Longer Shifts for First-Year Residents to Start in July

[ProfMD]

General question here, just curious. Not trying to protest the system because its obviously worked well, but as a soon to be med student, just want to know the reasoning behind why there are such long shifts for residents? What is it trying to achieve? Pros/cons?

Lots of stuff to learn.
Lots of work to be done.

Med school is prep work. Residency is where you really learn how to be a doctor.

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[VA Hopeful Dr]

Lol everyone finished says it's great (doesn't affect them) and everyone who it will affect says it's ****e.

K /thread.

Or maybe it's worth listening to the handful of us who were interns under both systems because maybe, just maybe, we might have some insight into the issue.

 

[Spectre of Ockham]

Or maybe some attendings really do suffer from the "no fast track for you" type of mentality. You know since change is hard and nasty especially when you have to plan your life by the minute ?

Lets get some things straight , going from 16 to 24 is terrible idea . First of all it completely halts the progress of moving on to a 12 hour shift and a small reduction of mandatory weekly work hours - you know because seeing medical personnel jump out the window is simply horrific - the data here is ironclad and there is not a shred of a solution in sight.
No one is going to dump patients on the next shift and no one will walk away from a surgery like some probably imagine. Just like surgeons having family time will not wreck medicine.

 

[ProfMD]

Or maybe some attendings really do suffer from the "no fast track for you" type of mentality. You know since change is hard and nasty especially when you have to plan your life by the minute ?

Lets get some things straight , going from 16 to 24 is terrible idea . First of all it completely halts the progress of moving on to a 12 hour shift and a small reduction of mandatory weekly work hours - you know because seeing medical personnel jump out the window is simply horrific - the data here is ironclad and there is not a shred of a solution in sight.
No one is going to dump patients on the next shift and no one will walk away from a surgery like some probably imagine. Just like surgeons having family time will not wreck medicine.

Goal of 12 hour shifts? Whose goal is that?

And the shift work mentality is a serious concern to those of us who have been around for these changes. We already see the negative effects. Do you have any idea how often we hear "I am post-call" or "my shift is over?" Do you have any idea how many times my team gets consults from people who have no idea what is going on with a patient? They are call because they "got in sign out" that they were supposed to.

And, physician suicide is a terrible and complicated issue. It has to do with a myriad of factors including the type of person who goes in to medicine and the stress of being responsible for other people's lives. If you have evidence that work hours play a role, please share - I am not aware of any.

 

[VA Hopeful Dr]

Or maybe some attendings really do suffer from the "no fast track for you" type of mentality. You know since change is hard and nasty especially when you have to plan your life by the minute ?

Lets get some things straight , going from 16 to 24 is terrible idea . First of all it completely halts the progress of moving on to a 12 hour shift and a small reduction of mandatory weekly work hours - you know because seeing medical personnel jump out the window is simply horrific - the data here is ironclad and there is not a shred of a solution in sight.
No one is going to dump patients on the next shift and no one will walk away from a surgery like some probably imagine. Just like surgeons having family time will not wreck medicine.

Actually, shift work does directly lead to dumping patients on the next shift. Anyone who has ever done shift I'm working medicine will test this.

Also have no idea what you're talking about with mandatory reductions and hours or 12 hour days, as no one is suggesting anything like that for residency training or most practicing Physicians now that I think on it.

 

[Spectre of Ockham]

The eternal dumping of train wrecks is a long standing problem. Anyone that has done more than a few hundred hours in the ER has witnessed the patient consulted by 9+ specialties and begrudgingly admitted only after a department chief intervened.

As for the imbeciles that vanish without properly transferring the cases they should be forced to do 1001 rectal exams or simply have a public penalty administered to them. However this is pure administrative chaos and irresponsibility not a work hour problem. You also need to add the entire EHR debacle that is not making anyone's life easier. Maybe in the US you are forced to have more than 20 plus patients per doctor but it still shouldn't take more than a few minutes to properly hand off the patients. I can see the ICU facing problems with patient hand off but the ICU is a whole different world to me and I believe that with some decent staffing levels such a problem should be manageable.

I know the bitterness of watching a patient code because the specialist never came in time . Seeing that day after day after day would make me as well yell "FRAK YOUR WORK HOURS YOU'RE MAKING A MOCKERY OUT OF MY WORK AND KILLING MY PATIENTS" but what we lack is decent staffing and maybe some decent union / administration balance. However AFAIK the US lacks a nation wide doctor union that can strike and make administrators come to the negotiation table.

@ProfMD At a quick glance :
#1 Too much work = more burnout Burnout and Internal Medicine Resident Work-Hour Restrictions
#2 More burnout = more corpses of colleagues Burnout, hopelessness and suicide risk in medical doctors. - PubMed - NCBI

 

[ProfMD]

The eternal dumping of train wrecks is a long standing problem. Anyone that has done more than a few hundred hours in the ER has witnessed the patient consulted by 9+ specialties and begrudgingly admitted only after a department chief intervened.

