Resident Union & AMSA petition OSHA (and NOT ACGME) to regulate hours

[ilubmedicine]

CIR (The union for interns and residents) join AMSA and Harvard sleep specialists to petition OSHA to regulate resident duty hours and among other things call for the same hours for all residents (PGY 1-4)

http://www.nixonpeabody.com/publications_detail1.asp?ID=3475

Petition:
http://www.im.org/PolicyAndAdvocacy... Public Citizen CIR AMSA Petition to OSHA.pdf

CIR Statement:
http://www.cirseiu.org/assets/asset...d6-be09-f98c35723e97/1/CIR_OSHA_Statement.pdf

ACGME Response:
http://www.acgme.org/acWebsite/home/OSHAACGMEResponseLetterOSHA.pdf

OSHA Response:
http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=NEWS_RELEASES&p_id=18285

ACGME is vehemently against any OSHA intervention.

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[McGillGrad]

As long as residents are happy to add an extra year on to their residencies then less hours should be fine.

 

[Parietal Lobe]

I'm curious, why don't you take this to the media? You can't send them the statement as it's too long. What I would do is pitch a story to them about following around a resident who's working a 30-hour shift (without showing any patients). A day in the life kind of thing. That might get the press interested in the story and get some publicity that way.

 

[ilubmedicine]

I'm curious, why don't you take this to the media? You can't send them the statement as it's too long. What I would do is pitch a story to them about following around a resident who's working a 30-hour shift (without showing any patients). A day in the life kind of thing. That might get the press interested in the story and get some publicity that way.

AMSA and CIR are the ones that are strong enough to take it to the media.

No residency program or hospital is going to allow their resident to be followed for a "duty hour" story. Good luck finding one!

I am not the expert on how duty hours should be regulated to be safe. I do know as a patient, I would not want someone operating on me close to their 24 hour shift. I do know that ACGME has MANY conflicts of interest in serving the residents best interest. If hypothetically a 16-hour shift is the safest shift for residents and patients alike (and I am assuming it is based on their new regs), why can the PGY1 drive home after a 16 hour shift, but the PGY2 still has to drive home after a 30 hour shift. This by itself makes me very skeptical. It seems to me that the ACGME that is comprised of many program directors feels that their programs would not be able to operate with such a loss of man-power. The hypocrisy in their own new rules makes me a little skeptical of the "research" they did.

The person that can take it to the media would have to be the "test case" for our court system. It would have to be the resident who did fall asleep at the wheel and suffer serious injuries. They actually have the power to make precedent through our judicial system.

Most normal professions don't have 30 hour shifts, much less ones with human life at stake. It seems ideal to have an independent group that is not comprised of actual program directors making these decisions. That's all. I just feel that ACGME has a conflict of interest in this plight.

 

[Parietal Lobe]

Believe me, media organizations would never tell a hospital the story is about duty hours. It would be wrapped up in another feel-good story about the holidays or something. Also, anyone can take it to the media. It doesn't have to be CBS News. The reporter at your local paper out in the sticks might be interested in the story locally at XYZ hospital. He/she writes a good story and it's picked up by the AP and maybe others will cover it from that. It doesn't need to be Charlie Gibson covering it for it to be news.

Agree with you about the ACGME. It's my understanding that the limit for PGY1 is based on their inexperience and by extension, the fact that they're prone to errors more than PGY2. But I agree it doesn't make much sense in all.

 

[NotAProgDirector]

The "sense" in this decision is that it was a compromise. Some people on the ACGME wanted no overnight call for anyone. Others wanted no changes at all. Limiting overnight call to PGY-1's was a compromise that everyone could "live with". I expect the next duty hour revision (in 5 years I expect) will remove overnight call for anyone.

The "data" is in the eye of the beholder. There is pretty clear evidence that working for 30 hours in a row increases MVA's and +/- needlesticks. The evidence that 30 hour shifts increases medical errors is inconclusive -- depends on which studies you believe.

 

[alwaysaangel]

The "sense" in this decision is that it was a compromise. Some people on the ACGME wanted no overnight call for anyone. Others wanted no changes at all. Limiting overnight call to PGY-1's was a compromise that everyone could "live with". I expect the next duty hour revision (in 5 years I expect) will remove overnight call for anyone.

The "data" is in the eye of the beholder. There is pretty clear evidence that working for 30 hours in a row increases MVA's and +/- needlesticks. The evidence that 30 hour shifts increases medical errors is inconclusive -- depends on which studies you believe.

Have they looked at whether or not handing off patients to night floats etc. increases errors just because not all the information is passed on? I've seen that happen with patients over time. Its like playing medical telephone and it seems like the biggest issue when it comes to having a night float system.

 

[Law2Doc]

Have they looked at whether or not handing off patients to night floats etc. increases errors just because not all the information is passed on? ...

Yeah they have, and yes it does. But for whatever reason this argument falls on dead ears. The public fears the tired doctor more than the doctor who wasn't brought up to speed. If they had more insight into how things actually work, they probably would prefer to take their chances with a tired doctor who actually knew the situation than the well rested one who got a crummy hand-off. I sure would, and I've been both these doctors during my intern year (as have many on here).

OSHA is probably not going to jump in and make changes when we have yet to see the results of the changes the ACGME just made. The logical approach is to wait and see if there is still an issue in light of those changes. So OSHA is likely going to say, let's wait and see.

But I think certain groups are not acting in their own longterm self interest here. The goal of residency isn't a chill, comfortable experience. The goal is training by immersion. Cutting hours means cutting some percentage of training. (Sure it cuts some scut too, but hospitals are going to make sure the lions share of the scut gets done by residents even with shorter overall residency hours, one way or another). So the logical step in ensuring that training doesn't take a hit will be McGillGrad's suggestion that this will lead to longer years of residency. It has to, unless the profession is ready to accept less trained individuals into its fold. Nobody likes long hours, but what people have to realize (and what med students running AMSA don't get) is that you learn a lot during those long shifts and overnights. You have more independence and less supervision and are learning under fire and you get pretty good at managing crashing patients, in a way you don't get during business hours when more experienced folks are around to jump in, or when you sign out the patients early in their management. So expect residencies to be lengthened if there's much more shortening of duty hours. There's always a push back on this kind of thing, and there are plenty of older attendings who already feel that residents aren't as prepared even under the current rules.

