The latest on work hours

[RichL025]

There are thousands and thousands of surgeons who trained under the "old school" system and who turned out just fine.

There are thousands and thousands of drunk drivers who made it home just fine without killing anyone.

I'm not arguing a point here, I just wanted to point out that your statement, above, is not by itself a justification for preserving the old system.

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[pseudoknot]

IShould we not learn something from what happened to Anesthesiology, Primary care FM, IM, Pediatrics, Psychiatry and EM?

Uh, what exactly happened to all those fields? Primary care has a lot of problems, yes, and clearly many of them have nothing to do with NPs. Despite CNRAs, anesthesiologists have a great job market and make tons of money (more than surgeons, on average).

I don't even know why psychiatry* and EM are on that list.

* You lose if you start talking about RxP instead of the actual job market.

 

[GIST]

I am currently at a program were we do have PAs. I am not a big fan of it. At first I thought it would allow me to go to the OR more, but that hasnt really changed. As it turns out, the nurses are more familiar and less intimidated by them so all the questions bascially go to them, and then directly to the attending via PA. I think it has made the intern the "typical floor monkey" obsolete. I think it is a bad idea and they should not be allowed in residency programs.

FYI: Ours do not go to the OR either

 

[Winged Scapula]

I am currently at a program were we do have PAs. I am not a big fan of it. At first I thought it would allow me to go to the OR more, but that hasnt really changed. As it turns out, the nurses are more familiar and less intimidated by them so all the questions bascially go to them, and then directly to the attending via PA. I think it has made the intern the "typical floor monkey" obsolete. I think it is a bad idea and they should not be allowed in residency programs.

FYI: Ours do not go to the OR either

So, if all the calls from nursing go to the PAs and you aren't in the OR more, then what are you doing?

 

[SocialistMD]

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.

I'm going to tell you that I don't need to do the minute to minute care of a patient with nausea >100 times to know what to do, but that is what I did my intern year while on the floor. Yes, recognizing the crashing patients and knowing what to do with them is important, but (a) the physician extenders always call the intern when they have a patient in trouble and (b) there are two months of night float where that is all the interns do, which I would say probably gives enough exposure to make interns adequate in these patient care skills.

In the long run, I think the 80 hour rule will be looked at as a mistake.

I disagree. I think what hurt residency training more is that attendings must always be present, which at many institutions has eliminated the chief taking the junior through the more complex cases while the attending supervises from afar. That is the reason so many graduates today feel unsure in their operative technique; it isn't because they weren't there 120 hours, it is because they only rarely got to lead someone else through the case.

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?

That is the fault of weak program directors, chairmen and faculty for caring less about the residency program than they should as well as residents allowing it to happen. I know that most environments aren't as collegial between the residents and faculty as it is here, but if residents are able to open and close cases but allow the physician extenders to do it, they can only really blame themselves.

As it turns out, the nurses are more familiar and less intimidated by them so all the questions bascially go to them, and then directly to the attending via PA.

Then your administration needs to step in and remind the attendings and PAs of the chain of command. Our physician extenders are told they need to keep the interns/residents in the loop on patient issues. Likewise, the attendings are reminded that they need to include their residents when they make rounds in between cases. In the end, though, our residents make sure they are on top of what the PAs are doing and when the attendings are making rounds so they aren't left out of the loop. Everything can't be spoon fed and you need to take the initiative to keep yourself involved. It is like anything else in surgery; if you don't show interest, no one will go out of his/her way to involve you. I'm also going to have to ask the same question as Winged Scapula above and Blade28 below; if they are doing the floor work, why aren't you in the OR and what are you doing with your time?

 

[Blade28]

I am currently at a program were we do have PAs. I am not a big fan of it. At first I thought it would allow me to go to the OR more, but that hasnt really changed. As it turns out, the nurses are more familiar and less intimidated by them so all the questions bascially go to them, and then directly to the attending via PA. I think it has made the intern the "typical floor monkey" obsolete. I think it is a bad idea and they should not be allowed in residency programs.