As for the imbeciles that vanish without properly transferring the cases they should be forced to do 1001 rectal exams or simply have a public penalty administered to them. However this is pure administrative chaos and irresponsibility not a work hour problem. You also need to add the entire EHR debacle that is not making anyone's life easier. Maybe in the US you are forced to have more than 20 plus patients per doctor but it still shouldn't take more than a few minutes to properly hand off the patients. I can see the ICU facing problems with patient hand off but the ICU is a whole different world to me and I believe that with some decent staffing levels such a problem should be manageable.

I know the bitterness of watching a patient code because the specialist never came in time . Seeing that day after day after day would make me as well yell "FRAK YOUR WORK HOURS YOU'RE MAKING A MOCKERY OUT OF MY WORK AND KILLING MY PATIENTS" but what we lack is decent staffing and maybe some decent union / administration balance. However AFAIK the US lacks a nation wide doctor union that can strike and make administrators come to the negotiation table.

@ProfMD At a quick glance :
#1 Too much work = more burnout Burnout and Internal Medicine Resident Work-Hour Restrictions
#2 More burnout = more corpses of colleagues Burnout, hopelessness and suicide risk in medical doctors. - PubMed - NCBI

Your second article is irrelevant. That was not about residents. Burnout is a potential problem over a person's entire career and has nothing to do with 16 vs 24 hour shifts as an intern.

Your first article was more relevant but still doesn't make your point. It basically says that the 2003 rules are good because they reduced burnout. No one is arguing for repealing the 2003 rules. We all think they are good.

You can certainly argue that because the 2003 rules are good, that the 2011 rules are better, but this has not born itself out in the literature.

And your argument that bad handoffs and shift work mentality should not happen does not change the fact that it does happen. And the phenomenon is worse with work hour restrictions.

With regards to "20 patients per physician" - I don't think this happens, especially not for interns whom this rule change affects. Also, how do you improve patient to doctor ratio by reducing physicians on each shift (which is what work hour restrictions does)?

Finally, I'm not sure about your "EHR debacle" comment. EHR is here to stay.

 

[WingedOx]

Lots of stuff to learn.
Lots of work to be done.
.

With regard to the bolded, I'm not exactly seeing a lot of alternative suggestions as to how nights should be covered in the hospital from the hard core complainers here.

 

[High Roller]

I support shift length restrictions for interns. I have my own personal and philosophical reasons that are too numerous to share.

But beyond that, this is kind of a poor PR move by the ACGME. We're asking our sleep deprived trainees to make critical decisions about people's lives in the middle of the night. Its 2017, and the public isn't going to understand or be accepting of this. There will be another Libby Zion around the corner. So we had better get more efficient at dealing with work hour restrictions because they'll eventually be back. I think some of us attendings need to stop burying our heads in the sand regarding public perception of this issue. It matters.

I do agree this is a minor issue in the big picture. Being a physician is a wonderful career, but throughout residency and beyond, you will be tested and forced to make big sacrifices that negatively affect your health and well being. There's no way around it. If you want to do this, don't let working 24 hours shifts as an intern scare you. Its just a match on a fire.

 

[VA Hopeful Dr]

I support shift length restrictions for interns. I have my own personal and philosophical reasons that are too numerous to share.

But beyond that, this is kind of a poor PR move by the ACGME. We're asking our sleep deprived trainees to make critical decisions about people's lives in the middle of the night. Its 2017, and the public isn't going to understand or be accepting of this. There will be another Libby Zion around the corner. So we had better get more efficient at dealing with work hour restrictions because they'll eventually be back. I think some of us attendings need to stop burying our heads in the sand regarding public perception of this issue. It matters.

I do agree this is a minor issue in the big picture. Being a physician is a wonderful career, but throughout residency and beyond, you will be tested and forced to make big sacrifices that negatively affect your health and well being. There's no way around it. If you want to do this, don't let working 24 hours shifts as an intern scare you. Its just a match on a fire.

Jesus tapdancing Christ, the new rule does not require interns to work 24 hour shifts. It just allows it.

There were programs before 2011 that had night float systems. They are not going to change. This rule doesn't affect them.

There are plenty of programs that have night float because of the 2011 rule who will not be changing back given how much of a pain it is to completely alter the schedule.

 

[High Roller]

Jesus tapdancing Christ, the new rule does not require interns to work 24 hour shifts. It just allows it.

There were programs before 2011 that had night float systems. They are not going to change. This rule doesn't affect them.

There are plenty of programs that have night float because of the 2011 rule who will not be changing back given how much of a pain it is to completely alter the schedule.

Oh I understand, and I don't agree with it. I support work hour restrictions for interns, as in, no program should be allowed to have its interns working greater than a 16 hour shift.

Mind you, I'm not that worked up over this issue. We as a profession and the ACGME have way bigger fish to fry. But I absolutely support certain work hour restrictions during that year. I think its a mistake to allow any program to 'go back'. I also fully realize and respect that I'm in the minority with most of my colleagues.

 

[F1rstGen]

Didn't read all the prior posts so I apologize if this has been mentioned before but to those saying that 24hr shifts are > than 16hr night float, is it possible that there is a better alternative and these aren't our only two possibile realities?

This issue is being discussed like it's either/or but it seems to me like we are arguing over the lesser of two evils when the possibility of a much better solution exists.

