Duty Hour Standards

[glade]

Actually, everyone keeps talking about how attendings work crazy hours and the new push is for surgical hospitalists and for surgeons to be hospital employees. I'm not saying I back it or anything, I'm just saying that to a certain extent all of this bravado and talk is just that: talk. Because the thing is, before duty hour restrictions (which may or may not be lip service anyways in some places, for all of your collective outrage), fewer applicants were going for Surgery and it was getting to be less and less competitive. And for all of the tough talk from surgery residents, there's a huge shift towards fellowship for the same reasons. You all keep acting like "we" all work 110 hours/week as attendings, but most of "us" talk big like that and immediately go for a fellowship where we DON'T have those hours. It's part of why General Surgery is supposedly dying out, although granted there are other factors.

All I'm saying is that it's easy for people to come here and post about how disgusted they are with the wimpy pathetic slime who are going into Surgery these days. I'd be willing to bet that at least a few of you guys are being at least semi-hypocritical in that regard yourself, however.

---

Members don't see this ad.

 

[JackADeli]

I found the extra hours off instrumental in doing well on the ABSITE...I'm not sure how accurate it is to say that all of us are using our extra spare time for drinking and going out.

It's not accurate... it's a generalization. In that aspect, "we" have not seen an overall marked increase in use of the extra hours for study and/or sleep. There are programs that are exceptions. There are groups with different mentalities. But, as a whole, the 80hr/wk has not demonstrated marked improvement on these fronts. I dare say, IMHO, it is more common to find residents using the time to expand their social lives then to knuckle down and study more.

 

[JackADeli]

Like they have with airline pilots? I wouldn't be suprised if some day they (don't know who) tried. I would bet in 10 years something along this line was enacted.

It won't take ten years. Anesthesia is already very much shift work in most places I have seen. There are plenty looking accross to Europe and their restrictions and shift work attendings. Discussions are on-going as to patient safety and physician fatigue concerns. I would be surprised if it did take that long.

Final note, I have been to numerous conferences in which the airline pilot and flight crew analogy was used extensively in reference to decreasing errors... and their approach to fatigue has been cited.

 

[glade]

I dare say, IMHO, it is more common to find residents using the time to expand their social lives then to knuckle down and study more.

...and that's apparently the end of the world as we know it, if you believe the gray beards.

 

[ESU_MD]

It won't take ten years. Anesthesia is already very much shift work in most places I have seen. There are plenty looking accross to Europe and their restrictions and shift work attendings. Discussions are on-going as to patient safety and physician fatigue concerns. I would be surprised if it did take that long.

we all know its just a matter of time before someone, somewhere clamps it down on the staff work hours. whether its OSHA, AMA, obama or some other nebulous entity, its gonna happen.

Jack, How do you feel personally when an anesthesiologist leaves your room and signs over mid-case on one of your big, complex cases? there has to be exceptions to blanket work-hour rules.

work hour restrictions are a great concept. i personally hate working long hours. I get tired at the end of work periods, but that doesnt absolve me from having to make good decisions.

 

[glade]

Most places have CRNAs covering cases and they do shift work, as do the scrub techs. How many times have all of us been in the middle of cases and suddenly the entire team other than the surgeon changes? Non-surgeons never understand how irritating that is, like you literally walk out in the middle of stuff while some patient is open on the table and yet they want you to act like they're an integral part of the healthcare team. How are you going to respect the Anesthesiologist when they aren't even in the room for more than the intubation and then they run around talking about how they ensure the safety of the patient in the OR? Literally the Anesthesiology department could all simultaneously die at many places and you'd not notice a huge difference.

 

[JackADeli]

...Jack, How do you feel personally when an anesthesiologist leaves your room and signs over mid-case on one of your big, complex cases? there has to be exceptions to blanket work-hour rules...

In general, I don't like it. The problem is the change can often happen quietly, while you are concentrating on a delicate portion of the procedure and may not even be aware a swap has occurred. You then discover there was a change. The new anesthesia is not up to speed on all the ins and outs to that point. He/she may often have completely different philosophy of how things should be managed. "new" interventions may be intiated that counter the entire care plan as discussed with the original anesthesia. You do not have a "4 hour transfer of care" scenario here.... The hand off is often measured in minutes & involves little more then, ~"I just dosed this, he peed this amount, there has or has not been this much bleeding, I've already given this much fluids.... goodbye". The new individual decides to "try a few ideas".

