when is this 56 hour work week supposed to start?

[jellygreen2001]

Hi everyone,
I have heard a lot about the 56 work week. If this come through, will it be put into practice any time soon. Probably not this year, but hopefully next year Would this effect people who would be PGY2 and PGY3s.
thanks

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[jdh71]

Hi everyone,
I have heard a lot about the 56 work week. If this come through, will it be put into practice any time soon. Probably not this year, but hopefully next year Would this effect people who would be PGY2 and PGY3s.
thanks

"Hopefully"?

Surely you jest.

 

[Instatewaiter]

Hi everyone,
I have heard a lot about the 56 work week. If this come through, will it be put into practice any time soon. Probably not this year, but hopefully next year Would this effect people who would be PGY2 and PGY3s.
thanks

I have to say, if they *ever* go to a 56 hour work week I think many programs would simply refuse to comply.

I highly doubt that this is going to come anytime in the next few years. Hell there are still a few hold outs (ahem, allegedly) from the 80 hour work week.

 

[Keg]

Discussing this with PD's on the trail, it seemed as if many thought that recommendations would come out this spring and then formal requirements would go into effect July 1, 2011.

Bottom line is, no one knows.

 

[medsRus]

I have to say, if they *ever* go to a 56 hour work week I think many programs would simply refuse to comply.

Same old arguments that were here before 80 hour rules.

 

[Instatewaiter]

Same old arguments that were here before 80 hour rules.

True but most programs were at least somewhere in the ballpark of 80 hours. Cutting down to 56 is a much bigger drop, especially for specialties still struggling with meeting the 80h requirement.

 

[jdh71]

Same old arguments that were here before 80 hour rules.

True but most programs were at least somewhere in the ballpark of 80 hours. Cutting down to 56 is a much bigger drop, especially for specialties still struggling with meeting the 80h requirement.

There's really no way to NOT expand the number of training years AND the number of residents needed if this happens. It would be a nightmare, and stupid, for so many reasons.

 

[J1515]

It'll never happen so stop waiting for it.

 

[digitlnoize]

There's really no way to NOT expand the number of training years AND the number of residents needed if this happens. It would be a nightmare, and stupid, for so many reasons.

Yeah, I think 56 is probably too low. 80 is probably a bit too high, though.

80 hrs/wk = 11.5 hrs/day x 7 days/wk. That's a lot. No breaks.

So, if you want 1 day off a week, you need to pull at least one 15-20 hour day. That, to me, is unacceptable and dangerous.

I think maxing out shifts at 12 hours per shift, and 1 day off per week is the best thing they could do. That's 72 hours a week. Not much of a drop from 80, and I think you'd actually see some results in patient safety then.

I would gladly take an extra year of residency if it promised me a sane schedule. Although, I really think this is only needed for the more procedural specialties, like surg...

 

[AuroraK]

56 hours wont happen, programs have a hard enough time keeping under 80 hours. There is not enough funding, especially in the new health care environment, to enact this. I know unfunded mandates are en vogue, but you could probably bankrupt all but the biggest 20 or so academic centers with such a law.

 

[jdh71]

Yeah, I think 56 is probably too low. 80 is probably a bit too high, though.

80 hrs/wk = 11.5 hrs/day x 7 days/wk. That's a lot. No breaks.

So, if you want 1 day off a week, you need to pull at least one 15-20 hour day. That, to me, is unacceptable and dangerous.

I think maxing out shifts at 12 hours per shift, and 1 day off per week is the best thing they could do. That's 72 hours a week. Not much of a drop from 80, and I think you'd actually see some results in patient safety then.

I would gladly take an extra year of residency if it promised me a sane schedule. Although, I really think this is only needed for the more procedural specialties, like surg...

I regularly do 80s, and it's doable - not even horrible. Though, I think most months I'm averaging closer to 65-70. I think most of the evidence seems to indicate problems not with total hours per week but with total time awake and working at one time is the problem. I'd be ok with a 16hr pershift type of cap, and I think it would be more sane. This would allow programs to push 96 hours per week in places that need the extra time, say the ICU, and still give you a day off per week.

I would NOT gladly do an extra year of residency. It's been a long road thus far, and I still have fellowship to go.

 

[scudrunner]

I regularly do 80s, and it's doable - not even horrible. Though, I think most months I'm averaging closer to 65-70. I think most of the evidence seems to indicate problems not with total hours per week but with total time awake and working at one time is the problem. I'd be ok with a 16hr pershift type of cap, and I think it would be more sane. This would allow programs to push 96 hours per week in places that need the extra time, say the ICU, and still give you a day off per week.