Some have mentioned that cutting hours would require training length extensions but there should be some way to make our training hours more efficient.

 

[VA Hopeful Dr]

Didn't read all the prior posts so I apologize if this has been mentioned before but to those saying that 24hr shifts are > than 16hr night float, is it possible that there is a better alternative and these aren't our only two possibile realities?

This issue is being discussed like it's either/or but it seems to me like we are arguing over the lesser of two evils when the possibility of a much better solution exists.

Some have mentioned that cutting hours would require training length extensions but there should be some way to make our training hours more efficient.

Propose it then.

In residency, I don't remember thinking that I was wasting time very often. If I wasn't seeing patients, discussing patients with my seniors/attendings, or doing other tasks related to patient care (notes, discharges, family meetings, consults) then I was either eating, sleeping, or at home.

 

[mimelim]

Didn't read all the prior posts so I apologize if this has been mentioned before but to those saying that 24hr shifts are > than 16hr night float, is it possible that there is a better alternative and these aren't our only two possibile realities?

This issue is being discussed like it's either/or but it seems to me like we are arguing over the lesser of two evils when the possibility of a much better solution exists.

Some have mentioned that cutting hours would require training length extensions but there should be some way to make our training hours more efficient.

Propose it then.

In residency, I don't remember thinking that I was wasting time very often. If I wasn't seeing patients, discussing patients with my seniors/attendings, or doing other tasks related to patient care (notes, discharges, family meetings, consults) then I was either eating, sleeping, or at home.

My residency gave me unilateral authority (or I took it, still not too sure) to make our coverage system. I have explored every single possible system within the ACGME and our GME rules. I came up with 3 different call systems, which I presented to the other residents who unanimously agreed upon after some short discussion at our town hall meeting. I won't go into the details and struggles of coverage at our hospital because they are multi-faceted and would be somewhat identifying, but here are the big points:

#1 People like regularity. a) This is mainly because it is easy to keep things fair and make it easy to keep track of everyone. b) It makes schedule building easier. Not everyone likes this administrative stuff (I'm apparently weird because I do) and it can be very time consuming if you can't make something standardized. Thus, things have to revolve around 8, 12 or 24 hour coverage. Now, obviously the actual time in the hospital is higher because of hand-offs and stuff happening right at sign-out.

#2 Every program can be more efficient. Every firm can be more efficient. This is why firms pay oodles of money to consultants who do nothing but find ways to make things more cost effective. Residency is no different, however, departments are typically already cash light and don't exactly attract the types of minds that are willing to get creative, break everything down and start from scratch, even if that is what is necessary. I'll give an example... What time should sign-outs be if you are based around a 12 hour day with night float? Options: 4am/pm, 5am/pm, 6am/pm, 7am/pm. The answer of course is that there is no one size fits all and if you don't spend time thinking about it, you will only be guessing. For us, it changed by an hour. If I were our IM program, I would change it by 2 hours (but that is their problem). Variables: when the ORs actually start going, our average census, when labs get back in the morning, etc.

 

[WingedOx]

Propose it then.

In residency, I don't remember thinking that I was wasting time very often. If I wasn't seeing patients, discussing patients with my seniors/attendings, or doing other tasks related to patient care (notes, discharges, family meetings, consults) then I was either eating, sleeping, or at home.

Plus, most of what's discussed is about nights, which are going to be variable in what you see. You can't really control the amount of responsibilities that are going to come in. I had nights where I didn't have a single moment to sit down and document the crazy stuff that happened until my shift was over in the mornings, and I had nights where I played a complete game of "Zelda: Link's Awakening" in a single sitting in the call room.

 

[mvenus929]

1 year extra, alone would be 33% more training time. If you cut hours 20%, say from 80 --> 60 (I'm aware the averages are more complex than this), you'd actually come out ahead. Under this "reduced hours extended training," it would result in a total of more experience and uninterrupted sleep. If you cut paperwork with tort reform or something, it could be even better educationally.

My program has an average weekly hour load of about 65 hours. There are weeks and months that absolutely suck, and there are weeks and months that are much better. I had a particularly bad month in February, which was partly my own doing because I needed to collect data for my research, which I can only do during working hours, and I was mostly working evening/night shifts during the month. This month is substantially better overall. The IM residents at our institution work less hours than we do. I can't imagine an IM program that is working 80 hours per week consistently throughout residency. Maybe a week or two here or there. But not for extended periods of time.

Cutting hours and extending training wouldn't benefit me much. I already feel like a perpetual resident because I'm going from residency to being chief resident to being a fellow (and we could get into a huge discussion about fellowships in peds, but that's a whole other can of worms)... if I had to do an extra year or two, I don't think I would really learn more.

 

[Crayola227]

Prove it, with sources please

True true, Dr. Bagel, about those long call days.
And I have this great quote from a physician about this idea of getting a "tolerance" for sleep deprivation

Not my words, I'm sorry I saved this verbati, but not plagiarism as I do not claim them as my words:, re: similarities between alcohol intoxication, sleep deprivation and perception of performance:
"How it works in medicine is a matter for research, but how it works in other fields is similar to how it works with habitual alcohol abuse: as you acquire experience at performing while impaired (e.g. driving drunk) you build a baseline of “normal” which includes your impaired behavior as perceived by your impaired judgment. Since the ability to recognize poor performance is degraded before the ability to actually perform, especially for tasks for which you have trained extensively, your self-perceived performance may actually improve. Thus the common opinion that “I actually drive better after a few drinks.”"