The worst is when you look up and discover blood has been hung without you being notified.... and the anesthesia tells you they are ~"a patient advocate". Or, better yet, the new individual has a different philosophy on who should be extubated and your patient that would have been extubated under the previous anesthesia is now forced to remain intubated and go to the ICU. We have seen numerous adverse events very much related to this change over.

 

[45408]

I find it quite surprising there isnt much push to enact work hour restriction for attendings.

I know a few attendings, more old school than not, who run full-throttle for an insane amount of time. I have a lot of respect for them, and I don't know how they do it, but they probably have a fair amount of control over their schedules. Obviously not on a day-to-day basis, but when you're the head of a department, you've made many decisions along the way to continue taking on more and more work. They can handle the workload, so they push on. The ones that come to mind for me were at my med school: the trauma division chief, the department chairman, and one of the peds cardiac surgeons. Putting a work hour restriction on these guys doesn't make a lot of sense to me. I'd trust my life (or son's life) in their hands at hour 30 before I'd hand it over to someone who wasn't as good.

 

[JackADeli]

I know a few attendings...They can handle the workload, so they push on. ...Putting a work hour restriction on these guys doesn't make a lot of sense to me. I'd trust my life (or son's life) in their hands at hour 30 before I'd hand it over to someone who wasn't as good.

I will disagree. I would personally want a skilled surgeon that is well rested.

Even the old-school legendary types have significant deterioration in performance with prolonged hours and fatigue. Many would like to believe these are unique "super humans". They have skill and experience and can recover from more errors then less skilled. But, their fatigue counters that by causing potential for increased errors from their fatigued. We have zero reason to believe a surgeon with fatigue is unique as opposed to any other field requiring technical ability & prolonged concentration. All we have is self promoting legend & lore.

Unfortunately, that just has not born out with analysis. Anectdotely, I have seen numerous, so called legends, well into prolonged cases make significant errors that are compensated for by a skilled team. The team anticipates these errors from their experience (i.e. the legend apparently makes these errors enough for them to expect it). The outside/uninformed observer misses these things (by blind admiration or ignorance of the details). There are little finesse points that occur. who is to say the bowel leak or vascular anastamosis failure is the result of patient disease or surgeon failure from fatigue?

I just assume remove the question of fatigue from the picture when feasible. There are too many "old timers" pushing the limits. It is a topic of national discussion. Too many have pride & ego that convinces them about how unique & special they are. Too many leave far to late in their careers after they have lost luster.

 

[Thanatos]

Most days at the hospital I feel like a firefighter trying to control multiple 4 alarm blazes. Especially at our county hospital, where I am intern/phlebotomist/transporter and nurse....without all their combined salaries of course.

In the most basic sense, there are "x" amount of things that must get done and "y" amount of people to do them. I don't really understand how hours can continue to go down for anyone unless "y" becomes much larger or "x" becomes much smaller. I won't give a **** what the ACGME/JCAHO/OSHA/whoever thinks about most things until they can answer that basic question.

Our options are to either hire more residents and attendings or cut back on the work load. Which do you think is easier? In a time when our healthcare is touted as being so ungodly expensive and the politicians are out for blood, you think the $$$ to hire more people will magically appear. Or will we cut elective surgeries in half so we can all sleep all day in anticipation for what "might" come in overnight that needs to be operated on. You can't schedule cases all day if you might have stuff come in all night with more cases/clinic the following day under the regulations.

There is only so much creative re-structuring you can do (ie night float) until the simple logistics catch up with you. You think PA's/NP's will step up to save healthcare? They're mercenaries who won't pick up a pen or throw a stitch when their shift ends at 3pm. Healthcare, especially at county/VA hospitals have depended on the altruism of overworked residents for a long time....what will happen to these places when you start kicking more of them out of the hospital?

I don't know about work hours being safe or fair or reasonable....I just don't see how they are logistically possible.

 

[glade]

That's the thing about the medical field that is the most stupid. Nobody cares about the ratio of patients to physicians. If thirty people come to the hospital tonight, then thirty people will be seen. Theoretically, if three hundred people came to the hospital tonight, they'd all be seen. Nobody says "wow, I guess someone won't get seen." They response is "guess you'll have to work harder, call me when you're done with the workups." Or, if it's an administrator, it's like "guess you'll have to work harder, I'll call you when I'm back from vacay and go over the QA reports."

 

[45408]

I will disagree. I would personally want a skilled surgeon that is well rested.