FYI: Ours do not go to the OR either

I'm confused. So you're not a big fan of them? But it sounds like they take care of the floor scut and that lightens the intern's workload? And if you're not going to the OR more, and they're not allowed there, then what's going on?

 

[Cheisu]

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.

I tend to favor the old-school way of doing things. I think I relate to Misterioso in a lot of ways, except I'm a sophomore in high school.

 

[SLUser11]

I tend to favor the old-school way of doing things. I think I relate to Misterioso in a lot of ways, except I'm a sophomore in high school.

What?

Oh, please tell me that this has been a beautiful, elaborate 9-month Misterioso troll-job.......

 

[GIST]

Have been reading alot of articles that I dont end up remembering. yea they do scut, but believe it or not you learn from doing scut and stupid calls about NG tubes and that sort.

 

[GIST]

Dont get me wrong, every once in awhile it is nice to have them. But we still end up doing the DC summaries 90% of the time and other dictations.

I think they originally started when our program had a hard time with the 80hrs, now that has been fixed. But, now the PAs have been around awhile and have been integrated into the program and I suppose are more difficult to get rid of.

Trust me, I wonder why they are here too. Maybe it gets better the higher I go in residency.

 

[Strength&Speed]

In order to meet the new 57 hr workweek, I have stopped accepting nurse's pages.

 

[nonesuchgirl]

What?

Oh, please tell me that this has been a beautiful, elaborate 9-month Misterioso troll-job.......

that would be epic.

 

[SocialistMD]

So, I was talking with someone "in the know" about this today, and he basically said the issue is being pressed by John Dingell, a Michigan house rep. (and the first guy to question Dr. Jarvik's credibility) and patient advocate who found an article about the effect on patient safety our hours have. He is going to be pushing this issue through congress. Creating an ACGSE wouldn't eliminate the confines of the regulation, as Medicare/Medicaid money would be withheld for any resident or attending working over 57 hours/week; it is the federal government, not our governing bodies pushing this agenda.

 

[HMSBeagle]

They also want to limit attending work hours? Insane in my opinion. How are they going to limit work hours and perpetuate the physician shortage? Totally irresponsible in my opinion.

 

[jubb]

That's an awesome Idea. We won't have doctors too tired and making mistakes, we'll have them poorly trained and making mistakes, Or handing patients off all the time and making mistakes. I'd rather be well trained.

 

[roja]

"Why do surgical residents hate q2 call? because they miss half the good cases" (told to be me by several different residents).

I am in no way a surgeon (although I play one on tv) but I have many friends who are. I also work with the ACGME and AAMC and have had many conversations with specialty board members, including surgery.

(the comparison to UK surgeons is completely off. as RHO's they work about 40 h a week and make about 90K euros a year. it is in part a way to keep down the number of 'attendings' and has absolutely nothing to do with the number of years/procedures needed to train a surgeon)

There is a strong academic push in the GME world to change the way residents are taught. What I find ironic, is that while many 'higher ups' espouse they are advocating for residents and encompassing adult learning concepts, they have completely negated resident input.

The reasons for work hour limits are long and complex. Some of them are for negotiating powers that have nothing to do with residents. Some of it is not to regulate good programs, but for those rare ones that seriously abuse residents.

Surgical residents want to be in the OR. Thier input should be wieghted in with the rest of the issues surrounding work hours.

Its a fine line: give the learners what they want but make sure they aren't so exhausted/frustrated that it impedes learning.

 

[SocialistMD]

Surgical residents want to be in the OR. Thier input should be wieghted in with the rest of the issues surrounding work hours.

It isn't the RRC or the ACGME that is trying to decrease our work hours, it is the federal government. The RRC and ACGME were behind the 80-hour thing because they were trying to prevent the government from getting involved in the first place. It doesn't appear to have worked.