I re-found the great quote I wanted to share with you about working while impaired. I still need to find the research that supports this person's point, but I was glad to find it since it was my jumping off place.

I know I was closer to some of the data about how alcohol affects performance when I came across this quote which is why it resonated with me, plus I was on nightfloat at the time.

Again, it's not hard data which I will try to get. However, this point stuck with me because personally I'll share that not only did I question how well I was learning while fatigued (which we all agree is somewhat impaired), I also questioned if I could really "learn" how to work while fatigued, and if I was learning, what was I learning exactly?

In any case, the only point I really argue is this idea that one gets a "tolerance" for sleep deprivation.

 

[LucidSplash]

I re-found the great quote I wanted to share with you about working while impaired. I still need to find the research that supports this person's point, but I was glad to find it since it was my jumping off place.

I know I was closer to some of the data about how alcohol affects performance when I came across this quote which is why it resonated with me, plus I was on nightfloat at the time.

Again, it's not hard data which I will try to get. However, this point stuck with me because personally I'll share that not only did I question how well I was learning while fatigued (which we all agree is somewhat impaired), I also questioned if I could really "learn" how to work while fatigued, and if I was learning, what was I learning exactly?

In any case, the only point I really argue is this idea that one gets a "tolerance" for sleep deprivation.

If hard data in support of your position was so overwhelmingly prevalent so as to tip the scales of logic in your favor, it wouldn't be that difficult to find.

 

[Crayola227]

If hard data in support of your position was so overwhelmingly prevalent so as to tip the scales of logic in your favor, it wouldn't be that difficult to find.

Actually, given how specific my question is, and how broad the field of inquiry is, getting the exact answer I seek is going to take more than the hour I've already put into it, but if you think you can do better, rather than your little snark which added nothing, why don't you find some data regarding the point made in that quote?

I'm sharing what I find as I go.

 

[VA Hopeful Dr]

Actually, given how specific my question is, and how broad the field of inquiry is, getting the exact answer I seek is going to take more than the hour I've already put into it, but if you think you can do better, rather than your little snark which added nothing, why don't you find some data regarding the point made in that quote?

I'm sharing what I find as I go.

Because we're for the status quo. We have a system that trains good doctors. If you want to change the system, it's up to you to prove why that's needed.

 

[Crayola227]

Because we're for the status quo. We have a system that trains good doctors. If you want to change the system, it's up to you to prove why that's needed.

I already linked plenty of data that suggests fatigue is a problem

um, actually given that we already established that the evidence behind the status quo still suggests that 24 hour shifts are not optimal for a range of physiological reasons, THAT we can probably just reference our medical degrees for,

I think that both sides are responsible for trying to support what they are putting forth.

I think your status quo argument is frankly more lazy than trying to support your opinion with reasoning, even if that is all you did.

I shared a quote of someone else's reasoned thoughts, and suggested that I would try to find more research on the topic. To my knowledge, SDN allows the expression of opinions without citation.

But I'll get some for you, duly noted.

 

[ProfMD]

I already linked plenty of data that suggests fatigue is a problem

um, actually given that we already established that the evidence behind the status quo still suggests that 24 hour shifts are not optimal for a range of physiological reasons, THAT we can probably just reference our medical degrees for,

I think that both sides are responsible for trying to support what they are putting forth.

I think your status quo argument is frankly more lazy than trying to support your opinion with reasoning, even if that is all you did.

I shared a quote of someone else's reasoned thoughts, and suggested that I would try to find more research on the topic. To my knowledge, SDN allows the expression of opinions without citation.

But I'll get some for you, duly noted.

In this case, there were good theoretical reasons to further limit work hours, including the studies that you have alluded to.

These theories led to a change in practice (the 16 hour rule) which led to no improvement in patient safety and a decrement in quality of training.

Hypothesis proposed and tested. Null hypothesis was not rejected. Back to the drawing board.

 

[VA Hopeful Dr]

I already linked plenty of data that suggests fatigue is a problem

um, actually given that we already established that the evidence behind the status quo still suggests that 24 hour shifts are not optimal for a range of physiological reasons, THAT we can probably just reference our medical degrees for,

I think that both sides are responsible for trying to support what they are putting forth.

I think your status quo argument is frankly more lazy than trying to support your opinion with reasoning, even if that is all you did.

I shared a quote of someone else's reasoned thoughts, and suggested that I would try to find more research on the topic. To my knowledge, SDN allows the expression of opinions without citation.

But I'll get some for you, duly noted.

Fatigue = bad, that's true. Fatigue = worse medical outcomes, that's not yet been proven.

 

[WingedOx]

Fatigue = bad, that's true. Fatigue = worse medical outcomes, that's not yet been proven.

Also re: 24 hour shifts vs night floats and more short weekend shifts = fatigue? I'm iffy on this too, especially in the resident well-being department.

