anything...productive......🙄

I'm glad you have such idealistic views of the profession. However, you should research the reasoning behind the work hour limitations and see why they were inacted. Even if you don't buy the patient safety issue (which really hasn't been shown, depending on how you look at the data), I know a great many surgeons who were (unnecessarily) involved in single-car accidents on their way home post-call as residents. Safety first!

the data is definitely not clearcut. There are a lot of conflicting reports. Decreases in fatigue-induced mistakes may be outweighed by hand-off-related and discontinuity-related errors. These things may be very specialty-specific.

 

[Pilot Doc]

the data is definitely not clearcut. There are a lot of conflicting reports. Decreases in fatigue-induced mistakes

The data for patient safety is unclear.

The data for RESIDENT safety is clearcut. Residents maim and kill themselves with automobiles when they work too hard.

 

[jbean]

My PD said the main focus at the APDS conference was changing surgery from a "learn by osmosis" sort of mentality to a focused educational program. In the past, you learned all the info because you were on call all the time and were bound to see it sooner or later. In this new focused way of working, when you have done enough elective lap choles, you only help with the complicated or emergent ones... in other words, prioritizing education over service.

I like this idea and think it is the only way to train residents in a less than 80 hr/week environment. Most programs over in England have a 56hr/wk limit. They manage to turn out fine physicians.

I think the key is that we cannot educate surgeons in the same manner and do it in less time. The method of training must change.

 

[Winged Scapula]

I like this idea and think it is the only way to train residents in a less than 80 hr/week environment. Most programs over in England have a 56hr/wk limit. They manage to turn out fine physicians.

You cannot compare the training schemes because the length of training in the UK is much longer, even if you don't count the general intern and RMO years prior to getting into surgical training.

I think most residents here, at least if SDN polls mean anything, would not be willing to work that few hours if it meant that the minimum length of training were 8 years or so.

 

[Blade28]

I think most residents here, at least if SDN polls mean anything, would not be willing to work that few hours if it meant that the minimum length of training were 8 years or so.

8 years? Pfff. That's still 20% less time than my current path of training! 🙂

... 🙁

 

[Leukocyte]

How about hiring more PAs to do the scut work for us and we will go to OR. Expensive?

Is this really a good idea? Should we not learn something from what happened to Anesthesiology, Primary care FM, IM, Pediatrics, Psychiatry and EM? Letting others do your job gives them the basis they need to lobby in Washington to expand their scope of practice. Is it that hard to beleive that in few years there will be nurses (DNPs) who can operate? DNP-General Surgery?

Please, let us not sell out our job responsibilities to others, thinking that they will never ask for more.

The whole CRNA, NP, DNP catastrophe is the fault of our greedy lazy elders.🙄

 

[SocialistMD]

Is this really a good idea? Should we not learn something from what happened to Anesthesiology, Primary care FM, IM, Pediatrics, Psychiatry and EM? Letting others do your job gives them the basis they need to lobby in Washington to expand their scope of practice. Is it that hard to beleive that in few years there will be nurses who can operate? DNP-General Surgery?

Please, let us not sell out our job responsibilities to others, thinking that they will never ask for more.

The whole CRNA, NP, DNP catastrophe is the fault of our greedy lazy elders.🙄

Working in a busy surgical residency with multiple services, I can tell you how things have changed since my intern year (when we had no physician extenders) and now (where nearly each service has them). The interns operate a lot more. A lot. I finished my intern year with ~110 cases where I was the primary surgeon, most in my class. I didn't go to the OR to assist unless I was the primary surgeon. Talking to an intern in January, he already has 140 cases logged as primary surgeon, and he has second scrubbed almost daily. He is not unique. There is a trade-off that happens in that I don't know that the current interns will be as efficient in taking care of general floor issues (I still think they will know how to manage patients, as they still do 2 months of night float) as my class, but they sure do see the OR a lot more and can get to clinic more, too. The (resident) physician extenders don't operate. Ever. They are solely responsible for the floor and clinic, and in that they are only to do the scut we used to have to do. It has nothing to do with the greed of our attendings, and it has cost the hospital a lot of money. It is an adjustment that has been made to ensure proper operative training of surgical residents at our program.

 

[Leukocyte]

It is an adjustment that has been made to ensure proper operative training of surgical residents at our program.

Well, it is an adjustment that has been made to ensure proper operative training of surgical residents....under the new 80 hour rule. And this is understandable. There is so much you can do in 80 hours. And that is what I have a problem with. I just do not think the 80 hour rule is such a great idea IN THE LONG RUN. A general surgeon is more than just a pair of hands who works in the operating room. He is a physician who takes care of the surgical patient. It is the "medicine of surgery" that seperates us from robots. Allowing the midlevels to run the floors, while the residents are in the OR is not such a good idea, IMHO.

In the long run, I think the 80 hour rule will be looked at as a mistake. I mean there are midlevels who are already opening and closing....is it hard to imagine that one day they will perform the entire surgery on their own? These residency programs are the perfect breeding ground for these midlevels who are getting their feet wet and then later move on to a more expanded scope of practice working with a private greedy lazy surgeon who will let then do most of his work.

There are thousands and thousands of surgeons who trained under the "old school" system and who turned out just fine. This 80 hour rule comes with disadvantages that we are yet to see their effects in the future.