The choice was between "a skilled surgeon that isn't well-rested" and someone who isn't as skilled. Of course, I'd like to have my cake and eat it too.

 

[opr8n]

• PGY-1 residents limited to 16 hours/day

EQUALS Night float


there is no other way

 

[opr8n]

i) Nobody is learning a damn thing on call, contrary to popular belief. In fact, 99% of people get more stupid the longer call progresses.
QUOTE]

I completely disagree!

Call is very important!
Ihave learned alot of what I know about takin g care of patients when i am on call when no one else is there. If forces you to work people up more on yuor own and take do procedures on your own. Thats how you learn. My calls have always been busy, i'm not sleeping on call.

Let me reiterate

1. most of my day work is **** skut money work
2. most of my night work is where I really learn surgical w/u and management

 

[opr8n]

Im surprised NO ONE has mentioned the trainaing of PGY 4-5 residents. Does anyone realize that the days of home call for these residents is OVER! The system set up to try to transition them the staff thinking and mindset is gone and now they are back to being a really good intern.

I mean just think of a hospital system that only has interns and a 4/5 at them. The interns used to take the call, and the chief would be at home backing them up, running the service like an attending, from home. Now the interns have to dived up to take night float, making it impossible to run the day day shift without adding residents and the chief may have to pick up the slack by taking call, when they should be primarily a manager


Just be glad the ACGME didnt say that interns had to have backup call at all times IN HOUSE! That might have been a consideration and might have been dropped.

 

[opr8n]

• PGY-2+ call no more frequent than Q3 (No averaging)

this will be very hard where there are only 3 residents to take call, as no one can take vacation or leave town for any reason

that or the chief will have to cover them in house
which im sure they are going to be jumping to do

this may lead more programs to the month on vacation rotation
which svcks IMO, but may be a necessary evil for the programs

 

[glade]

Call is very important!
Ihave learned alot of what I know about takin g care of patients when i am on call when no one else is there. If forces you to work people up more on yuor own and take do procedures on your own. Thats how you learn. My calls have always been busy, i'm not sleeping on call.

Let me reiterate

1. most of my day work is **** skut money work
2. most of my night work is where I really learn surgical w/u and management

Everything you said is popularly believed. Also, false.

Everyone has this belief that you learn "more" on call because you're all alone. What does that even mean? You mean you need to be "forced" to work up a patient on your own? How so? You know how you work up a patient on your own during the day? The same way you do at night, last time I checked. Except that you're not wearing dirty clothes and you don't smell as bad. You know why most of your day is scut? Because WAY MORE happens during the day. If you can't learn during the day, then I highly doubt you learn during the night.

 

[agranulocytosis]

Speaking as an MS-4 here, but someone please correct me if I'm mistaken: aren't these just proposals that the ACGME is deliberating until it comes up with a final draft of new standards for next year?

Because I sure as hell hope so.

I don't want my senior years consisting of something that I should be doing in my first 2 years. It would seem to me that I'd be less likely to come out of residency a trained surgeon being able to run a service if these proposals do take place. I thought that's what a residency was supposed to accomplish in the first place.

Maybe there's more teeth to the argument that gen surg programs will leave the ACGME and come up with their own accreditation council?

 

[toxic-megacolon]

Everything you said is popularly believed. Also, false.

Everyone has this belief that you learn "more" on call because you're all alone. What does that even mean? You mean you need to be "forced" to work up a patient on your own? How so? You know how you work up a patient on your own during the day? The same way you do at night, last time I checked. Except that you're not wearing dirty clothes and you don't smell as bad. You know why most of your day is scut? Because WAY MORE happens during the day. If you can't learn during the day, then I highly doubt you learn during the night.

I actually strongly agree with glade. But we tell ourselves this isn't the case to perpetuate the cycle of "I had to do it, so you have to do it." And when we send people home during the day because they were in house at night, we are basically just substituting a high-yield time to be in the hospital with a low-yield time to be in the hospital.

 

[LucidSplash]

Speaking as an MS-4 here, but someone please correct me if I'm mistaken: aren't these just proposals that the ACGME is deliberating until it comes up with a final draft of new standards for next year?

If I'm reading the press release correctly, the "community" has 45 days to comment on these standards and there is "potential" that the ACGME could modify the proposed standards based on feedback. However, the impression I get from those above me is that these will be, in all likelihood, the final standards effective July 2011.