As I said upthread, I've seen a resident have a manic episode in my own program. It was during night float. n= 1. anecdote = data, blah blah blah.

 

[VA Hopeful Dr]

Also re: 24 hour shifts vs night floats and more short weekend shifts = fatigue? I'm iffy on this too, especially in the resident well-being department.

As I said upthread, I've seen a resident have a manic episode in my own program. It was during night float. n= 1. anecdote = data, blah blah blah.

I was an intern under both systems and while 24 hour shifts did, and do, suck overall I felt better. Seriously, the impact of a Golden Weekend is huge.

 

[Urzuz]

I have no clue how I stumbled upon this thread, but having read only the last couple comments, this is all I will say (sorry if it has been said earlier): after you grow up and get out of residency, your partners won't give a $!%# that you worked all night. You suck it up and you keep going. Even beyond the ocean of clinical knowledge you have to acquire as a resident, you HAVE to be able to work and function for long periods of time with little or to no sleep as an attending. It is part of the job.

You can easily say that I chose my field and practice setting so I have no right to complain about it, but my response would be that you choose your training program as a resident as well. If you don't like 24 hour shifts, find a community program in the middle of wherever that caters to your needs.

 

[LucidSplash]

Actually, given how specific my question is, and how broad the field of inquiry is, getting the exact answer I seek is going to take more than the hour I've already put into it, but if you think you can do better, rather than your little snark which added nothing, why don't you find some data regarding the point made in that quote?

I'm sharing what I find as I go.

My point was that the data you seek does not exist. And personally I think my snark was very timely.

 

[SunsFun]

Fatigue = bad, that's true. Fatigue = worse medical outcomes, that's not yet been proven.

My issue is more with residency setup being a selection mechanism for a certain type of candidate that may not be ideal. While in theory we all want to end up with hardworking doctors willing to work day and night for the benefit of the patients, having only people like that in medicine could be a reason the whole system is so damn inefficient.

I have zero proof for this as a everything I am writing here is a theory, but people who are willing to relinquish control over their lives for extended period of time while completing menial tasks that are often hard to directly relate to patient outcomes will less likely be the the people to actively seek better models of healthcare delivery or training after the residency.


Sent from my iPhone using SDN mobile app

 

[VA Hopeful Dr]

My issue is more with residency setup being a selection mechanism for a certain type of candidate that may not be ideal. While in theory we all want to end up with hardworking doctors willing to work day and night for the benefit of the patients, having only people like that in medicine could be a reason the whole system is so damn inefficient.

I have zero proof for this as a everything I am writing here is a theory, but people who are willing to relinquish control over their lives for extended period of time while completing menial tasks that are often hard to directly relate to patient outcomes will less likely be the the people to actively seek better models of healthcare delivery or training after the residency.


Sent from my iPhone using SDN mobile app

As both a guy excited that interns now have the option to do 24 hour call again AND a guy actively promoting a better model of health care delivery, I think you're right but for the wrong reasons.

Most doctors after residency want to just do their job, get paid well for it, and go home. Most fields, in fact, are like this - lawyer, plumber, teacher, whatever. Innovation requires risk and that's the one thing I think med school does select against quite well. You also have heavy regulations involved in medicine that don't exist in many other fields - hence why PP in general, and solo practice in particular, is dying.

 

[WingedOx]

I was an intern under both systems and while 24 hour shifts did, and do, suck overall I felt better. Seriously, the impact of a Golden Weekend is huge.

Yeah, I started residency just as the rule went into effect. As a med student I thought it was a great idea. In practice, it didn't really make a difference.

 

[Crayola227]

Also re: 24 hour shifts vs night floats and more short weekend shifts = fatigue? I'm iffy on this too, especially in the resident well-being department.

As I said upthread, I've seen a resident have a manic episode in my own program. It was during night float. n= 1. anecdote = data, blah blah blah.

I'm a little confused and just trying to put into perspective. Are you citing the resident with the manic episode on night float as a cautionary tale for or against 24 hr shifts? Or against having a dedicated nightblock? How was night float arranged at your program?

My program nightfloat was 1 month blocks, you could have 1-2 in a year.
Seniors on wards months would do 1 call shift a week. (3-4 months a year)

There was another program I interviewed that was proud to guarantee no overnight shift, ever. Everyone was guaranteed 16 hours or less, even the seniors. They had a robust nightfloat system and did warn that you would bust your ass for your 1 month a year on nights, but that it made everything more humane the rest of the year. They still had a good amount of golden weekends and they weren't pushing work hours or the 16 hours promise. (sounds too good to be true? nightfloat sounded pretty intimidating).

Another program did away with nights completely, but they were experimental and mostly primary care oriented. Lots of golden weekends. They were a hospital system with a newer residency program, so they were already built to not have residents work nights. When they built the program in, they built it for the residents to just be days. I don't think there's education value to a 24 hr shift you can't get by working days and nights, but I think there's value to nights, so I'll admit I had mixed feelings on this. As far as having ownership of your patients at night, they did have them in the hands of the program's teaching attendings and not just the private attendings.

I already shared that my friend at a different program where they do like 3 or 4 weeks on days, then do 1 week same service but on nights. Rinse repeat. That sounds like circadian hell to me.