I would NOT gladly do an extra year of residency. It's been a long road thus far, and I still have fellowship to go.

Just curious, do you have a family (husband/wife and kids)? I can't imagine anybody with a family thinking an 80hr week not being horrible. Doable, but horrible.

 

[digitlnoize]

Just curious, do you have a family (husband/wife and kids)? I can't imagine anybody with a family thinking an 80hr week not being horrible. Doable, but horrible.

That's kinda what I was thinking. I used to do 80 hour weeks back when I worked (before med school, I'm a non-trad) and it was no fun then. I can't imagine it being much better...also, I'm not as young as I once was, and neither are many of us...

 

[jdh71]

Just curious, do you have a family (husband/wife and kids)? I can't imagine anybody with a family thinking an 80hr week not being horrible. Doable, but horrible.

I do the family thing. Obviously that side of things can get tricky, but the work isn't bad.

 

[jdh71]

That's kinda what I was thinking. I used to do 80 hour weeks back when I worked (before med school, I'm a non-trad) and it was no fun then. I can't imagine it being much better...also, I'm not as young as I once was, and neither are many of us...

I think it helps that I like my job. Working 80 hours a week roofing houses was HELL.

 

[motoo]

most of the PDs on the interview trail felt some sort of work hour change was coming in the next 1-2 years.

does that mean senior residents will have to work more to cover the interns, especially at currently front-loaded programs?

 

[randomedstudent]

Yeah, I think 56 is probably too low. 80 is probably a bit too high, though.

80 hrs/wk = 11.5 hrs/day x 7 days/wk. That's a lot. No breaks.

So, if you want 1 day off a week, you need to pull at least one 15-20 hour day. That, to me, is unacceptable and dangerous.

I think maxing out shifts at 12 hours per shift, and 1 day off per week is the best thing they could do. That's 72 hours a week. Not much of a drop from 80, and I think you'd actually see some results in patient safety then.

I would gladly take an extra year of residency if it promised me a sane schedule. Although, I really think this is only needed for the more procedural specialties, like surg...

Have you ever heard of a call night? Oh, that's right, med students don't have to take call anymore (at least not at my program). One call night eats up 30 hours of the 80 hr week. Most specialties still have many months of q3 or q4 call.

 

[digitlnoize]

Have you ever heard of a call night? Oh, that's right, med students don't have to take call anymore (at least not at my program). One call night eats up 30 hours of the 80 hr week. Most specialties still have many months of q3 or q4 call.

I know, but why not just rotate 12 hour shifts so there is coverage all the time. ER manages to do it, amongst others...

 

[ResidentMD]

Is the four/five hour uninterrupted sleep on call rule going to be implemented this year? Or is that too just in thin air?

 

[futureres]

This is such a ridiculous idea. Many programs do not heavily use a NF system (i.e. 24-30 h Q4 overnight call for interns). If you cut work hours, you absolutely (you=government/health care system/your tax dollars) would have to fund more slots, which would essentially dilute the quality of training for all residents, especially interns. Even if you shifted the work to PGY2/3 years, well, that would cut down on elective time that would be used for strengthening their position for fellowship apps. And I don't want them to decide later to fix this new problem by extending residency.

Who the hell enters residency expecting a regular work week (i.e. approaching 40-50 hours)? I understand how ridiculous it is to do 24+ hours straight without sleep, so sure, take a nap. But 4-5 hours of a required nap? You've got to be kidding. On my advanced medicine rotation I worked 80-90 hours...it was tough, I won't lie. Doing it for a whole year...I'm afraid. Even a derm resident doing a decent medicine prelim puts in work (>56 hours/week). Surgical specialties are even more resistant to these changes...the effects would be fewer operations/resident/year, leading to longer training time or lower overall quality of training.

I think those trying to implement these changes need a reality check on what residency actually entails and its goals. I think <80 hours is a good idea, but going down into the 50s is not feasible without disrupting training.

 

[lapooh]

Is the four/five hour uninterrupted sleep on call rule going to be implemented this year? Or is that too just in thin air?

I saw one program on the interview trail where it has already been implemented. The residents personally seemed to like it. However, it could be chaos for anyone locate the resident responsible for a particular patient during those few hours.

I am guessing there maybe more places that have already implemented this. I don't know if it is going to become a rule, per se.

 

[mauvespice]

This is such a ridiculous idea. Many programs do not heavily use a NF system (i.e. 24-30 h Q4 overnight call for interns). If you cut work hours, you absolutely (you=government/health care system/your tax dollars) would have to fund more slots, which would essentially dilute the quality of training for all residents, especially interns. Even if you shifted the work to PGY2/3 years, well, that would cut down on elective time that would be used for strengthening their position for fellowship apps. And I don't want them to decide later to fix this new problem by extending residency.