Next, I think folks have to realize that if you restrict the availability of residents too drastically this requires either (1) the hiring of more NPs, CRNAs, PAs, which ultimately will lead to fewer physician jobs down the road, or (2) increasing the number of residents, which will lead to greater competition for physician jobs down the road, and perhaps corresponding lower salaries.

So no, pushing and pushing for lower and lower hours can definitely blow up in your face, and, as aPD suggests possibly doesn't even lead to better patient care, although it may reduce resident traffic accidents. You will end up with longer residencies, more competition, more midlevels, all bad things for someone anxious to get into the field. I would suggest that if avoiding MVAs is the only real benefit, folks should really simply be pushing for a resident car service -- it would be cheaper to the hospitals and could allow residents to work 30 hours without risking car wrecks. Or just sleep it off in the on call room if you are too tired to hit the road.

 

[ilubmedicine]

I didnt have to drive but I cant imagine having to do so after a 30 hour shift.

Bottom line is the ACGME is not the right body of individuals to be regulating work safety when they have a clear conflict of interest. The people on the RRCs are program directors thinking about how they are going to run their programs without these residents! And it is interesting that they are vehemently opposed to intervention. Wouldn't they want one less thing on their hands to have to regulate.

I do not claim to know the right numbers of hours thats safe for patients and residents. I just think that ACGME should continue to monitor resident education NOT duty hours. The government and OSHA regulates work conditions, minimum wage, labor laws, and they are the appropriate body that should be regulating duty hours.

NY's laws also grew out of a "test case"-- Libby Zion. And now the state regulates compliance with these regulations. Libby Zion's father was a well-respected NY journalist. What we need is another test case, and although I dont wish that kind of tragedy on anyone, I think that is the only way to implement changes.

AMSA and CIR have emphasized resident safety in this 2nd petition (the first petition in 2002 was denied by OSHA) and they have emphasized that they want OSHA to only regulate the duty hours portion. ACGME can continue to monitor resident education. This makes perfect sense to me.

and OSHA also responded with a positive statement this time:

http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=NEWS_RELEASES&p_id=18285

"very concerned about medical residents working extremely long hours, and we know of evidence linking sleep deprivation with an increased risk of needle sticks, puncture wounds, lacerations, medical errors and motor vehicle accidents.
. . .
Hospitals and medical training programs are not exempt from ensuring that their employees’ health and safety are protected."

 

[Substance]

Nobody likes long hours, but what people have to realize (and what med students running AMSA don't get) is that you learn a lot during those long shifts and overnights. You have more independence and less supervision and are learning under fire and you get pretty good at managing crashing patients, in a way you don't get during business hours when more experienced folks are around to jump in, or when you sign out the patients early in their management.

.

You make a lot of good points about the long-term professional repercussions of restricting duty hours. But the above one is always that one assumption that I've never fully understood.

If on-call learning is more independent and therefore more valuable, then why have so much supervision during the daytime? I'd say that well-rested independent practice is far more useful and safe than dead-tired independent practice.

 

[ANCAdoc]

I agree.

I disagree that you learn so much more at night. Other than admitting, I was a receptionist, fielding calls from nurses. 95% were for very minor orders (tylenol, sleep aid) or clarifications. Whether you admit during the day or at night, the learning is the same. It's only busier because you are cross-covering.

For most fields, I do not believe training will be extended. The only exception I can think of are the surgical fields.

As L2D pointed out, many attending already think we're stupid and have it so easy. We'll be like that one day, doesn't matter the circumstance, the prior generation felt they had it harder.

For some perspective, read:
"The house officers changing world". NEJM. 314(26):1713-15, 1986.

 

[Boba Q Fett]

You learn a lot at night because you are the only one there fielding all those calls from nurses. I agree a lot of them are ******ed but people tend to crump in the night and without a lot of support staff you have to do figure out whats wrong quick. At my hospital, the medicine residents basically run everything at night so you learn a bunch and it helps you get efficient. There's no substitute for experience, and overnight call can give you a lot in a short period of time. I did so many procedures in the ICU at night because there weren't any other residents or interns to share with.

I can't understand why anybody listens to AMSA, it's a bunch of first and second year medical students who have no clue what they're talking about.

 

[Law2Doc]

...

NY's laws also grew out of a "test case"-- Libby Zion. And now the state regulates compliance with these regulations. Libby Zion's father was a well-respected NY journalist. What we need is another test case, and although I dont wish that kind of tragedy on anyone, I think that is the only way to implement changes. ...

You aren't really using the phrase "test case" correctly. A test case is a case that a prosecution or plaintiff is waiting to come along that it can use to prove a point. The Libby Zion case was more an example of a media circus making bad law, not a test case. In this case, a young woman came to a NY hospital ED, didn't provide a good history of what substances (legal and illegal) she happened to be taking, and ultimately died. The father of the woman, a member of the print media, went on a national campaign in the press blaming the hospital system and residency structure for his daughter's demise. He managed to sway public opinion not in the court, but somewhat in the media. In fact, the jury ultimately found that Libby Zion was at least partially to blame for her demise, due to her undisclosed drug habit. But the NY hospital involved feared the bad publicity, basically threw their resident under the bus, and this debacle indirectly led to adoption of the 80 hour rule. Not because this was a good test case brought by someone seeking to prove that tired doctors make bad errors, and not even that this case demonstrated that fact to a jury, but simply because a NY hospital administrator didn't like bad press. It's a horrible case on which to base a change of the rules, but unfortunately we are stuck with it -- a non-empirical, emotional driven rule. It's these emotional driven cases that universally make bad law, and the Zion case is no exception.

 

[Law2Doc]

...

As L2D pointed out, many attending already think we're stupid and have it so easy. We'll be like that one day, doesn't matter the circumstance, the prior generation felt they had it harder. ...

Except that thanks to the change of hours, the prior generations will truly have had it harder. If you think it's hard to live up to unreal expectations now, wait until you don't live up to real expectations folks actually did.