I don't know the outcomes, just sharing that there's different structures out there.

 

[WingedOx]

I'm a little confused and just trying to put into perspective. Are you citing the resident with the manic episode on night float as a cautionary tale for or against 24 hr shifts? Or against having a dedicated nightblock? How was night float arranged at your program?

I'm saying 24 hour call or no 24 hour call, there's really no great way to cover nights that doesn't act as a stressor on the mental health of residents. Now to be fair this resident had a history of abysmal self-care, which didn't help things. (it also occurred only a couple weeks before I took over as chief resident so that god it wasn't something I had to deal with).

My program nightfloat was 1 month blocks, you could have 1-2 in a year.
Seniors on wards months would do 1 call shift a week. (3-4 months a year)

There was another program I interviewed that was proud to guarantee no overnight shift, ever. Everyone was guaranteed 16 hours or less, even the seniors. They had a robust nightfloat system and did warn that you would bust your ass for your 1 month a year on nights, but that it made everything more humane the rest of the year. They still had a good amount of golden weekends and they weren't pushing work hours or the 16 hours promise. (sounds too good to be true? nightfloat sounded pretty intimidating).

Another program did away with nights completely, but they were experimental and mostly primary care oriented. Lots of golden weekends. They were a hospital system with a newer residency program, so they were already built to not have residents work nights. When they built the program in, they built it for the residents to just be days. I don't think there's education value to a 24 hr shift you can't get by working days and nights, but I think there's value to nights, so I'll admit I had mixed feelings on this. As far as having ownership of your patients at night, they did have them in the hands of the program's teaching attendings and not just the private attendings.

I already shared that my friend at a different program where they do like 3 or 4 weeks on days, then do 1 week same service but on nights. Rinse repeat. That sounds like circadian hell to me.

I don't know the outcomes, just sharing that there's different structures out there.

Before the 16 hour rule went live, we'd just have residents on call stay the night then take a post-call day. The frequency of calls were variable, but interns carried the most and I think interns averaged a night of call per week IIRC. After the rule, we went to a night float system. 2 weeks at a time x2 for interns and PG2 and one week a year for PG3s. NF was Sunday thru Thursday night and Fridays coverage was a PG2 or 3 resident working a 24hr. Sat and Sun were 12 hour shifts.

Ownership of patient didn't really matter since call had more to do with ED and crisis line coverage as well as administrative stuff like managing patient transfers. Plus, where you took call didn't have any relation to what rotation you were on.

We occasionally had residents who wanted to get as many night calls out the way as they could at once and would grab a Friday and Saturday night shift in between their two weeks of night float but I had to temporarily stop allowing them to do that once I took over the call schedule as chief... because of said resident.

 

[SurfingDoctor]

I just had a 28 hours of straight clinical work where I sat by a 5 year olds room all night on an oscillator to prevent them from arresting till someone could come in a do a bronch (or they crashed onto ECMO... which they came close, they were draped but fortunately they didn't go on). Also had 6 other admissions, who thankfully were only marginally ill. Then I took a shower, 2 hour nap and had meetings for the rest of the day till 4 pm. This is all after being Q2 for the past +2 weeks. I'm not complaining in any regard, but perspective in this conversation is very helpful.

 

[Crayola227]

I just had a 28 hours of straight clinical work where I sat by a 5 year olds room all night on an oscillator to prevent them from arresting till someone could come in a do a bronch (or they crashed onto ECMO... which they came close, they were draped but fortunately they didn't go on). Also had 6 other admissions, who thankfully were only marginally ill. Then I took a shower, 2 hour nap and had meetings for the rest of the day till 4 pm. This is all after being Q2 for the past +2 weeks. I'm not complaining in any regard, but perspective in this conversation is very helpful.

what's the point? that sounds like a disaster. That's the perspective I get from this story.

I don't hear that and think "Oh goodie, take the whip to those residents!"

I think we need to control healthcare costs (tort reform?) or something so that we can train enough physicians that attending don't have to work those sorts of hours either. There's literally no shortage of qualified candidates if MD/DO admission offices are to be believed. (yes, I know that as we expand MD/DO enrollment we need to expand Medicare dollars for resident training slots) (and I don't suggest we cram in more NPs and PAs unless it's totally appropriate to the degree of their training and supervision).

I don't suggest we completely eliminate overnights, 24 hours shifts can make a lot of sense to me for continuity of care in many instances. q2 for two weeks OTOH? Tell me that was essential for patient care EVEN IF you had another body just as qualified as you available, and I'll just have to shrug and say, what the patient must have given to them, they must have.

Otherwise, you're just making my point that our current healthcare system is totally ridiculous.

Also in another thread in the psych forum that I can link, finally someone had some evidence that the ability to judge impaired performance goes down when one is fatigued. Also one doesn't get "better" at fatigue over time by being fatigued, this thread has a citation from me that chronic fatigue doesn't work that way. The deficit takes longer to correct than a Golden Weekend or post-call day, as well.