Who the hell enters residency expecting a regular work week (i.e. approaching 40-50 hours)? I understand how ridiculous it is to do 24+ hours straight without sleep, so sure, take a nap. But 4-5 hours of a required nap? You've got to be kidding. On my advanced medicine rotation I worked 80-90 hours...it was tough, I won't lie. Doing it for a whole year...I'm afraid. Even a derm resident doing a decent medicine prelim puts in work (>56 hours/week). Surgical specialties are even more resistant to these changes...the effects would be fewer operations/resident/year, leading to longer training time or lower overall quality of training.

I think those trying to implement these changes need a reality check on what residency actually entails and its goals. I think <80 hours is a good idea, but going down into the 50s is not feasible without disrupting training.

When I last checked there were two groups arguing about this. One saying EXACTLY what you said here and the other reasoning the hour cuts based on sleep neurobiology, effects on long term cardiovascular and memory problems and poor performance in "controlled experimental" settings of residents deprived of sleep. I think both groups diverge strongly the more they argue, lets see who comes out on top in the end. I guess we'll find out in July Why aren't we on that committee?

 

[jdh71]

I know, but why not just rotate 12 hour shifts so there is coverage all the time. ER manages to do it, amongst others...

The ER is unique in that they can do this much easier than medicine because their responsibility is reasonably limited, menaing they stabilize the acutely ill, and triage everything else. Medicine has responsibility of admitting and caring for the patient until they leave the hospital, and since cancer, MI, and sepsis don't respect work hours, weekends, or holidays . . . well . . . medicine needs to be around to deal with the acute processes involved with these issues and this does not always lend itself very well to, "Oh shizzle, that's 12, I'm out bitches! Good luck!"

 

[jdh71]

Naps . . . actually might not be that bad an idea if implemented correctly. I know I'd take one because I like "happy time", but I think most residents would use the 5 hours to catch up on work, like dictations and perhaps notes.

I think night float systems have been implemented VERY effectively and sanely and have essentially demonstrated that there is no need for Q4 call on general medicine, while allowing for rested residents and reasonable work hours. Hand offs can be tricky, but if done in a formal fashion, essentially do not causes any more problems than not.

 

[digitlnoize]

The ER is unique in that they can do this much easier than medicine because their responsibility is reasonably limited, menaing they stabilize the acutely ill, and triage everything else. Medicine has responsibility of admitting and caring for the patient until they leave the hospital, and since cancer, MI, and sepsis don't respect work hours, weekends, or holidays . . . well . . . medicine needs to be around to deal with the acute processes involved with these issues and this does not always lend itself very well to, "Oh shizzle, that's 12, I'm out bitches! Good luck!"

Hospitalists do it.

I think this is a great example of doctors simply becoming too resistant to change. "Things are done this way because they are" just isn't a good enough excuse anymore. We've encountered the same resistance in many aspects of medicine from surgery checklists to diagnostic algorithms...

I, for one, think it's time for a change. Again, I do think that a 50-some hour limit is too much, but dropping to 72 with no more than 12 to 14 hour shifts seems reasonable.

There's lots of talk about "learning" but you know how much learning I'm doing on hours 13-18? Not very much.

 

[jdh71]

Hospitalists do it.

They also are not in training.

 

[ResidentMD]

Hospitalists do it.

I think this is a great example of doctors simply becoming too resistant to change. "Things are done this way because they are" just isn't a good enough excuse anymore. We've encountered the same resistance in many aspects of medicine from surgery checklists to diagnostic algorithms...

I, for one, think it's time for a change. Again, I do think that a 50-some hour limit is too much, but dropping to 72 with no more than 12 to 14 hour shifts seems reasonable.

There's lots of talk about "learning" but you know how much learning I'm doing on hours 13-18? Not very much.

Can you imagine the kind of life you would lead if you are working 12 hours a day for 6 days?

You go to work at 7 AM and leave at 7 PM (and from what I hear, residents rarely leave on time because there is always something to be completed). Doing an overnight call takes out a good 24-30 hours (which is fine or whatever) but at least then you can consider going home at 4:30-5 PM on other days if things work out well.

Also keep in mind those 80 hr weeks are considered by many programs in the light of 320 hours/month. So you can possibly work 120 hours in 1 week and 200 over the next 3.

I'm not saying if its good or bad, I'm just saying that I would rather not work for 12 hours 6 days a week.