 

[GIST]

SocialistMD,

How do you know it is John Dingell pushing for this legislation? He is the chair of the committee that is in charge of health care so everything eventually goes through him if he is pushing it or not.

But my response is...we do all this moaning and blogging on this website about what could happen, contact your local congressperson and senator and do something about this before we dont have a voice at all. It doesnt take long to do.

Dingell
http://energycommerce.house.gov/

List of Congresspeople
http://www.house.gov/house/MemberWWW_by_State.shtml

 

[SocialistMD]

SocialistMD,

How do you know it is John Dingell pushing for this legislation? He is the chair of the committee that is in charge of health care so everything eventually goes through him if he is pushing it or not.

But my response is...we do all this moaning and blogging on this website about what could happen, contact your local congressperson and senator and do something about this before we dont have a voice at all. It doesnt take long to do.

Dingell
http://energycommerce.house.gov/

List of Congresspeople
http://www.house.gov/house/MemberWWW_by_State.shtml

I already have. As I said, he is a strong patient advocate and the people I've talked to say he is the one leading the fight.
Exhibit 1
Exhibit 2

 

[GIST]

SocialistMD,

thanks for posting those.

 

[jubb]

hmmm... I'm ready to mail the guy and tell him to knock it off, but that statement is over a year old. Is it even an issue they are considering right now?

I'm scared to death they'll cut it down right after I finish 2nd year or something, so will have already done the crappy floor coverage 80 hour weeks and then don't get to operate the 80 hour weeks. That'll be sooooo lame.

 

[SocialistMD]

hmmm... I'm ready to mail the guy and tell him to knock it off, but that statement is over a year old. Is it even an issue they are considering right now?

It has enough steam to have the Association of Program Directors in Surgery talking about it at their annual meeting.

 

[roja]

It isn't the RRC or the ACGME that is trying to decrease our work hours, it is the federal government. The RRC and ACGME were behind the 80-hour thing because they were trying to prevent the government from getting involved in the first place. It doesn't appear to have worked.

It was a combination from both. The 80 hours started in NYC when politicians daughter was accidentally killed by 'an overtired resident'. It started through the government but had to be pushed through, first the ACGME and then the RRC.

The ACGME, in essence, creates the broad general policies that run true to all specialties. The RRC's work on creating and enforcing the specialty specific issues (and execution of the broad policies).

So, the ACGME will mandate things like resident wellness, etc and the RRC will determine what you, as a specialty need, to become a 'resident'. So, the number of surgeries, procedures, etc is determined by your RRC. Major changes have to be submitted to your RRC and then approval through the ACGME. (ie, I sat on a conference development panel to analyze our 5 hours/week conference requirements in EM. We created recommendations and then submitted them to the RRC. If they approve them, they then have to get ACGME approval)

Somehow the boards are also tied into all this, but I haven't picked out the knots in that web yet!

 

[DrDawg]

It has enough steam to have the Association of Program Directors in Surgery talking about it at their annual meeting.

Discussed this the other day with someone that sits on multiple boards as well as the APDS. A group has apparently drafted a letter to the IOM listing all the reasons that this should not be done. this letter should be publically available in the not so distant future. Among the chief concerns were the increase in number of disease treated by surgeons, the changes in the way they are treated, failure to validate any change or improvement with an 80hr work week, failures/problems seen in the UK system, increase $, ect.

 

[SocialistMD]

It started through the government but had to be pushed through, first the ACGME and then the RRC.

Actually, the government can mandate what happens with or without the approval of the ACGME or the RRC. It's called, we say what you will do and you will do it or you will not get any money from us. The ACGME and RRC approved the 80-hour week proactively in an effort to curtail any legislation passed by the government; I don't know that it would have been addressed had the government not taken an interest first and the ACGME/RRC wanted to remain seemingly under their own control.