 

[mom2doc]

You aren't really using the phrase "test case" correctly. A test case is a case that a prosecution or plaintiff is waiting to come along that it can use to prove a point. The Libby Zion case was more an example of a media circus making bad law, not a test case. In this case, a young woman came to a NY hospital ED, didn't provide a good history of what substances (legal and illegal) she happened to be taking, and ultimately died. The father of the woman, a member of the print media, went on a national campaign in the press blaming the hospital system and residency structure for his daughter's demise. He managed to sway public opinion not in the court, but somewhat in the media. In fact, the jury ultimately found that Libby Zion was at least partially to blame for her demise, due to her undisclosed drug habit. But the NY hospital involved feared the bad publicity, basically threw their resident under the bus, and this debacle indirectly led to adoption of the 80 hour rule. Not because this was a good test case brought by someone seeking to prove that tired doctors make bad errors, and not even that this case demonstrated that fact to a jury, but simply because a NY hospital administrator didn't like bad press. It's a horrible case on which to base a change of the rules, but unfortunately we are stuck with it -- a non-empirical, emotional driven rule. It's these emotional driven cases that universally make bad law, and the Zion case is no exception.[/QU

Not quite. My cousin was part of the plaintiffs' team, and was in charge of the DBT of that resident....trust me, she threw herself under the bus. She wasn't well coached and said very stupid things about not needing to check with anyone about drug interactions. The verdict was, in fact, quite mixed, but the resident's statements would make any administrator consider settling.

 

[randomedstudent]

I agree.

I disagree that you learn so much more at night. Other than admitting, I was a receptionist, fielding calls from nurses. 95% were for very minor orders (tylenol, sleep aid) or clarifications. Whether you admit during the day or at night, the learning is the same. It's only busier because you are cross-covering.

For most fields, I do not believe training will be extended. The only exception I can think of are the surgical fields.

As L2D pointed out, many attending already think we're stupid and have it so easy. We'll be like that one day, doesn't matter the circumstance, the prior generation felt they had it harder.

For some perspective, read:
"The house officers changing world". NEJM. 314(26):1713-15, 1986.

60 hrs/week x 49 weeks/yr x 3 yrs (for IM)

vs.

110 hrs/week x 50 weeks/yr x 3 yrs

hmmmm....do the math. Those extra hours they worked in the old days weren't spent sleeping I can guarantee you. Additionally, the amount of information that must be learned in the same number of years has increased dramatically. I promise you, in the very near future most residencies will be extended in length.

 

[JackADeli]

60 hrs/week x 49 weeks/yr x 3 yrs (for IM)

vs.

110 hrs/week x 50 weeks/yr x 3 yrs

hmmmm....do the math. Those extra hours they worked in the old days weren't spent sleeping I can guarantee you. ...in the very near future most residencies will be extended in length.

I am not sure there will be any extension of "residency". Rather, I suspect we will see more of an apprentice role develop after "graduation" from "residency". Hospital credentialling boards may require formal "junior" status for several years, followed by submission of case logs, outcomes, and completion of board certification before "full or unrestricted" privileges are granted.

 

[McGillGrad]

I am not sure there will be any extension of "residency". Rather, I suspect we will see more of an apprentice role develop after "graduation" from "residency". Hospital credentialling boards may require formal "junior" status for several years, followed by submission of case logs, outcomes, and completion of board certification before "full or unrestricted" privileges are granted.

You mean a more British system of medical residency?

 

[JackADeli]

You mean a more British system of medical residency?

Yes, probably something in that manner.

http://en.wikipedia.org/wiki/Specialist_registrar

 

[Jorski]

If it comes down to working more hours/wk or working less hours and extending residencies for a year, I would gladly work the extra hours. We are talking a year of freedom from residency. I know its easy for me to say as a second year medical student, but tough out the extra hours. That one less year of being controlled and having to answer to someone has got to mean something.

Maybe I'm wrong and I'll change my tune when Im at that point.

 

[Ronin2258]

Yes, probably something in that manner.

http://en.wikipedia.org/wiki/Specialist_registrar

Does that mean a few extra years at resident pay? I am not familiar with the pay scale for a registrar vs. an attending. Though I would suspect it would be around the same cost as a midlevel.

It would be one way to cheapen medical labor. Which is what I suspect the bean counters/other entities would want; a force of people at a pay rate that would not keep us ahead of our debt load to work the long hours as a registrar. And it would be one more area to blur the line between midlevels and physicians (i.e. making us all look equal and interchangeable.)

Personally, I am looking forward to my independence and not being salaried. If it means being an independent, hit me with the extra hours.

 

[JackADeli]

Does that mean a few extra years at resident pay?...

It would be one way to cheapen medical labor. Which is what I suspect the bean counters/other entities would want; a force of people at a pay rate that would not keep us ahead of our debt load to work the long hours as a registrar. ...If it means being an independent, hit me with the extra hours.

It would probably be more then just a few years. It would also mean lesser pay during those years. The US system would not necessarily be identical to UK. However, I suspect it will be something like going into residency. then, you graduate and go into a junior/apprenticeship role for "x" years. During your junior/apprenticeship, you would take your boards and log a certain number of cases... with a senior oversight (which brings potential for abuse). You would then apply for senior status.

As for more hours, that is the point isn't it? Everyone cries for an easier path. There is a trade off. I think more accountability at the teaching level and consequences for the abuse that was the tradition of 120+hrs/wk. But, you now have the trade-off.

 

[Ronin2258]

I will be one first to comment on abuse of hours, I've seen it before the rules in 2003 hit. And unfortunately, I saw it after 2003 as "under the table hours."

What needs to happen is that the current rules on hours need to adhered to all above board. If that means the programs are forced to be held accountable, so be it. I concur with JackADeli that the teaching level has to be responsible and accountable for the traditional abuse. I personally thought the hours in 2003 were just about right for specialties across the board, it just needed to have more teeth to force the programs to be responsible.

The one thing people are forgetting is this path is *NOT* an easy path. I never had any delusions that it would be. I keep saying jokingly that "medicine isn't a job, it's a lifestyle." However, I know that in order to succeed, that quip has some shade of truth to it. I was thoroughly expecting to be used, abused, and dropped into fire throughout the years of training. If it was easy to be a doctor, we would be facing a physician overage like the lawyers overage. It is neither cheap, quick, nor easy to train us.

But then, I was brought in to medicine by old-gaurd surgeons and anesthesiologists, so I am probably a bit jaded in my view.

 

[Law2Doc]

... She wasn't well coached and said very stupid things ...