 

[Pkboi24]

Hi everyone,
I have heard a lot about the 56 work week. If this come through, will it be put into practice any time soon. Probably not this year, but hopefully next year Would this effect people who would be PGY2 and PGY3s.
thanks

If IM programs ever implement this, I will eat my hat, sir.

 

[digitlnoize]

Can you imagine the kind of life you would lead if you are working 12 hours a day for 6 days?

You go to work at 7 AM and leave at 7 PM (and from what I hear, residents rarely leave on time because there is always something to be completed). Doing an overnight call takes out a good 24-30 hours (which is fine or whatever) but at least then you can consider going home at 4:30-5 PM on other days if things work out well.

Also keep in mind those 80 hr weeks are considered by many programs in the light of 320 hours/month. So you can possibly work 120 hours in 1 week and 200 over the next 3.

I'm not saying if its good or bad, I'm just saying that I would rather not work for 12 hours 6 days a week.

I get what you're saying, but I think that my way works out better for a variety of reasons.

Sleep deprived people make mistakes. Not just in patient care, but also in driving home after working for 30 hours. It's simply safer for the patients and us if we work sane hours.

There are multiple studies showing the negative effects of both sleep deprivation and night shift work. Obviously we can't get out of it altogether, but grouping the night shifts together as a few days of 12's in a row, to me seems both easier and more healthy than doing a 30, having a day off, then doing a bunch of 10's.

I think that it is time that we, as a profession admit that the idea that residency must be miserable because that makes you learn better/more is an antiquated and unsafe practice that should have been abandoned long ago.

 

[nomogram3]

We have attendings who work far more than 80 once you factor in clinic, research, teaching, faculty meetings, and even travel between satellite clinics. That doesn't even consider phone calls in the middle of the night when you're on service. What do you think you signed up for?

 

[digitlnoize]

We have attendings who work far more than 80 once you factor in clinic, research, teaching, faculty meetings, and even travel between satellite clinics. That doesn't even consider phone calls in the middle of the night when you're on service. What do you think you signed up for?

Ha! Not that! I understand that I might have to do it during residency, but after that, private practice is what you make it. I know more than a few IM docs who don't work those kind of crazy hours. Obviously, you might not make as much money, but that's not really my goal. Also, I plan on doing no research EVER (if I can help it), and very little teaching, until I'm older. I might not even do IM, I've still got some time before I have to make THAT decision.

I'm certainly not lazy, but I get older every day, and my time is more valuable than anything else. I plan on working enough to have the lifestyle I want, and spending my remaining days with my family.

Again, the notion that "good doctors work 80 hours a week" is tired and simply untrue. If our profession is to survive and flourish amidst possible salary cuts, we need to attract people into it, and we're not going to continue to do that if we don't make it more attractive.

 

[ranmyaku]

I'm not saying if its good or bad, I'm just saying that I would rather not work for 12 hours 6 days a week.

I second that. I am on a block right now where we do work 12 hour shifts 6 days a week. 2 weeks of day shift, 2 weeks of night shift. It sucks, plain and simple. I'd much rather be on your typical q4 call schedule. I have much more free time on a q4 call schedule than on a 12 hour shift schedule.

 

[NotAProgDirector]

Hi everyone,
I have heard a lot about the 56 work week. If this come through, will it be put into practice any time soon. Probably not this year, but hopefully next year Would this effect people who would be PGY2 and PGY3s.
thanks

This has been talked about at PD meetings. First:

Discussing this with PD's on the trail, it seemed as if many thought that recommendations would come out this spring and then formal requirements would go into effect July 1, 2011.

Bottom line is, no one knows.

Actually, we know that they will release the new rules this spring/summer, open them for comments, approve, and then implement them in July 2011 as you say. The DH committee of the ACGME has been meeting regularly and is committed to this schedule, so we should see something this summer.

As for 56 hours, that's not happening. Although many details are still being worked out, the 80 hour rule isn't getting changed this cycle. However, they did mention that they were considering some flexibility in the rules based on PGY level -- with more senior people having looser rules. Not sure if senior PGY residents would be capped at 80 and others at less, or interns at 80 and chiefs at more.

Is the four/five hour uninterrupted sleep on call rule going to be implemented this year? Or is that too just in thin air?

Ahh. The 5 hour nap. That idea is dead, probably due to marketing. They never should have called it a nap, for the obvious reasons. I actually thought the 5 hour sleep period made sense, if the resident could then work a full day the next day. The IOM called for a 5 hour sleep and going home by 24+6 the next day -- that makes it almost pointless to have someone stay on call (since you need a night float to cover the sleep anyway).

I know, but why not just rotate 12 hour shifts so there is coverage all the time. ER manages to do it, amongst others...