 

[BlondeDocteur]

I think a large portion of the problem is that surgery is very poorly represented in the ACGME decision-making. Few surgeons are much interested in committes and policy-making and the like. And honestly, the vast majority of residents training in this country are non-procedural specialty trainess (surgery residents are what, 5% of the total? Adding in all sub-specialties and ob/gyn, you might get 10-15%?).

And it's not just the 80-hrs thing. Take night float for example. Night float for a non-surgical resident is actually a fabulous learning opportunity. They're usually the only person in-house (senior medicine residents take much less call) and they learn lots about floor management of complex, sick patients in an acute limited-info scenario. Which is a major point of their entire residency. For surgical residents, however, night float sucks donkey balls. It's great to be well-versed in floor management, but the operative opportunities for interns/juniors on night float are exactly zero. And the entire point of *our* training is to learn to operate (and when to operate, and caring for surgical patients, but really-- to operate). So if surgery residency becomes as float-heavy as IM-based specialties, our training would acutely suffer.

 

[JackADeli]

I think a large portion of the problem is that surgery is very poorly represented in the ACGME decision-making. Few surgeons are much interested in committes and policy-making and the like...

IMHO, if there were more surgery attendings representing at the ACGME level, it would be worse. The grunting and bravado would just prove the point of the ACGME that surgeons will never solve this problem without outside intervention. i.e. all the kicking, screaming, heel dragging cries of the apocalypse when the current restrictions were enacted. Even here, we have folks already concerned they will become the intern again to carry their juniors if the new/proposed changes go into effect.

Maybe it is the mantra of "don't whine" that has left surgery without an adequate voice. Instead, like in residency, "we" sitting around whining amongst ourselves but fail to speak up when it matters or will have an impact. Add to that the utter fairlure of residents (and attendings) to even take advantage of the current work hour restrictions in order to study, sleep, improve surgical education.

...And it's not just the 80-hrs thing. Take night float for example. Night float for a non-surgical resident is actually a fabulous learning opportunity. ...For surgical residents, however, night float sucks donkey balls. ...So if surgery residency becomes as float-heavy as IM-based specialties, our training would acutely suffer.

I agree there will likely be some decline in the education.... no matter what policy goes into effect. I feel well qualified/competent as a surgeon. But, the vast majority of my attendings and senior residents were nothing near being good educators. On top of that, you add the buffer that overides education obligation, most frequently used in surgery, i.e. "patient comes first".

Until surgery attendings actually become true educators and stop looking for the "pay your dues" model, there will be no education improvement. Surgery has long held off from enterring the modern era of education and employing what has been learned about effective teaching and effective learning. In general, it is a one size fits all mentality in surgery...

That "size" is ~we will beat-up the resident for five years. They will quit or stick it out. If they stay up late and nobody dies, I might let them do some suturing. If I allow them to participate in the case I have done my job and "taught them something". They might read something or they might not. Once they graduate, well, they will have demonstrated the tenacity to actually leave and go read so they can pass their boards and "it will take 10 additional years of practice after residency to gain technical mastery".....

 

[glade]

Maybe it is the mantra of "don't whine" that has left surgery without an adequate voice.

Or maybe it's because we're working while everyone else is at home playing with themselves.

 

[glade]

That "size" is ~we will beat-up the resident for five years. They will quit or stick it out. If they stay up late and nobody dies, I might let them do some suturing. If I allow them to participate in the case I have done my job and "taught them something". They might read something or they might not. Once they graduate, well, they will have demonstrated the tenacity to actually leave and go read so they can pass their boards and "it will take 10 additional years of practice after residency to gain technical mastery".....

Don't forget, retracting during a case provides you with endless knowledge and excitement and is a valuable learning opportunity that only a very few people are allowed to experience.

 

[eyesupply]

Could surgery programs band together and leave the ACGME?
It seems to me they have no idea what it takes to train a surgeon.
Why is it that they are so hellbent on messing with a system that has consistently created the best surgeons in the world?

Strawman logic. Even better surgeons can be created with the new ACGME proposals. However, the ACGME forgets to add a year of residency. PGY1 and half of PGY2 can do the intern work. The last half of PGY5 and a new PGY6 can be the chief year (or PGY8 if there are two years of research). Better yet, cut two years off college at add one year to medical school and yet another year to residency.

 

[eyesupply]

Most days at the hospital I feel like a firefighter trying to control multiple 4 alarm blazes. Especially at our county hospital, where I am intern/phlebotomist/transporter and nurse....without all their combined salaries of course.