And whose job was it to "coach" the resident? The hospital lawyers. This was a big part of throwing this resident under the bus. You take a 20 something year old person who is naive to the ways of the courtroom and basically say "fend for yourself" -- that's pretty much the definition of throwing her under the bus.

 

[Law2Doc]

...
Personally, I am looking forward to my independence and not being salaried. If it means being an independent, hit me with the extra hours.

FWIW, most folks leave residency and go into some form of salaried job, whether it's working for a hospital system or for a private practice.

 

[Gabby]

Nobody likes long hours, but what people have to realize (and what med students running AMSA don't get) is that you learn a lot during those long shifts and overnights.

I'm sorry, I'm just a second year, but I can't imagine learning anything after being awake for 30 hours. Why is it necessary to be sleep-deprived in order to learn medicine?

You have more independence and less supervision and are learning under fire and you get pretty good at managing crashing patients, in a way you don't get during business hours when more experienced folks are around to jump in, or when you sign out the patients early in their management.

So have residents do night shifts. It's not like the hospital closes down at 5 p.m.

 

[Gabby]

If it comes down to working more hours/wk or working less hours and extending residencies for a year, I would gladly work the extra hours. We are talking a year of freedom from residency. I know its easy for me to say as a second year medical student, but tough out the extra hours. That one less year of being controlled and having to answer to someone has got to mean something.

Maybe I'm wrong and I'll change my tune when Im at that point.

It's implied that your assumption is the only objection to working long hours and overnight call is that residents want an easier schedule. That's not why these restrictions were put in place.

 

[Gabby]

And whose job was it to "coach" the resident? The hospital lawyers. This was a big part of throwing this resident under the bus. You take a 20 something year old person who is naive to the ways of the courtroom and basically say "fend for yourself" -- that's pretty much the definition of throwing her under the bus.

What ever happened to that resident?

 

[Hernandez]

idiots, you NEVER invite the government into your lives, you're going to get screwed.

I'm sorry, I'm just a second year, but I can't imagine learning anything after being awake for 30 hours. Why is it necessary to be sleep-deprived in order to learn medicine?

So have residents do night shifts. It's not like the hospital closes down at 5 p.m.

there is more autonomy at night, and most learn better under pressure and when they don't have an attending around to coddle them, I learn more practical clinical medicine on call than any other educational setting.

 

[Law2Doc]

idiots, you NEVER invite the government into your lives, you're going to get screwed.



there is more autonomy at night, and most learn better under pressure and when they don't have an attending around to coddle them, I learn more practical clinical medicine on call than any other educational setting.

Agreed.

 

[Law2Doc]

I'm sorry, I'm just a second year, but I can't imagine learning anything after being awake for 30 hours. Why is it necessary to be sleep-deprived in order to learn medicine? ...

It's not that it's "necessary to be sleep deprived", so much as you have to actually take care of patients over a very long stretch of time, on your own without a lot of hand holding and supervision, to actually get comfortable and good doing this job. Anyone can keep someone circling the drain for a few hours, maybe even a dozen. But until you know the satisfaction of having being handed an ICU full of crashing patients one day, and be able to hand back all of those patients, still kicking, to the next team 30 hours later, you really don't know how to manage patients. A short night float shift isn't going to offer the same experience, and during the days you will be anything but independent.

So yeah, you are only a second year med student and you can't appreciate it yet. But you are going to have a much harder time obtaining the same level of training the folks finishing up their intern year now and prior got. And though you will be better rested, you are probably getting a raw deal in some respects.

Certainly to some extent the mere number of hours can be addressed by adding years onto residency. But I think it's tough to replicate a lot of the learning one gets managing sick patients over long stretches of time, which is basically eliminated under the new rules. And I think some of the long shifts did a lot of shaping of physicians in positive ways that can't happen now.

 

[Gabby]

idiots, you NEVER invite the government into your lives, you're going to get screwed.



there is more autonomy at night, and most learn better under pressure and when they don't have an attending around to coddle them, I learn more practical clinical medicine on call than any other educational setting.

I'm not arguing that point. My point is, why does the nighttime autonomy have to follow a regular workday? If the point is autonomy and learning things on off-hours, then why is it necessary to work a 30-hour shift since, IMO, that's counterproductive to actual learning.

 

[Gabby]

Anyone can keep someone circling the drain for a few hours, maybe even a dozen. But until you know the satisfaction of having being handed an ICU full of crashing patients one day, and be able to hand back all of those patients, still kicking, to the next team 30 hours later, you really don't know how to manage patients. A short night float shift isn't going to offer the same experience, and during the days you will be anything but independent.

So you're saying that the only way to learn medicine and how to manage patients is to be deprived of sleep? What's the trade-off? I can keep the patients alive (assuming I make no mistakes and after a 30-hour shift, that's anything but a given), but I will likely be a danger to myself and anyone else on the road after my call nights, not to mention my personal health takes a hit if I'm doing this for years. I'm sorry, it doesn't make sense to me.

Also, I thought I read that there was no change in the number of medical errors after the 2003 restrictions went into place. If that's true, then doesn't that mean the hand-off errors equaled the number of sleep-deprived errors made under the old system? And if THAT'S true, then doesn't that mean there was no detriment to working less hours?

So yeah, you are only a second year med student and you can't appreciate it yet. But you are going to have a much harder time obtaining the same level of training the folks finishing up their intern year now and prior got. And though you will be better rested, you are probably getting a raw deal in some respects.

Maybe my first year out of residency that'll be true, but I can't see a change so slight affecting the rest of my career as a doctor. Doing so would mean that I'd have to assume that any resident graduating residency now and working for the next 30 years will never measure up to a doctor who graduated residency 20 years ago, when residents worked 100 hours a week. I just don't believe that's true.

Certainly to some extent the mere number of hours can be addressed by adding years onto residency. But I think it's tough to replicate a lot of the learning one gets managing sick patients over long stretches of time, which is basically eliminated under the new rules.

I just don't see why 30-hour shifts are necessary to learn how to manage patients. If it was necessary, then every program in the country would require it and that's not the case.

To be clear, my point isn't about wanting a "chill" residency. It's about safety and health. As physicians, the majority of you are going to be telling your patients to get plenty of sleep at night while you turn around and tell your residents how working 30-hour shifts for 3, 4, or 5 years is the best thing they can do? It sounds extremely hypocritical to me.

 

[Ronin2258]

FWIW, most folks leave residency and go into some form of salaried job, whether it's working for a hospital system or for a private practice.