The ER is unique in that they can do this much easier than medicine because their responsibility is reasonably limited, menaing they stabilize the acutely ill, and triage everything else. Medicine has responsibility of admitting and caring for the patient until they leave the hospital, and since cancer, MI, and sepsis don't respect work hours, weekends, or holidays . . . well . . . medicine needs to be around to deal with the acute processes involved with these issues and this does not always lend itself very well to, "Oh shizzle, that's 12, I'm out bitches! Good luck!"

Naps . . . actually might not be that bad an idea if implemented correctly. I know I'd take one because I like "happy time", but I think most residents would use the 5 hours to catch up on work, like dictations and perhaps notes.

I think night float systems have been implemented VERY effectively and sanely and have essentially demonstrated that there is no need for Q4 call on general medicine, while allowing for rested residents and reasonable work hours. Hand offs can be tricky, but if done in a formal fashion, essentially do not causes any more problems than not.

I fully agree that we should do away with 24 hour calls. There are plenty of negatives to them, that have been discussed. There aren't many positives -- the only one I can think of is, when I was a resident and on call, no one else was there to look over my shoulder. So, I got used to actually taking care of patients. The danger with all these shifts is that we will over supervise residents, so that when they graduate they still don't feel comfortable working on their own. But that's theoretical, and it can be fixed by backing down supervision of PGY-3 residents.

The problem is simply person power. When you switch from a q4 system to a shift based system, it's inherently 20% less efficient -- you need to hire someone else to do that extra 20% or you have to remove 20% of work.

 

[randomedstudent]

I know, but why not just rotate 12 hour shifts so there is coverage all the time. ER manages to do it, amongst others...

To state the obvious, ER doctors aren't responsible for actually following pts, unlike internists, surgeons, psychiatrists, etc. Shift work has real drawbacks when it comes to managing pts in house. Errors occur often c pt handoffs, there is no possible way to checkout every thing going on with a patient or every possible thing that could go wrong.

 

[jdh71]

Errors occur often c pt handoffs, there is no possible way to checkout every thing going on with a patient or every possible thing that could go wrong.

Well . . . you're going to have to figure some things out of your own, you are playing a "doctor" on TV and all . . . check-outs if done right, aren't that big of a deal. And you can easily check out everything you think is actually important reasonably easily. All it takes is a little attention to detail, and truth is, the future of medicine outside of residency training programs is shift work, so it's probably valuable to get to used to hand offs.

 

[dilated]

As for 56 hours, that's not happening. Although many details are still being worked out, the 80 hour rule isn't getting changed this cycle. However, they did mention that they were considering some flexibility in the rules based on PGY level -- with more senior people having looser rules. Not sure if senior PGY residents would be capped at 80 and others at less, or interns at 80 and chiefs at more.

Ahh. The 5 hour nap. That idea is dead, probably due to marketing. They never should have called it a nap, for the obvious reasons. I actually thought the 5 hour sleep period made sense, if the resident could then work a full day the next day. The IOM called for a 5 hour sleep and going home by 24+6 the next day -- that makes it almost pointless to have someone stay on call (since you need a night float to cover the sleep anyway).

So if they're blowing off changes to 80 hours, and they're blowing off the 5 hour nap... it certainly doesn't seem like this is going to be much of a change. They're going through all these panels and committees to require 5 days off a month instead of 4? That seems ridiculous.

 

[ResidentMD]

So if they're blowing off changes to 80 hours, and they're blowing off the 5 hour nap... it certainly doesn't seem like this is going to be much of a change. They're going through all these panels and committees to require 5 days off a month instead of 4? That seems ridiculous.

I was told on more than one occasion on my trail, that the ACGME is trying to make a significant proportion of the IM training on an outpatient basis (something like 60-40 outpatient:inpatient ratio). I have a feeling that may actually be one of the important components of the discussion.

I also find it interesting how most of the people in favor of working hard - including the 12 hours per day - (on this thread) - are med students.

 

[digitlnoize]

I was told on more than one occasion on my trail, that the ACGME is trying to make a significant proportion of the IM training on an outpatient basis (something like 60-40 outpatient:inpatient ratio). I have a feeling that may actually be one of the important components of the discussion.

I also find it interesting how most of the people in favor of working hard - including the 12 hours per day - (on this thread) - are med students.

Don't get me wrong, I'd love it if residency was 9 hours a day x 5 days a week, but that will never happen.

I also don't think that 7-7 is the best time for the 12's. I'd rather see 5-5 or 6-6...that way when you get home, you still have some time with the family in the evening (on your day shifts), or in the morning (on your night shifts). Doing 7-7's just takes away everything, and is not the ideal place to put that time marker.