.

This is a waste of manpower. Drawing blood does not make you smarter. A few blood draws are educational. Night after night is slavery.

 

[opr8n]

Has anyone heard from their PDs of the ramifications of these new standards and how it will affect your program? just curious

 

[JackADeli]

Has anyone heard from their PDs of the ramifications of these new standards and how it will affect your program? just curious

I think their input would be useless at this point. Their position will likely be it is impossible.... until they are actually forced to do it. PDs have a very bad and recent track record on these things. They have proven to be whoefully unreliable. Every PD I spoke with around the time of the 80hr thing ~8 years ago decried the destruction of resident education. They said, "it will be improssible to train competent surgeons", "patients will be neglected", "residents will be unable to operate", "hospitals will go broke and close because of excessive added costs of hiring PAs", etc, etc.... However, they have all consistently graduated and more importantly affirmatively endorsed residents to sit for the boards.... though trained under the 80hr restrictions. Further, they have all made testamony to the ACGME/RRC that they are training residents in compliance with those rules/regulations/guidelines.

PD are going to do what they did ~8yrs ago. They will decry this and attempt to convince residents that they (residents) will be incompetent and suffer. They will convince residents to speak out and be their minions against additional changes. We will then read in these forums medical students, new residents, and senior residents talking about lying and "being old school". They will go on and on about wanting their metal to be forged like the old legends.

 

[psipsina]

Just a 4th year medstudent here so I don't think I can weigh in on what it takes to train a surgeon properly. I can say that I had some amazing learning experiences on overnight calls this year. We were well supervised with an intern, an upper level and an attending on all trauma activations and operations. I never felt like patient care was compromised by fatigue (granted I have limited ability to judge this). I did see countless examples of rushed checkouts and near-misses with float teams on other services (that even I could pick up on). While the appeal of no overnight call is obvious I worry about lost experiences (both educational and for personal/professional growth) and the safety issues of a night float system.

 

[JackADeli]

...I don't think I can weigh in on what it takes to train a surgeon properly...

I suspect this is true of numerous PDs. There is this inability to think outside the box and consider new and or novel approaches. It seems the presumption works something like this....

I am a board certified, successful surgeon in an academic training program. I arrived here by way of a "rigorous" training program with very long hours, limited sleep, skin thickening experiences, etc. Therefore, I can assume four important facts:
1. The system works
2. I am a qualified educator because I have as much training in education as the residents and attendings ahead of me
3. If it isn't broke we shouldn't mess with it
4. I am a leader

...I did see countless examples of rushed checkouts and near-misses with float teams on other services (that even I could pick up on). While the appeal of no overnight call is obvious I worry about lost experiences (both educational and for personal/professional growth) and the safety issues of a night float system.

There is infinite learning opportunities and gained and lost experiences. The problem is an unwillingness to consider modern and/or efficient possibilities. The PDs and attending staff are in general not trying to come up with new ways to improve the process, IMHO. They are recalcitrant until someone else, outside of a given specialty comes in and mandates the changes.... This is a consitant pattern of physicians at all levels from HMOs to national healthcare reform. We have an absolute failure of leadership. Our programs are filled with people lacking in formal training in education. Our programs are filled with people lacking in formal training in leadership. Our programs are filled with people lacking in formal training in business.

 

[balaguru]

During one of our residency meetings with the PD the ACMGE proposal was discussed. He believed that they represented a reasonable compromise to the IOM's original recommendations on work hours and other recommendations to limit hours to 56/wk. Therefore, he predicted a high likelihood that this proposal will go into effect with little to no change. We will be playing with a few ideas this year, night float being one, to be compliant by next year. So, at least, one PD is responding appropriately to the proposal.

I think their input would be useless at this point. Their position will likely be it is impossible.... until they are actually forced to do it. PDs have a very bad and recent track record on these things. They have proven to be whoefully unreliable. Every PD I spoke with around the time of the 80hr thing ~8 years ago decried the destruction of resident education. They said, "it will be improssible to train competent surgeons", "patients will be neglected", "residents will be unable to operate", "hospitals will go broke and close because of excessive added costs of hiring PAs", etc, etc.... However, they have all consistently graduated and more importantly affirmatively endorsed residents to sit for the boards.... though trained under the 80hr restrictions. Further, they have all made testamony to the ACGME/RRC that they are training residents in compliance with those rules/regulations/guidelines.