 

[DrDre311]

I feel like I woke up this morning and George Orwell is now running the world. I guess the government can do whatever it wants if it gets enough people pissed off about an issue. It seems like most of the time medicine-related legislation is passed, it's spearheaded by someone with either a personal vendetta related to the issue and no real knowledge of the issue as a whole, or by someone who's trying to be re-elected and needs some wool to pull over people's eyes.

I really don't like the idea that Uncle Sam could be telling me how much I can work when I'm an attending surgeon. Big Brother has his finger in every pie that relates to money...

 

[pseudoknot]

As an historical note, the state of New York passed legislation limiting resident hours to 80/week in 1989 after the Libby Zion case, obviously well before the ACGME's action at the national level.

Also, commercial pilots have had limitations on their hours for a very long time (and I think also commercial truck drivers). You can argue that it would be wrong for medicine, but it's not a new idea.

 

[Miami_med]

As an historical note, the state of New York passed legislation limiting resident hours to 80/week in 1989 after the Libby Zion case, obviously well before the ACGME's action at the national level.

Also, commercial pilots have had limitations on their hours for a very long time (and I think also commercial truck drivers). You can argue that it would be wrong for medicine, but it's not a new idea.

With commerical pilots, it isn't improving crash rates (which have been VERY low since like the early '60s, pilots have lost their prestige, wages are dropping, and there are an ever increasing amount of flight delays. I had a flight delayed for 4 hours once at a small airport because the crew got in late the night before, and had to have X amount of time off.

Truck drivers just speed a lot and then lie on their logs.

It's not a new idea, but it's got a nasty history of destroying the people that it's applied to. We should really strive to NOT make productive behavior illegal. Of course, there's a major physician shortage in many fields, and this should just about bring on a full Atlas Shrugged style meltdown.

 

[DrDawg]

As an historical note, the state of New York passed legislation limiting resident hours to 80/week in 1989 after the Libby Zion case, obviously well before the ACGME's action at the national level.

Also, commercial pilots have had limitations on their hours for a very long time (and I think also commercial truck drivers). You can argue that it would be wrong for medicine, but it's not a new idea.

Not sure what the exact legislation is for pilots or Truckers, but for many pilots full time is 80hrs a month.

 

[Blade28]

With commerical pilots, it isn't improving crash rates (which have been VERY low since like the early '60s, pilots have lost their prestige, wages are dropping, and there are an ever increasing amount of flight delays. I had a flight delayed for 4 hours once at a small airport because the crew got in late the night before, and had to have X amount of time off.

They need to remember to stop drinking before flying though.

 

[pseudoknot]

With commerical pilots, it isn't improving crash rates (which have been VERY low since like the early '60s, pilots have lost their prestige, wages are dropping, and there are an ever increasing amount of flight delays.

Wages are probably dropping because of decreasing air travel and higher fuel costs since 9/11. As I said, the pilot duty hour restrictions have been in place for quite some time, so I wouldn't expect that safety would continue to improve.

I don't know what the answer is for medicine, or if it should be different for surgery. However, it's obvious (and well-documented in many fields) that human cognitive and motor performance decline with sleep deprivation. If you think that you can learn or perform surgery after sleeping for four hours and then being awake for 24 just as well as a well-rested person, then either you are not subject to the limitations of normal humans, or surgery is less cognitively demanding than driving.

 

[DrDre311]

Surgery (and surgeons!) are different. We are not the same as pilots and truckers, and shouldn't have the same rules applied to us.

And I refuse to stop drinking.

 

[jubb]

Wages are probably dropping because of decreasing air travel and higher fuel costs since 9/11. As I said, the pilot duty hour restrictions have been in place for quite some time, so I wouldn't expect that safety would continue to improve.

I believe the pilots unions had a strangle hold on the airlines until business went bad. They had it too good and are now suffering. Same with the doctors in the golden age of medicine and now we will suffer.

I hope surgeons overseas are ready to come flooding in because if we wanna cut hours, lengthen training, overspecialize, and face the baby boomers we'll be in for a wild ride.