I do understand that 6 12's might result in slightly less "free time". That being said, it's better for us physically, it's safer for us and the patients, and a reasonable work schedule might help entice more people into a profession most people see as past its prime.

The difficulty of hand-offs is a lame excuse, IMO. Yes, we made it through undergrad with 3.8 GPA's, rocked the MCAT, made it through medical school, and the boards...but we can't handle a patient hand-off. Riiight.

Having worked in an ER, I also think that saying that ER docs have less responsibility and thus, have an easier time doing hand-offs is also a poor excuse. ER docs will often do a hand-off on a patient with no clear diagnosis, sometimes in rather serious condition. Imagine walking into your shift and being handed a patient with no diagnosis, no labs back, no imaging back, and only a weak EMT history and another guy's physical exam to go on. Happens all the time, and it's not a big deal. I can't imagine it'd be that much worse for anyone else, training or not.

I'm actually glad the 5 hour nap is dead. 5 hours does nothing for me.

I should add that I am rather partial to my sleep. I have a PSVT that gives me much more trouble when I don't get much sleep (despite an ablation at one of the best centers in the country...it's just in a terrible place (right at the superior aspect of the coronary sinus os), unless I want a pacemaker, which I don't). So, I'd rather work sane hours and be able to sleep. I can make do otherwise, but it's not my favorite thing to do. Also, I'm old and the joints and stamina are not quite what they were when I was 24 and running around stages rocking out at all hours of the night and day.

I love IM, but one of the main things pushing me away from choosing it is the arduous (for me, at least) schedule. EM and FP residents and attendings (amongst others) have a much more humane schedule...we'll have to see who wins out over the next couple of years...

 

[Punchap]

Ha! Not that! I understand that I might have to do it during residency, but after that, private practice is what you make it. I know more than a few IM docs who don't work those kind of crazy hours. Obviously, you might not make as much money, but that's not really my goal. Also, I plan on doing no research EVER (if I can help it), and very little teaching, until I'm older. I might not even do IM, I've still got some time before I have to make THAT decision.

I'm certainly not lazy, but I get older every day, and my time is more valuable than anything else. I plan on working enough to have the lifestyle I want, and spending my remaining days with my family.

Again, the notion that "good doctors work 80 hours a week" is tired and simply untrue. If our profession is to survive and flourish amidst possible salary cuts, we need to attract people into it, and we're not going to continue to do that if we don't make it more attractive.

Definitely agree.

 

[Reddpoint]

digitlnoize, I dont mean to be a prick but until you have been a resident it is very hard to understand how residency works. ER can function on shifts because they are passing off at most 12 hours of care (although typically 2-4 hrs). Handing off medicine patients that have been in the hospital for days to weeks is much more dangerous. When I cross cover at night on 20 patients that I have had maybe 5 minutes of sign out on routinely results in me walking into a patients room with no background on the patient. I definitely cannot provide the same care for these patient's as their primary MD on my team. The more we go towards the shift/hand off model the more our patients will suffer.

 

[digitlnoize]

digitlnoize, I dont mean to be a prick but until you have been a resident it is very hard to understand how residency works. ER can function on shifts because they are passing off at most 12 hours of care (although typically 2-4 hrs). Handing off medicine patients that have been in the hospital for days to weeks is much more dangerous. When I cross cover at night on 20 patients that I have had maybe 5 minutes of sign out on routinely results in me walking into a patients room with no background on the patient. I definitely cannot provide the same care for these patient's as their primary MD on my team. The more we go towards the shift/hand off model the more our patients will suffer.

You're not being a prick

I understand completely what you're saying, but I simply don't believe it's true.

Most hospitals in the US do not have residents. Yet somehow, despite relatively standard 12 hour hospitalist shifts, and attendings not working 24hrs a day for "days or weeks", the patients still manage to usually not die, despite tons of handoffs.

There is absolutely no reason that residency can't be the same.

 

[cocolopez]

For me, the major issue with cutting work hours is the sneaking suspicion that we will be also cutting the quality of resident training. The 80 hour work week was originally implemented with the idea that pt care was suffering with resident sleep deprivation. However, there is no evidence to support the idea that cutting back to 80 hrs/wk has actually improved patient outcomes.

Additionally, there is no evidence that cutting back the work week even further to 56 hours will improve patient outcomes. Most of the data supporting the change comes from sleep studies looking at responsiveness, alertness, etc but there is not much data looking at the role of sleep deprivation in clinical care settings.