Granted. But at least those positions tend to pay what it takes to get the average medical student debt under control instead of deferrals and have something that resembles a life. Basically start to get ahead. In some places, resident pay is just above ramen and cardboard box living.

I'm sorry, I'm just a second year, but I can't imagine learning anything after being awake for 30 hours. Why is it necessary to be sleep-deprived in order to learn medicine?

So have residents do night shifts. It's not like the hospital closes down at 5 p.m.

Maybe not necessary, but you can be in a bad situation where you are locked up for a long time. It is performance under those stressors that are simulated on call.

Shift work tends to be impractical for the procedure heavy specialties. I have had cases that lasted the ENTIRE 27 (I trained in NY,) hours I was on call, with about 5 minutes every so often for a pee/drink break. Locked us up for the night. Tagging someone out of a case like because of a time limit on the resident isn't feasible. It's not "sharing the wealth," of a good case but more "ripping off my work," by finishing what I started. The resident that is in wants to stay in to finish what they started, and it is a mindset of the procedure heavy specialties.

Had a trauma case that the senior and I (as a PGY-2,) were scrubbed in on call. Worked all the way through rounds and "beyond the line" substantially (hours beyond.) The guy who put the knife into the kid's PA and lung started the mess, we cleaned it up. The incoming team couldn't relieve us (but they did do rounds with the intern we left out for the purpose of continuity,) as we were elbow deep holding things for the CT surgeon could do the repair. Don't ever want to honk of a CT surgeon by messing up his repairs by moving. Ever.

Even as a scrub tech, I ABHORRED being forced out of a case because it was time. Which is why techs in the day were paid well by the surgeons they worked for. Shift work scrubbing was something I didn't encounter until residency.

I got into the long hour thing in undergrad as well. Ever pull an all-nighter in undergrad? Quite a few of us did.

In the anatomy classes I had, students were up overnight studying for a 5am (no joke, really,) lab practicals, and they went until noon. And you couldn't skip the afternoon classes and crash. During the time I was in college, you had to be in attendance at all your classes (which can run up to 6pm nonstop.) or you risk losing your financial aid.

Those that did stay up all night rocked the practicals. No curves/scaling.

I know I am coming off more than a bit hardcore. I am all for keeping the hours regulated in training for sleep and breaks between shifts. I also want reporting all above the table. But realize those training hours go away upon graduating residency, and you will have to work longer hours as an attending in some specialties. Don't be fooled.

What ever happened to that resident?

If my work in wiki and google are correct:
The intern is now an attending IM/prime care.

The resident is now a cardiologist.

(names withheld from post due to privacy reasons. One less place their names get a hit on search engines after going through the hell they went through.)

 

[Boba Q Fett]

I'm not arguing that point. My point is, why does the nighttime autonomy have to follow a regular workday? If the point is autonomy and learning things on off-hours, then why is it necessary to work a 30-hour shift since, IMO, that's counterproductive to actual learning.

It's called continuity of care, and most patients prefer to have the same doctor throughout their care, especially at the start when they're usually the sickest. You're preclinical but once you get to the wards you'll see how many patients get annoyed by having to repeat their story to everyone. And trust me, once you see how ****ty some handoffs are, you'll be taking your own history from these people.

Also, just because residents won't be working the same hours doesn't mean they'll be more rested. Half of them will probably use the opportunity to stay out late and then go into work just as tired.

 

[Arcan57]

Maybe my first year out of residency that'll be true, but I can't see a change so slight affecting the rest of my career as a doctor. Doing so would mean that I'd have to assume that any resident graduating residency now and working for the next 30 years will never measure up to a doctor who graduated residency 20 years ago, when residents worked 100 hours a week. I just don't believe that's true.

You assume a couple of points that may not be true. The first is that your post-residency job is going to be easier/less time-consuming than residency. I look at my IM hospitalists taking q3 call and admitting 20+/night or my surgeon begging me not to accept anymore transfers because he's been operating for 18 straight hrs and we just had a helicopter drop off a lady with dead gut. There's not usually a cap in the real world, and a full day of clinic (not home by noon) post-call is the norm.

The second point is that the training in residency is unique. The level of feedback and support structure found in residency doesn't exist post-residency. Procedures that you aren't comfortable with in residency will likely be procedures you are never comfortable performing. The feedback you do receive as an attending is usually negative, and often medically irrelevant. If you don't anger patients/adminstration, you can get away with practicing pretty poor medicine and nobody is going to tell you what you're doing wrong.

Is the proposed changes in work hours going to cause permanent deficiencies in the residents that train under the new system? We'll never know, because we don't have the metrics to measure what makes a good physician. But shortening residency, which is what decreasing work hours does, is unlikely to be consequence free.

 

[Gabby]

t's called continuity of care, and most patients prefer to have the same doctor throughout their care, especially at the start when they're usually the sickest. You're preclinical but once you get to the wards you'll see how many patients get annoyed by having to repeat their story to everyone. And trust me, once you see how ****ty some handoffs are, you'll be taking your own history from these people.

I admit you guys know a hell of a lot more than I do. I'm just giving my opinion as a second year and as a patient.

Yes, hand-offs suck from the patient's point of view. But as a patient, I'd rather have a doctor who's well-rested and have to repeat my story 12 times than a doctor who's been up and working for the past 24 hours. I think if you think about it in those terms, most patients would feel the same. Repeating your story is a nuisance. An exhausted intern can be fatal.

Also, just because residents won't be working the same hours doesn't mean they'll be more rested. Half of them will probably use the opportunity to stay out late and then go into work just as tired.

Maybe you're right. I think that's extremely irresponsible, but some probably will. I just feel like when I have someone's life in my hands, I better be at my best and I know for a fact that I'm not when I'm sleep-deprived. I was the one who always tanked a test if I pulled an all-nighter. I just can't think straight without sleep (and it doesn't have to be 8 hours; I'm fine with just 3-4 hours) and it scares me that I'll be responsible for patients after being up for so long. I just don't understand why that's necessary to be a good doctor.

The first is that your post-residency job is going to be easier/less time-consuming than residency.