PD are going to do what they did ~8yrs ago. They will decry this and attempt to convince residents that they (residents) will be incompetent and suffer. They will convince residents to speak out and be their minions against additional changes. We will then read in these forums medical students, new residents, and senior residents talking about lying and "being old school". They will go on and on about wanting their metal to be forged like the old legends.

 

[ESU_MD]

Good surgeons can be trained in 40 hr/week if the conditions are right.

The work hour restrictions affect mostly only surgical training and really dont impact other types of residencies. Ironically, all of the restrictions end the day you graduate residency.

Besides, who cares if the resident goes home early, in most places- theres another body (intern, resident, PA, etc..) to take their place. Will be interesting to see how the real problem of attending work hours is tackled. There arent enough surgeons to go around now, let alone if someone tried to cut down on work hours. plus for private practice guys- not working means not getting paid.
Anyone with ideas about that?

 

[JackADeli]

Good surgeons can be trained in 40 hr/week if the conditions are right...

Agreed. Will all the "real educators" please step forward! It is just like surgery. Just about any bad surgeon can get an appendix out with unlimited time and incision size. So to can really bad educators train residents with innefficient use of time... if they are given an excess of said time.

 

[deleted50541]

Has anyone heard from their PDs of the ramifications of these new standards and how it will affect your program? just curious

My PD opened the issue up for discussion last week. Some of his ideas included pulling resident coverage from one or two hospitals where the operative experience is already suboptimal, introducing additional float coverage, and extending home call for more senior residents. He also brought up the possibility of shaping the program into one that is more performance based, including more stringent metrics of competence that must be met within a set time line.

We've already seen some limited changes this year, including the addition of a senior resident to our busiest general surgery service and a dedicated junior float at our university hospital. But we're still stretched very thin for coverage. Since starting intern year, I'm routinely in the OR when on-call (I've logged about 30+ cases in the last 3 weeks), which makes it very difficult to manage the floors, the ICU, and the ED between only myself and my senior resident. But somehow, we get it done.

 

[JackADeli]

...the possibility of shaping the program into one that is more performance based, including more stringent metrics of competence that must be met within a set time line...

It has taken fears of efficient use of markedly limitated available time to force PDs to actually consider efficiency in teaching as opposed to the brute force endurance approach of old. Sadly, should have been on-going for years to both assure quality standards in graduating residents AND in teaching attending staff.

 

[treehorsio]

Our PD met with us last week. We already have a NF at the big house, but not at the VA and the community hosp, so he thinks we will have to institute that. That will be tough.

Part of the problem is that many studies have shown that increased # of hand offs are where patient safety issues rise...so now instead of sat/sun coverage being 24/12 for the interns, it will be 16/16/16. Adding another hand off is only going to compound the problem.

What I will say is, yes, NF sucks just due to pure volume of patients and the crappiness of living like a vampire, but even as an intern I scrubbed at least a few times every week and saw some awesome trauma cases. In fact, there is a bizarre form of continuity of care, too...you cover 85-100 gen surg patients for the month, but it's often the same patients night after night. You quickly get to know the trouble ones. So sign out is easier as the month progresses. AND you are guaranteed sleep every night. and that does help patient safety. If it's 2 am (equivalent of 2 PM when on nights), I'm a lot more likely to leave the call room and go see Mr. X who's having CP/SOB/diarrhea/hallucinations with the intern (or, shocker, even TEACH the students/interns) if am not trying to eke in a few hours of sleep before a big case the next day.

 

[opr8n]

other ideas being floated ...

intern home call for the VA?? (or other places that can be slow at night)
gets around the rule of being in house
but then the ER docs will be forced to drain abscess instead of just call the surg resident

only problem is the rules regarding having inhouse surgical coverage will have to change

 

[opr8n]

im still not sure what makes a PGY2 so much more capable of taking call compared to an intern, gotta learn sometime

i guess its a good thing that the rules didnt require in house backup for the interns, that would be difficult to impossible at some places

 

[JackADeli]

im still not sure what makes a PGY2 so much more capable of taking call compared to an intern...

I think it is a "catch 22". When I was in genersal surgery residency, we were aware that by the end of our intern year, we had as much clinical experience or more then most ER/IM/FP residency grads (at our hospital). We did not have any sort of "cap" on number of patients we could see/admit/consult on/etc... This is why in the past the distance between intern & PGY2 competency was impressive.