 

[HMSBeagle]

While the "golden days" may be over I dont think we'll starve. What do you think?

 

[GIST]

so here are the people proposing work hour restrictions. they have a committee together researching it. they actually have an open public forum in a few days. doesnt look like they will have any answers till the begining of '09.

http://www.iom.edu/CMS/3809/48553.aspx

 

[jubb]

so here are the people proposing work hour restrictions. they have a committee together researching it. they actually have an open public forum in a few days. doesnt look like they will have any answers till the begining of '09.

http://www.iom.edu/CMS/3809/48553.aspx

They are having a public panel on thursday and friday of this week. Any one near DC gonna go? If my wife were able to I'd consider going. I just wanna see what kind of people we have running this show so I can know how scared I should be.

 

[DrDre311]

I like how "a detailed cost analysis is outside the scope of this study." That means that these people get to grandstand without saying how much will be added to healthcare costs by having to hire either more residents or more physician extenders.

 

[jubb]

I like how "a detailed cost analysis is outside the scope of this study." That means that these people get to grandstand without saying how much will be added to healthcare costs by having to hire either more residents or more physician extenders.

It's not as much fun to knowingly set unrealistic standards.

 

[mmu]

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

The other option is to make these greedy lazy elders do the scut work. How about an attending doing discharges?
Sounds pretty unrealistic to me.
By the way, a nurse prescribing tylenol sounds good to me. Why am I getting paged for otc drug? I choose to be a peson who delegates rather than being a micromanager.

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.

Agree.

 

[Plastikos]

Is there anyone who honestly thinks that given more time in a week (from residents) that PDs/programs will make the learning opportunity greater for us, and that the 80h work week has been a mistake? I think it has forced people to delegate what is actually important, and think about training in general. Instead of just knowing that since they are always here, it will happen, there is a plan. When has giving someone more time made that particular issue more important?

There is of course an opposite end of the spectrum, and i think 57h is definitely too little. Its not even that though, its the idea of making someone with a relatively unpredictable schedule of opportunity and forcing them into the possibility of missing out. We are not the only people who work more than 40h/wk, we are just in the spotlight as of late.

Maybe everyone else's programs break the 80h rule consistently, but i dont think its violated as often as we like to portray. My program takes a lot of home call, the intern gets absolutely hammered, there are a few predictable difficult rotations, but is maintained with those caveats. It takes a lot of time to hit more than 80h/wk if your not taking in house call, comes out to 13.33h/day from mon-sat with one day off a week. If your only in house for 4h on a saturday though, it comes out to 15.2h/d. If thats the case for EVERYONE on EVERY rotation, I'd be surprised.

There seems to be enough qualified candidates currently, the problem seems to be spots available. With the projected shortage, the answer should be obvious, and could help everyone get closer to the 80h week on every rotation and at every pgy level. Unfortunately one seems to need an act of congress to approve spots.

Having had some really crazy weeks where i have worked way over the limit (not averaged over 4 wks of course), i dont think 80 is all that much, the problem is it sounds crazy to the average person on the street working part time. Thats who you ultimately have to convince, not other doctors (surgeons at least).

 

[Plastikos]

I already have. As I said, he is a strong patient advocate and the people I've talked to say he is the one leading the fight.
Exhibit 1
Exhibit 2

If you follow some of the links you can get the original article, http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0030487.
Which if you read is a self reported/self control study done only on interns, and was done in the 02-03 academic year, when hardly anyone was 80h compliant. They were basically asked if they thought they made mistakes due to sleep deprivation, which is huge recall bias, and also, who wouldnt want to place some blame on sleepiness instead of the law of averages or just screwing up? Terrible study, someone needs to blow that thing to shreds, before they allow it to ruin medicine. Falling asleep in lecture really has nothing to do with patient care. Also, it shows the difference in sleep per month to be 14h from a good month to a terrible month. Doesnt seem that big a number to make any difference.
Also, although interns may feel that they were the ones responsible for a certain error or problem, rarely is it actually squarely their fault, thats the point of residency, graduated responsibility. Seems they have taken advantage of the martyr attitude most drs have to use it for bad science.