It's not about being easier. As an intern, it's about safety. Interns are going to make mistakes an attending isn't and being sleep-deprived is only going to punctuate those mistakes. As an attending, you can work those hours if you feel you can function and still provide good patient care, but you're not forced to the way you are in residency. There are some people who work fine with no sleep. There are others who shouldn't be trusted to pour a glass of coke with no sleep. Both types of people are forced to be sleep-deprived in residency. Only one type would probably choose to work 80+ hours a week in practice. The other type, knowing he or she would be a detriment to patient care working that much, could shop around for a specialty that doesn't require those kinds of hours (no surgery or IM) and/or can try to find a practice with enough people that it doesn't require q3 call. They have an MD degree, are fully licensed, and presumably, board certified. They have a lot more options than an intern does.

In the anatomy classes I had, students were up overnight studying for a 5am (no joke, really,) lab practicals, and they went until noon. And you couldn't skip the afternoon classes and crash. During the time I was in college, you had to be in attendance at all your classes (which can run up to 6pm nonstop.) or you risk losing your financial aid.

Since I was the one who tanked after all-nighters, I didn't pull them often. Those who did, great. They'll be your gung-ho surgeons. My point is, I know my limits and I'm certain I'm not alone.

A 5 a.m. lab practical sounds cruel by the way!

 

[McGillGrad]

I admit you guys know a hell of a lot more than I do. I'm just giving my opinion as a second year and as a patient.

Yes, hand-offs suck from the patient's point of view. But as a patient, I'd rather have a doctor who's well-rested and have to repeat my story 12 times than a doctor who's been up and working for the past 24 hours. I think if you think about it in those terms, most patients would feel the same. Repeating your story is a nuisance. An exhausted intern can be fatal.

Most patients are ignorant of what is best for them. That includes doctors who are patients.

 

[alwaysaangel]

Most patients are ignorant of what is best for them. That includes doctors who are patients.

Not only that but her inexperience of how wards work is showing. She is assuming that handoffs are benign things that just cause pts to repeat their story but that's not how it works.

As mentioned above - studies have shown that hand offs hurt patients.

Even if we assume a pt is well enough to tell their story that's irrelevant. The doc who got the handoff isn't going to come redo the history and physical. They go off the history and lab data given to them at hand off and continue meds already on. Making changes as needed. But meds get dropped in the process OFTEN. as does lab data, consult recs etc. And the new doc doesn't have time to do a chart review on every pt they are given and no patient would know all their meds, labs or recs to tell the doc.

But most of the patients who are the sickest, most complicated and on the most meds couldn't tell their story if they wanted.

As someone who has spent time on wards I would always take a tired doc who knows about my care over someone who was handed my case.

 

[Arcan57]

I just feel like when I have someone's life in my hands, I better be at my best and I know for a fact that I'm not when I'm sleep-deprived. I was the one who always tanked a test if I pulled an all-nighter. I just can't think straight without sleep (and it doesn't have to be 8 hours; I'm fine with just 3-4 hours) and it scares me that I'll be responsible for patients after being up for so long. I just don't understand why that's necessary to be a good doctor.

It's good that it scares you to be responsible for patients, although I'd suggest that you remove the qualifier of "while tired". That's a rational and appropriate response to the fact that you currently have no clinical skills. Dealing with fatigue is a necessary part of being a physician, because there are not many jobs that will allow you to practice without having to deal with fatigue. And it's better to learn to deal with fatigue in a supervised setting then in an unsupervised setting where you won't get appropriate feedback.

 

[B-Bone]

I realize that in most fields, after residency, the days of 24 hr+ in house calls are gone, but as an anesthesiologist, I still work 24 hour in house calls about once a week. I have a number of colleagues, particularly in the ICU, who will be in house for as long as it takes (e.g. 72 hours) to ensure appropriate care for their sickest patients. My sister-in-law is a PP general surgeon who used to go to the hospital and not come home for a week when it was her call week. granted, this isn't every job, but these are attending positions. I can't imagine doing my current job without having spent 24-30 hour days in the ICU or in a busy OR doing 30 cases on a saturday. Also, the people you see at night and on the weekends in residency are a whole different breed: trauma, death-warmed-over types transferring in from other hospitals, etc. And figuring out how to deal with their issues without the resources available during the day (colleagues, consult services, even patient transport, etc) is valuable time spent. Taking care of patients at all hours of the day trains you to take care of patients at all hours of the day, and this might be your job after residency.

 

[Gabby]

Not only that but her inexperience of how wards work is showing. She is assuming that handoffs are benign things that just cause pts to repeat their story but that's not how it works.

Actually, I'm quite aware that's not all there is to it. But my response was specifically to this statement:

t's called continuity of care, and most patients prefer to have the same doctor throughout their care, especially at the start when they're usually the sickest. You're preclinical but once you get to the wards you'll see how many patients get annoyed by having to repeat their story to everyone.

So while I realize there's more to hand-off cons than just patients repeating their story, it was patients repeating their story that I chose to reply to.

 

[Boba Q Fett]

Actually, I'm quite aware that's not all there is to it. But my response was specifically to this statement:



So while I realize there's more to hand-off cons than just patients repeating their story, it was patients repeating their story that I chose to reply to.

This is a huge issue. Stories always change, and the more irritated the patient is, the less they will tell you. Also, there's nothing more valuable than seeing a patient at admission and being able to compare any changes to how you first saw them. Not to be rude, but stick to commenting on basic science issues and wait until you have actual clinical experience to talk about work hours.

 

[Gabby]

This is a huge issue. Stories always change, and the more irritated the patient is, the less they will tell you. Also, there's nothing more valuable than seeing a patient at admission and being able to compare any changes to how you first saw them. Not to be rude, but stick to commenting on basic science issues and wait until you have actual clinical experience to talk about work hours.

Well, that was rude. I've been completely above-board in saying repeatedly that I'm just a second year and that you guys know way more than I do, but as a med student, I don't think it's out of line for me to express my opinion, whether or not you feel it's wrong.

 

[Roofie]

Personally, I never hated the long hours of residency training. But that does not mean I will "drink the cool-aid" in thinking that longer hours trains better physicians.

The long hours implicate a nexus between competing interests like education and manpower needs. The ACGME, who controls the education, redefined manpower needs as education, i.e. hours upon hours of scut as education. This benefited the hospital interests more than the residents. In a sense, this is the wax on wax off approach that lasts for several years instead of several weeks.