Anyway, from a resident perspective:

1. Before I was a resident, I was terrified by the idea of regularly taking overnight call and by working up to 80 hrs per week. I came from a program where med students were required to take overnight call on most rotations and even then, I didn't like it.

2. I put in long, long hrs as an intern. I was exhausted -- but shockingly, I wouldn't have traded those sleepless overnight calls for anything. I liked being the first one to evaluate sick pts in the middle of the night and having the autonomy to decide what I wanted to do.

3. I have several friends at places were they did away with overnight calls in IM, only to have the residents ask for overnight call back! The problem with no overnight call is daily admits. Overnight call = bolus of admits. Yes, you work 30 hrs continuously but then you have a few days during the call cycle where you can possibly get out early in the afternoon. Though, honestly, a "light day" for me on wards usu. means I get there at 6:30 or 7am and get to leave by 3. That's still an 8 hr day. For me, better than 7a-7p x 6 days a week with 2 new admits every day. Oof.

4. I'm looking at jobs post-residency in the "real world." Hospitalist gigs are still tough -- you work 12 hours a day usually for 18 out of 28 days per month covering anywhere from 8-20 pts on your service, depending on the hospital (plus 1-2 admits/day!). That means 10 days off which equals weekends plus two days off. Some places also require 1-2 night shifts (yes only 12 hrs but mixing day/night really throws your clock off).

And for anyone who thinks primary care clinics are an easy gig? Yeah, 8-4pm on the books but you're seeing around 20 pts/day. And they don't figure in the extra time not officially in the office you spend reviewing pt charts, writing notes, doing paperwork, etc.

5. At our institution, all the work that isn't getting done by residents is getting shifted to fellows/attendings. Who, after putting in their time already, aren't thrilled about having to pick up the slack. Remember, YOU will be that fellow/attending someday.

Bottom line -- you want a cush life, pick a cushy job with a correspondingly cushy course of training. Derm, anesthesia, ER, echo mommy, path, allergy, rad onc. Don't come into my field and cry about wanting a 56-hr work week and a 5 hr nap every night! That's not what I signed up for.

 

[ropeadope1983]

Let's face it, a career as a physician these days = damaged goods compared to what it used to be. With the direction things are headed, might as well just follow the lead of the nurses, union up and entirely turn this yatch into a shift job (yes, starting with residency).

For me, the major issue with cutting work hours is the sneaking suspicion that we will be also cutting the quality of resident training. The 80 hour work week was originally implemented with the idea that pt care was suffering with resident sleep deprivation. However, there is no evidence to support the idea that cutting back to 80 hrs/wk has actually improved patient outcomes.

Additionally, there is no evidence that cutting back the work week even further to 56 hours will improve patient outcomes. Most of the data supporting the change comes from sleep studies looking at responsiveness, alertness, etc but there is not much data looking at the role of sleep deprivation in clinical care settings.

Anyway, from a resident perspective:

1. Before I was a resident, I was terrified by the idea of regularly taking overnight call and by working up to 80 hrs per week. I came from a program where med students were required to take overnight call on most rotations and even then, I didn't like it.

2. I put in long, long hrs as an intern. I was exhausted -- but shockingly, I wouldn't have traded those sleepless overnight calls for anything. I liked being the first one to evaluate sick pts in the middle of the night and having the autonomy to decide what I wanted to do.

3. I have several friends at places were they did away with overnight calls in IM, only to have the residents ask for overnight call back! The problem with no overnight call is daily admits. Overnight call = bolus of admits. Yes, you work 30 hrs continuously but then you have a few days during the call cycle where you can possibly get out early in the afternoon. Though, honestly, a "light day" for me on wards usu. means I get there at 6:30 or 7am and get to leave by 3. That's still an 8 hr day. For me, better than 7a-7p x 6 days a week with 2 new admits every day. Oof.

4. I'm looking at jobs post-residency in the "real world." Hospitalist gigs are still tough -- you work 12 hours a day usually for 18 out of 28 days per month covering anywhere from 8-20 pts on your service, depending on the hospital (plus 1-2 admits/day!). That means 10 days off which equals weekends plus two days off. Some places also require 1-2 night shifts (yes only 12 hrs but mixing day/night really throws your clock off).

And for anyone who thinks primary care clinics are an easy gig? Yeah, 8-4pm on the books but you're seeing around 20 pts/day. And they don't figure in the extra time not officially in the office you spend reviewing pt charts, writing notes, doing paperwork, etc.

5. At our institution, all the work that isn't getting done by residents is getting shifted to fellows/attendings. Who, after putting in their time already, aren't thrilled about having to pick up the slack. Remember, YOU will be that fellow/attending someday.