 

[barcalounger]

Hunt Batjer's presentation (linked above) is great. Batjer (chairman at Northwestern) is simply awesome.

 

[Plastikos]

Yes.

I do very few cases as an intern. The reason for that is that I am tossed out post-call, which is when I actually have time to go to the OR. No OR time means no presenting at preop/postop conference, which means I have no incentive to read on the operative aspect of the cases. Less reading, fewer presentations, fewer conferences . . . yeah, there's a substantial decrease in the "learning opportunities".

Not that I'm worried about that. I'll more than make it up as a junior. But it's a lot less fun for me as well.



I don't think so. I don't think the general public gives two sh*ts about our hours, and other than an occassional news story, 99% of America could care less about residents. Unfortunately, we have put ourselves in the spotlight with policy-makers, which is infinitely worse. Thanks to all the whiners out there who are screwing our programs.

Point was that will they make it any better for learning? Operating after a 30 hour shift cant be the most efficient form of learning as opposed to operating during the regular portion of the day.
Programs are different, which makes things confusing. You feel like you have time for the OR because your "off", but if you werent kicked out, you'd problably be expected to continue your normal routine. Your program just isnt set up traditionally as a intern operating culture it seems, which is fairly normal.
The interns operate a ton here, also have the floorwork, and daily conferences with required reading, which can be overwhelming the first 6 months of intern year, but ends up being really beneficial.
Like someone else said, its not the hours necessarily, but the training model that needs to adapt.
If the problem is mostly in the junior years, i really could care less, because youll get something out of those years and get the benefit later, even if it is less exciting.
Your statement about policy makers is true, its their incentive for getting involved, which cant possibly be for the greater good.

 

[Winged Scapula]

If you follow some of the links you can get the original article, http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0030487.
Which if you read is a self reported/self control study done only on interns, and was done in the 02-03 academic year, when hardly anyone was 80h compliant. They were basically asked if they thought they made mistakes due to sleep deprivation, which is huge recall bias, and also, who wouldnt want to place some blame on sleepiness instead of the law of averages or just screwing up? Terrible study, someone needs to blow that thing to shreds, before they allow it to ruin medicine. Falling asleep in lecture really has nothing to do with patient care. Also, it shows the difference in sleep per month to be 14h from a good month to a terrible month. Doesnt seem that big a number to make any difference.
Also, although interns may feel that they were the ones responsible for a certain error or problem, rarely is it actually squarely their fault, thats the point of residency, graduated responsibility. Seems they have taken advantage of the martyr attitude most drs have to use it for bad science.

Although I agree with you regarding the bias in this study, wanted to point out that few programs were "in compliance" in 02-03 because the 80 hr work week rules were not in place at that time.

 

[BlackSails]

I tend to favor the old-school way of doing things. I think I relate to Misterioso in a lot of ways, except I'm a sophomore in high school.

You are aware that Misterioso is a troll, right?

 

[Winged Scapula]

I disagree.

And I miss his posts almost as much as I miss JPH.

You forgot kinetic/snoopy, etc.

Although, if you didn't have that ortho intern thing down so good, I'd think you were all the same person.

 

[SLUser11]

And I miss his posts almost as much as I miss JPH.

Brokeback SDN.

 

[BlackSails]

I disagree.

And I miss his posts almost as much as I miss JPH.

I miss his posts too, as they were entertaining, but he was very obviously a troll.

 

[Blade28]

You forgot kinetic/snoopy, etc.

Although, if you didn't have that ortho intern thing down so good, I'd think you were all the same person.

What about the older guys?

Squat & Squeeze comes to mind.

 

[Winged Scapula]

What about the older guys?

Squat & Squeeze comes to mind.

True...but Tired is new, I didn't think he would know S&S, Dr. Barry Zlatsko, etc.