However, with additional work hour restrictions (without any improved/modernized teaching), it is likely the marked difference will vanish. That is, a resident that does 50-60 hours/wk clinical will see less disease, less patients, less procedures, etc then residents in the past that saw 80+ clinical hours/wk.

I am not harkening back to PDs and "old school" attendings that just can not move into the modern world. The truth is that 100-120hrs/wk were often filled with wasted time and education inhibiting exhaustion. There needs to be a middle ground in which fatigue/exhaustion is seriously considered while at the same time MODERN education techniques are used to optimize adult learning with real metrics as to quality.

 

[sinombre]

I thought about posting a new thread about the reporting of duty hours by residents, and then I found this thread from 2010. I figured this would be an appropriate thread to bump (it's interesting reading the opinions of everyone when this all went into effect).

After the first month of intern year, taking q3 call (on acs/trauma), I'm kind of split on the idea of the 80-hour work week. The only possible way to get under 80 hours is to leave in the middle of the day on the non-call days (so every other shift), which sounds great in theory. But in reality, doing this would mean dumping my own work on someone else who already has their own work to do. I really dislike the idea of doing that unless absolutely necessary, and as a result I've worked between 90 and 100 hours each week--which is less exhausting than I thought it would be as a med student, and probably better than the alternative of dumping my work on whoever is on call.

So now I'm left with the dilemma of whether or not to report my hours accurately. It seems like reporting accurately would do nothing but hurt my program, which I'm really not interested in doing (my program is great, and I'm really happy to be where I am). At the same time, I feel like having some amount of oversight is probably a good thing... and having standards/regulations are useless unless people actually follow them.

Maybe the 80 hour rule should be amended or relaxed? I'm really not sure. I'm interested in hearing feedback from those of you with more than 4 weeks of experience. @ThoracicGuy @dpmd @MediCane2006 @Winged Scapula @SouthernSurgeon

 

[vhawk]

Without knowing the specifics of your program, in 2017 no program should have difficulty coming up with solutions that prevent residents from ROUTINELY violating 80hr/week, if they are so inclined. I guess it's conceivable there are exceptions but this isn't 15 years ago, the methods and scheduling practices are all out there, it's not believable your program has hurdles so unique they cannot be overcome. So with that in mind I would conclude that any program that ROUTINELY has residents violating 80hr/week is basically doing so intentionally.

The word ROUTINELY is important though. Setting policies such that residents NEVER violate is much different (and really stupid and wasteful imo) than setting policies such that they don't routinely violate. By routinely I mean more weeks than not for more than 2 months in a row. Having a month long rotation that for whatever reasons(logistical, educational, etc) requires 90 hrs/week or that is "hit or miss" but happens to hit for a couple weeks in a row is very different.

You should report your hours honestly in general and you should be aware of exactly what parts of your time are required to be logged and what counts as a violation. Lots of things you think are a violation aren't and many violations can be excused if they are explained. But you should also be an adult about things and take responsibility for your own education. This means getting as much out of your training as you can but also not passing the costs of that off to your program and fellow residents by unnecessary violations. How you resolve that apparent conflict is up to you and can be considered a first test of your professionalism and general adulthood.

 

[dpmd]

Agree completely. I logged my hours very honestly at first, then once I realized that I was routinely in compliance even though that one month on neurosurg put me way over I got a little lax in logging so would guess weeks later how the days had gone (terrible, I know but one less task to do daily was nice). Then again I was the kind of person who when offered the chance to go home after rounds post call would take that (then again I had the advantage of my years as a nurse so was pretty efficient in getting my work done) unlike my co resident who would stick around in the hopes of doing more cases. I don't know how she logged but certainly if you are staying after you have been told you could leave that would be a bad reason to get your program in trouble if that makes you violate hours repeatedly. Staying until your work is done when no one says to leave is a different story but that should improve as you get better and faster.

 

[vhawk]

Right. I had many times where I was "told to go home" and I exercised my judgment in those situations and sometimes I did go home (super tired, cases routine) and sometimes I didn't (had an easy night, whipple) but those were choices I made and it would be asinine to consider that in the spirit of work hour violations. I can very comfortably say that in general my program was very compliant with work hours and the majority of times I may have technically violated were of my own volition and "against medical advice" but since I'm not a child and was being trained to exercise my judgment to make decisions involving human lives....well let's just say I don't sit at red lights on empty streets at 2 am either.