By defining manpower needs as education, the ACGME is able to keep many laws from applying to itself due to deference given this profession. However unfettered deference is a prescription for abuse. Their is no doubt in my mind that prior generations of physicians have been abused whether they admit to it or not. By definition, working 130 hours per week is abusive. Slaves were never worked that hard.

It is possible to make residency training more humane by focusing more on activities that are rich in learning rather than poor in learning. The focus on residency is not making a flawless resident, but rather, one who can function independently safely. Every physician continues to improve his clinical ability as he gains experience in private practice. However, this humane approach will require more funding for ancillary staff.

An exception to this argument would involve the procedural fields. You need enough manual exposure to cases which could entail long hours waiting for those cases to come in. However, that could change in the future when we develop hologram rooms like in Star Trek--where learning to operate could be like playing a video game.

The argument for a conflict of interest is compelling. In law, lawyers or whole law firms could get bounced from cases for a conflict of interest. When evaluating arguments, you need to balance conflicts of interest. A person can speak a literal truth while inferring a false inference or hiding his motivations.

As for the Zion Case, the father was a graduate of Yale Law School, the most competitive law school in the country. He later went on to become a journalist and passed away almost two years ago. He did make an emotional argument, but one that was based on the flaws of a system that went unchecked due to deference.

One such flaw is an abuse of a hierarchal system where seniors scut out juniors. This concept is fine in a free-market employment at will system but not becoming of a profession that prides itself on moral dignity and leadership. In that case, the senior was sleeping instead of helping out his intern. The culture was established that if an intern needed too much help, she was a bad intern. I believe that as hours shorten, everyone stays awake and everyone keeps on working the full time that they are there. That means residents doing the same scutwork as interns, although respecting their other activities. Indeed, in private practice, the attending is the intern as well.

This "all hands to battlestations" approach will require a cultural change. Resistance is evidenced by many attendings who pride themselves on having it much worse than current residents. But change will more likely occur if enough attendings see the flaw in this argument.

Finally, Cornell did not throw its residents under the bus. It provided legal support. The affected residents graduated despite what happened. However, the attending did try to throw the residents under the bus to protect himself from a charge of malpractice.

 

[Law2Doc]

...As for the Zion Case, the father was a graduate of Yale Law School, the most competitive law school in the country. He later went on to become a journalist and passed away almost two years ago. He did make an emotional argument, but one that was based on the flaws of a system that went unchecked due to deference. ...

Um no. His argument was not based in flaws of a system that went unchecked in his daughters case. His daughters case at least in part turned on the fact that she used illegal drugs, didn't tell the doctor what she was on, and the combination of illicit and licit drugs she ultimately ended up on proved fatal. But his daughters missteps were lost on him. In his mind, the tired doctors killed his daughter. And he went on a CRUSADE to change this system that he felt killed his daughter (even though the jury ultimately didn't really agree). He was lashing out emotionally and we all are living the consequences. It's you who shouldn't drink the koolaid and buy the false claim that Zion did anyone a favor other than perhaps quell his own internal angst.

 

[Law2Doc]

...
Yes, hand-offs suck from the patient's point of view. But as a patient, I'd rather have a doctor who's well-rested and have to repeat my story 12 times than a doctor who's been up and working for the past 24 hours. I think if you think about it in those terms, most patients would feel the same. Repeating your story is a nuisance. An exhausted intern can be fatal...

As mentioned above, it's the handoffs, not the exhaustion that are far more likely to be "fatal". And no, we aren't talking about lucid, healthy patients having to repeat histories, although that is certainly a pain. It's more about the dangers of functioning on a lack of information. Which is really dangerous when a patient is sick or crashing. For example if I know that I inadvertently turned a patient fairly hypoxic with a small dose of morphine early in my shift but I forget to mention that to the floater I hand off to, that night when the floater gets called by the nurse that "the patient is in pain, can we give them morphine?", the floater might give them morphine and kill them. The floater is well rested, but doesn't know the story. The tired intern would. And it's this kind of thing that makes handoffs really dangerous. Because every time you have a handoff, you lose more of the story (sort of like a bad game of telephone). And these omissions really truly can and do kill people. Someone who is dragging after a 30 hour shift isn't optimal but not nearly as likely to kill someone, IMHO. (And as mentioned, I have been the doctor in both kinds of situations).

So just don't forget these important details, you might say. But I suggest that if you are covering, say, 30 patients and you are anxious to sign out, you are going to just give the highlights, the things that jump to mind at the moment as being important, and thus lots of details like this slip through ON EVERY HANDOFF, for every patient. The patient is fine now and has been for hours, so it doesn't occur to you to mention anything. It might be written down someplace in your handoff document, but when they are covering lots of patients and things are really busy, they might not have the time to read.

Once you have actually worked as an intern, I think there's no question you would pick the informed intern over the tired intern as your choice of care provider every time. You'll see why.

 

[ilubmedicine]

As mentioned above, it's the handoffs, not the exhaustion that are far more likely to be "fatal". And no, we aren't talking about lucid, healthy patients having to repeat histories, although that is certainly a pain. It's more about the dangers of functioning on a lack of information. Which is really dangerous when a patient is sick or crashing. For example if I know that I inadvertently turned a patient fairly hypoxic with a small dose of morphine early in my shift but I forget to mention that to the floater I hand off to, that night when the floater gets called by the nurse that "the patient is in pain, can we give them morphine?", the floater might give them morphine and kill them. The floater is well rested, but doesn't know the story. The tired intern would. And it's this kind of thing that makes handoffs really dangerous. Because every time you have a handoff, you lose more of the story (sort of like a bad game of telephone). And these omissions really truly can and do kill people. Someone who is dragging after a 30 hour shift isn't optimal but not nearly as likely to kill someone, IMHO. (And as mentioned, I have been the doctor in both kinds of situations).

So just don't forget these important details, you might say. But I suggest that if you are covering, say, 30 patients and you are anxious to sign out, you are going to just give the highlights, the things that jump to mind at the moment as being important, and thus lots of details like this slip through ON EVERY HANDOFF, for every patient. The patient is fine now and has been for hours, so it doesn't occur to you to mention anything. It might be written down someplace in your handoff document, but when they are covering lots of patients and things are really busy, they might not have the time to read.

Once you have actually worked as an intern, I think there's no question you would pick the informed intern over the tired intern as your choice of care provider every time. You'll see why.