I'm not again against hard work, long shifts, patient ownership, and I'm not a snowflake. I do think we need to train more physicians, address costs in a sensical manner, and work to increase the amount of rest and work/life balance all physicians need available to them as human beings so they can stay healthier, have less burnout (premature exit or early retirement of docs mostly due to burnout is a real issue), and to provide patients with less burnt out more well rested docs who can spend more time with them.

My med school had us read evidence that showed in a number of fields more patient-physician facetime in a variety of settings leads to better outcomes. I doubt that the sort of schedules we're discussing leads to more facetime with patients. If anything, I see it as evidence of the "crunch," to get more throughput by a physician for financial reasons.

I want more docs working at a slower pace. In a lot of fields this could be achieved with more docs to carry the load. There could be strategies to ensure residents still get enough case exposure.

 

[SurfingDoctor]

what's the point? that sounds like a disaster. That's the perspective I get from this story.

I don't hear that and think "Oh goodie, take the whip to those residents!"

I think we need to control healthcare costs (tort reform?) or something so that we can train enough physicians that attending don't have to work those sorts of hours either. There's literally no shortage of qualified candidates if MD/DO admission offices are to be believed. (yes, I know that as we expand MD/DO enrollment we need to expand Medicare dollars for resident training slots) (and I don't suggest we cram in more NPs and PAs unless it's totally appropriate to the degree of their training and supervision).

I don't suggest we completely eliminate overnights, 24 hours shifts can make a lot of sense to me for continuity of care in many instances. q2 for two weeks OTOH? Tell me that was essential for patient care EVEN IF you had another body just as qualified as you available, and I'll just have to shrug and say, what the patient must have given to them, they must have.

Otherwise, you're just making my point that our current healthcare system is totally ridiculous.

Also in another thread in the psych forum that I can link, finally someone had some evidence that the ability to judge impaired performance goes down when one is fatigued. Also one doesn't get "better" at fatigue over time by being fatigued, this thread has a citation from me that chronic fatigue doesn't work that way. The deficit takes longer to correct than a Golden Weekend or post-call day, as well.

I'm not again against hard work, long shifts, patient ownership, and I'm not a snowflake. I do think we need to train more physicians, address costs in a sensical manner, and work to increase the amount of rest and work/life balance all physicians need available to them as human beings so they can stay healthier, have less burnout (premature exit or early retirement of docs mostly due to burnout is a real issue), and to provide patients with less burnt out more well rested docs who can spend more time with them.

My med school had us read evidence that showed in a number of fields more patient-physician facetime in a variety of settings leads to better outcomes. I doubt that the sort of schedules we're discussing leads to more facetime with patients. If anything, I see it as evidence of the "crunch," to get more throughput by a physician for financial reasons.

I want more docs working at a slower pace. In a lot of fields this could be achieved with more docs to carry the load. There could be strategies to ensure residents still get enough case exposure.

Well, I think the answer to a lot of what you said boils down to 1 thing: money. From a hospital standpoint, which is cheaper, paying 1 salaried physician to work one 24 hour shift or paying 2 salaried physicians to each work one 12 hour shift in sequence. While there may be personnel who can do the job, all other things being equal, there may not be money to hire that personnel. Especially for children's hospitals in the era of decreasing Medicaid reimbursement, the system makes you do more with less. Of course, that is not the best scenario and it could/should be better, but its not just as easy as saying you want more financial support. Maybe that will happen, but the trend has not favorable. Thus, one needs some realistic expectations going in what is expected, otherwise you are right, the ideal of what life will be like for a physician will not be achieved, leading to distress and burnout.

 

[J ROD]

My program was one of the pilot programs that allowed interns to work the 24 +4 shifts. We also had "2 guaranteed hrs of sleep"...don't believe that hype...lol. But, overall, I thought the shifts were not that bad. And in fact, I agree with many in here and liked having the rest of that day off. And we were allowed to schedule the next day off so it was like we had almost 2 days of IM wards off every 9 days or so. I prefer getting that small mental break than days of 14 hr shifts back to back to back. That shot gets old fast.

 

[OnePunchBiopsy]

I did Q3 24 hour call on a busy trauma service.

While me and the intern worked like dogs during the night, there was something about that post-call breakfast and post-call day off that made it all worth it.

 

[Light at end of tunnel]

I did Q3 24 hour call on a busy trauma service.

While me and the intern worked like dogs during the night, there was something about that post-call breakfast and post-call day off that made it all worth it.

Could that 'something' have been the recognition of the fact that you had no choice in the matter and that you're fortunate to live to fight another day?

 

[OnePunchBiopsy]

Could that 'something' have been the recognition of the fact that you had no choice in the matter and that you're fortunate to live to fight another day?

I'm just fortunate I'm not doing residency at a major trauma center. Hey oh!!!!

 

[Psai]

Could that 'something' have been the recognition of the fact that you had no choice in the matter and that you're fortunate to live to fight another day?

You have a choice. Quit.

 

[kineticdeux]

Jeebus...where to start?

Back in the dark ages, we all worked at least 24 hours on call and usually more. Only those whiny EM, Path and Derm residents worked less. Someone we all survived and so did the patients.

Like @Psai says, if you don't like the conditions of the job quit. You know like sometimes I think it would be cool to be a nurse and only work 36 hours a week and not be on call, but then I remember I don't like doughnuts, so that dream dies.