Bottom line -- you want a cush life, pick a cushy job with a correspondingly cushy course of training. Derm, anesthesia, ER, echo mommy, path, allergy, rad onc. Don't come into my field and cry about wanting a 56-hr work week and a 5 hr nap every night! That's not what I signed up for.

 

[Scut]

56 hr work week!? It is going to be detrimental to training and learning. How in the world do you expect to learning anything by staying in the hospital for a bit more than 9 hours a day? I hope it does not get to be the new law. I would hate to be kicked out of the hospital when an interesting case comes along!

As it is now, I occasionally get frustrated with the 80-hr work week since I can't stay in the hospital beyond that limit, even if there is a case, procedure, lecture, etc. that is worth staying for. I learn best when my sleeves are rolled up and my hands are up to the elbows in it. Yeah, I know about the benefit of the 80-hr work week, so save your lecture for the next guy.

My favorite time in the hospital is at night, when I am with my team, doing midnight rounds or evaluate new admits.

 

[Firebird]

I know, but why not just rotate 12 hour shifts so there is coverage all the time. ER manages to do it, amongst others...

The largest percentage of mistakes take place at discharge. I think statistically, the second most common area for mistakes to be made is during cross-coverage hand-offs. The more night shift players that get involved, the more likely a mistake is to be made in patient care.

I'm not sure anyone is thinking about the long term effects of such a heavy reduction in work hours. Sure, in the short term frequency and severity of mistakes will be reduced by a single resident because A) the resident isn't participating in patient care as much and B) because the resident is obviously going to be more aware and fresh when work hours are decreased. However, how about when you're the attending who has never worked more than 60 hours in a week and it's your 8th night on call in a row and you are so tired from rounding that your legs hurt too bad to go to sleep? Are you going to be conditioned to not make mistakes then? Part of the grueling nature of residency is to train people to be able to survive and make good decisions when you're very tired.

 

[docscience]

And for anyone who thinks primary care clinics are an easy gig? Yeah, 8-4pm on the books but you're seeing around 20 pts/day. And they don't figure in the extra time not officially in the office you spend reviewing pt charts, writing notes, doing paperwork, etc.

Bottom line -- you want a cush life, pick a cushy job with a correspondingly cushy course of training. Derm, anesthesia, ER, echo mommy, path, allergy, rad onc. Don't come into my field and cry about wanting a 56-hr work week and a 5 hr nap every night! That's not what I signed up for.

Just an MS3 but the anesthesia residents here work just as hard if not harder...they come in a lot earlier to do surgery prep work...but seems like they do have it easier with cases all day.

Also, the OB/GYN I worked with last semester saw 40 pts a day...so 20 doesn't sound that bad. Just another opinion.

 

[Firebird]

Just an MS3 but the anesthesia residents here work just as hard if not harder...they come in a lot earlier to do surgery prep work...but seems like they do have it easier with cases all day.

Also, the OB/GYN I worked with last semester saw 40 pts a day...so 20 doesn't sound that bad. Just another opinion.

Let's compare an internist's patients with an OBGYN's patients.

On a typical day, an internist would see several patients that have coronary artery disease, hypertension, diabetes, hyperlipidemia, heart failure and peripheral vascular disease all together. An internist would also see 10-12 patients who have 2-3 less significant problems, but no doubt all of them would have something inconsequential that they would "just like to run by" their physician...but this would no doubt take 10 min to discuss. Another 5-8 pts would have something like hypertension alone or GERD or need to follow up on old labs, radiographs, etc.

Many of them will have polypharmacy, and just to add sugar on top, they will want refills on their lortab and xanax. And, if that isn't enough, I have to discuss head-to-toe health mtx on all of them.

The typical OBGYN's day, if it's their OB day, will see a bunch of pts with one or no medical problems...they just happen to be pregnant. If they do see a pt with medical problems, I will admit that can be a tricky, time consuming pt. But this is not the rule, it's the exception. Additionally, GYN pts can be a little more time consuming, but still not as complicated as my diabetic vasculopath who's allergic to plavix and has a hx of HIT type II who now has cellulitis over a non-healing ulcer that has failed outpt therapy who comes into the office complaining of chest pain.

A surgeon can see 40-50 pts in an afternoon. For an internist to see 40 patients in the same time frame would be ridiculous and dangerous. When you're a subspecialist you can get into a groove. An obstetrician asks many of the same questions every visit. They do the same exam every visit. They dictate and note the same things every visit. There are clearly variations, such as when to do glucola testing and when to do gbs swabs, but this is the same with each pt, essentially. My conversation, note and to a large extent my exam, is different from pt to pt.