Your logic makes no sense. Whether you work a 16 hour shift or a 30 hour shift, you still have to HAND-OFF your patient. Either you hand it off that night, or you hand it off the next day, and somebody still covers your patient the entire time you are gone post-call. If you work only a 16 hour shift, you can still come in the next morning and take care of your patient. Often times, I would come back after a post-call day and so much had happened on my patient in the 24 hours I was gone that I felt I was getting just as much new info on my hand-off.

Your hand-off argument holds no merit. So let's just work continuously because you never have to hand off your patient! You will have to reliably and efficiently sign-out your patients even as attendings. Pilots, truckers, police man, no one who has the responsibility of human lives in their hands for 30 hour shifts. Stop drinking from the same KoolAid as was well quoted above.

If we want to show whether 30 hour shifts are or are not safe, we need to ask ACGME to stop regulating it. Doesn't the fact that they are vehemently oppposed to outside intervention make you suspicious?

The Federal Aviation Administration/NTSB regulates pilot hours
The Federal Motor Carrier Safety Administration regulates trucker hours

Trucker Unions and Pilot unions fight for these hour regulations, and yet the ACGME, who is neither our union, nor a government entity, but just a different version of the same people that run the residency programs are designating what's safe duty hours?

I would never want a pilot flying my plane after 30 hours working. That is exactly what caused the Buffalo Continental crash. Pilot fatigue. But suddenly we are allowing doctors to perform thoracentesis and cause a PTX after a 30 hour shift?

Why is it the rules change when it comes to MDs?

I dont claim to know what the best schedule is for residents, but I am opposed to ACGME regulating it.

 

[Ronin2258]

...Your hand-off argument holds no merit. So let's just work continuously because you never have to hand off your patient!

Eight years ago the above was the case. Been there, worked that, didn't stop until the patient was stable. One member of the team that admitted the patient was always in the hospital. Spent 6 weeks of general surgery as a STUDENT, working the same hours as an intern by schedule, seeing the sun all of 3 times; trip to the hospital's city, trip back to the school for the shelf, and after the shelf was done.

...I dont claim to know what the best schedule is for residents, but I am opposed to ACGME regulating it.

The ACGME regulations ends when you are finished with residency. Period. Take comfort in that you are not a resident forever; 3-8 years out of a lifetime, depending on the specialty.

I believe you assume too much in thinking that attending life is easier. As an attending, you work until the job is done. I know my attendings busted their butts on call only to work a booked clinic the day after while I slept. In a staff hospital (no residents,) you still take the clinic after a night of operating, and maybe get home before midnight the night after call.

When a truck driver takes their mandatory break, their vehicle should be ready to go when they wake up without deterioration. When a pilot takes their break can swap out with another pilot who knows the particular plane they are flying, so they can go right into it.

How is a heart surgeon supposed to do a procedure that takes 36 hours when a federal agency forces them out of the room to take 10 hours to sleep after the first 24 hours? How is a plastic surgeon and neurosurgeon supposed to rebuild a cervical spine and a pharynx in 24 hours or less? What do those patients do, just hang out in the operating room with their chest flayed open or their spinal cord exposed? That surgeon or surgical team may be the only one (or the only one in safe transport distance,) who does that procedure. When you are an attending, there is no swap out for a refreshed physician. There is no break when the patient is deteriorating. It can, and more than likely will be, just you and your skills set.

The ACGME rules are there in residency so that you have time to rest and recover enough mental faculties to learn as much of the specialty that you can. Once you are out of residency, those rules go away, and you are completely at the mercy of the needs of your patient with no backup. And THAT is why physicians are, in a sense, OSHA exempt. Patients, to quote a favorite quote, "...want us to make it better...or make it not so. They want to be healed and they come to me when their prayers aren't enough." If it means you are up for 2 days straight, then you're up.

When you do clinical rotations, look at the attendings, NOT the residents. Do they work longer hours than the residents? Odds are in a procedure heavy specialty, or a busy community medical center if you are more medical, attendings do work harder and longer than the residents (mine did.) Even my chiefs who are now attendings realize they work harder then they ever did as a resident.

Now attendings have to be called with every admission on a procedure specialty. Eight years ago, a PGY-5/chief could take a junior resident down to the OR to do at least start simple appy, if not do it as a housestaff only case. Now ACGME rules require the attendings to be there for every case in the operating room, woken up from sleep to travel to the hospital. And these same attendings had to pull a full day of clinic they can't cancel (you get your patients for electives initially in the clinic,) the day after you gave them the patient from hell.

I quote the following to drive that point home.

You assume a couple of points that may not be true. The first is that your post-residency job is going to be easier/less time-consuming than residency. I look at my IM hospitalists taking q3 call and admitting 20+/night or my surgeon begging me not to accept anymore transfers because he's been operating for 18 straight hrs and we just had a helicopter drop off a lady with dead gut. There's not usually a cap in the real world, and a full day of clinic (not home by noon) post-call is the norm.

And for the the one that thought a 5am lab practical is cruel, it gets better; it went for seven hours straight. Imagine going through that then going to a 1pm organic chemistry or physics class for another couple of hours. Did it for three semesters.

 

[ANCAdoc]

Odds are in a procedure heavy specialty, or a busy community medical center if you are more medical, attendings do work harder and longer than the residents (mine did.)

[1] I find the talk that "the ACGME won't protect you when you are an attending" pretty amusing. When you finish residency, you have a wide array of jobs available to you. Can you find an opportunity where you can work extremely long hours and take frequent call, working more than 80 hours a week? Yes. Can you find an opportunity to work part time? Yes. Can you find an opportunity to work weekdays only with no call? Yes.

So long as there remains a physician shortage, it will be a buyer's market. You can negotiate your contract, sometimes significantly to make it more appealing to your lifestyle.

For those of you who dislike call or working 30 hours straight, life is much better after residency. Don't let a few stories of some CTS attendings scare you that it will be doom and gloom when you leave residency.


[2] I'm in Internal Medicine. I can guarantee you that >90% of my attendings work less than 80 hours a week. They only staff two weeks at a time. When off service, their hours are pretty much 8-5 doing clinics, administrative/educational service. And they never work for more than 12 hours at a time.

As for call, they are only on when their team is on call. They leave the hospital and are available by phone. I've never called them so they sleep just fine.