 

[nlax30]

Currently on my next to last weekend call of fellowship and I would absolutely kill right now to have stayed here, even awake and working, for 24 hrs and then have a post call day. Since Thursday night I think I've had at most like 1.5- 2 hours of uninterrupted sleep.

 

[Perrotfish]

Jeebus...where to start?

Back in the dark ages, we all worked at least 24 hours on call and usually more. Only those whiny EM, Path and Derm residents worked less. Someone we all survived and so did the patients.

Like @Psai says, if you don't like the conditions of the job quit. You know like sometimes I think it would be cool to be a nurse and only work 36 hours a week and not be on call, but then I remember I don't like doughnuts, so that dream dies

1) No, the patients didn't all survive. Libby Zion wasn't unique.

2) No, the residents didn't all survive either. Lots of MVAs, lots of suicides.

3) No, you can't quit. You spent your youth on this profession. You took out 300K in nondischargable debt. Quitting is an option, but only in the sense that its an option to leave your office on the 6th story by the window rather than the door.

 

[ProfMD]

1) No, the patients didn't all survive. Libby Zion wasn't unique.

2) No, the residents didn't all survive either. Lots of MVAs, lots of suicides.

3) No, you can't quit. You spent your youth on this profession. You took out 300K in nondischargable debt. Quitting is an option, but only in the sense that its an option to leave your office on the 6th story by the window rather than the door.

Libby Zion's case was tragic, but also occurred pre-2003 rules. No one is arguing for reversing the 2003 rules. Although her case was turned into a resident work hour case, really it happened because of poor resident supervision.

Physician suicide is a huge topic, much bigger than this thread. Beyond anecdata, I am not aware of any evidence that directly links resident suicide to work hours.

 

[Light at end of tunnel]

Libby Zion's case was tragic, but also occurred pre-2003 rules. No one is arguing for reversing the 2003 rules. Although her case was turned into a resident work hour case, really it happened because of poor resident supervision.

Physician suicide is a huge topic, much bigger than this thread. Beyond anecdata, I am not aware of any evidence that directly links resident suicide to work hours.

I am sure that leading up to the Libby Zion case, folks were justifying the pre existing duty hour rules as well. Then people start dying, and you cant keep your head in the sand any longer and use the "old tymers" ecxcuse...

The link doesnt have to be direct. 100 hour weeks --> depression/despair --> suicide. It may not be directly linked, but it sure as heck is black and white if your head isnt in the sand.

On an unrelated note: smoking has never been directly linked to lung cancer either.

 

[VA Hopeful Dr]

I am sure that leading up to the Libby Zion case, folks were justifying the duty hour rules as well. Then people start dying, and you cant keep your head in the sand any longer and use the "old tymers" ecxcuse...

The link doesnt have to be direct. 100 hour weeks --> depression/despair --> suicide. It may not be directly linked, but it sure as heck is black and white if your head isnt in the sand.

You'd be surprised how often the obvious in medicine turns out to be untrue.

 

[Light at end of tunnel]

You'd be surprised how often the obvious in medicine turns out to be untrue.

Not at all actually. Thats why we have things like randomized control studies. It is precisely because the "obvious" isnt always true.

 

[SunsFun]

Jeebus...where to start?

Back in the dark ages, we all worked at least 24 hours on call and usually more. Only those whiny EM, Path and Derm residents worked less. Someone we all survived and so did the patients.

Like @Psai says, if you don't like the conditions of the job quit. You know like sometimes I think it would be cool to be a nurse and only work 36 hours a week and not be on call, but then I remember I don't like doughnuts, so that dream dies.

Congrats you managed to put everyone down in just one short paragraph.

Nobody cares how much you worked back in the day. It's irrelevant to discussion at hand. Also "your patients" survival less than they do now with advent of evidence-based medicine.

I got a bright idea. Why don't you and people like you quit instead of telling others to quit. That way we could actually attempt to attract non-malignant individuals who you'd actually want to be around for longer.


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[ProfMD]

I am sure that leading up to the Libby Zion case, folks were justifying the pre existing duty hour rules as well. Then people start dying, and you cant keep your head in the sand any longer and use the "old tymers" ecxcuse...

The link doesnt have to be direct. 100 hour weeks --> depression/despair --> suicide. It may not be directly linked, but it sure as heck is black and white if your head isnt in the sand.

On an unrelated note: smoking has never been directly linked to lung cancer either.

There were no work hour limits before the Libby Zion case. And, like I said, if you read the details it becomes clear that the problem was really poor oversight of residents, not work hours.

Also, like I said, there has never been a documented link between work hours and suicide. It may make sense that there would be, but it is all anecdotes. And, mind you, there have been numerous anecdotes in this thread about how he 16 hour rule made exhaustion worse, not better, for residents.

Finally, who said anything about 100 hour weeks? The rule that has been rescinded was the limit on interns to 16 hour shifts. The 80 hour work week and all other 2003 reforms are still in place and supported by us "old timers."

 

[Light at end of tunnel]

You have a choice. Quit.

That's like telling cancer patients if they don't like chemo side effects, they can quit! But oh yeah, then they die!

Pure genius.