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

[Winged Scapula]

I think one of the issues you seem to be neglecting EagertoBe is that nightfloaters aren't only up 12 hours. As smq and others have noted, there is a terrible disruption to the circadian rhythms. These residents doing NF aren't going home and sleeping right away, and therefore may have been up a significant number of hours already when they show up for work. And for those who do NF, they'll tell you that the sleep they do get is not restful and they actually feel better on a more normal qwhatever call schedule. So its *not* up 12 hours versus up 30 hours.

NB: I've never done NF and don't have an opinion on it. But I can state that the type of patient, the type of work is much different at night than in the day - the level of supervision and independence is much different and I firmly believe that bad things happen after dark. Patients are much more likely to crash in the wee hours, or so it always seemed to me.

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[JackADeli]

I'm not against work hour reform that's driven by data.

My residency hours mostly averaged in the 65-70 hours/week range...

But honestly, it's no skin off my back. I'm done. I've got no interest in resisting change just to pointlessly force others to pay dues or something. I'm not a voting member of any committee; I don't work for the ACGME or OSHA; I'm not a Congressman. ...If the perspective-deficient inmates over at AMSA want a crack at running the asylum and shoot themselves in the foot, it's their education.

I somewhat agree. From a purely selfish standpoint, it could potentially have great benefit to my pocket book if all the young, hotshot turks coming out of residency after me are actually under trained.... i.e. 30-40hrs/wk training vs my past experience. Just from a statistical standpoint, many will have very unfortunate events related to their lack of foundation/training. Instead of patients leaving my practice for the "new hot shot grad from the Ivy league", rather they will flock to my practice and others to avoid the "new hot shot grad from the Ivy league".

It really is your training and your future. I have consistently argued that the education needs reform. However, focusing on "hours" is simplistic and as noted above may result in a bad pedal injury. With healthcare reimbursements being what they are, many argue an inability to make enough to pay off student loans. It would be very, very sad if you go through happy, kinder residency and are unable to get a job or keep a job because you have been heavily sued for lack of training (i.e. incompetence). Try paying them loans now!

PS: I have no dog in this fight. I currently don't use medical students or residents. When an occasional resident shows up on the service, I do not depend on them. I take call for MY patients. I teach the residents while they are around but do not even try an make a schedule for when they should be around. It is a new wave era, they show when they want to and are not missed when they don't.... that's how THEY like/want it.

 

[Law2Doc]

I somewhat agree. From a purely selfish standpoint, it could potentially have great benefit to my pocket book if all the young, hotshot turks coming out of residency after me are actually under trained[/I].... i.e. 30-40hrs/wk training vs my past experience. Just from a statistical standpoint, many will have very unfortunate events related to their lack of foundation/training. Instead of patients leaving my practice for the "new hot shot grad from the Ivy league", rather they will flock to my practice and others to avoid the "new hot shot grad from the Ivy league".

It really is your training and your future. I have consistently argued that the education needs reform. However, focusing on "hours" is simplistic and as noted above may result in a bad pedal injury. With healthcare reimbursements being what they are, many argue an inability to make enough to pay off student loans. It would be very, very sad if you go through happy, kinder residency and are unable to get a job or keep a job because you have been heavily sued for lack of training (i.e. incompetence). Try paying them loans now!

PS: I have no dog in this fight. I currently don't use medical students or residents. When an occasional resident shows up on the service, I do not depend on them. I take call for MY patients. I teach the residents while they are around but do not even try an make a schedule for when they should be around. It is a new wave era, they show when they want to and are not missed when they don't.... that's how THEY like/want it.

I too am past the point when duty hours will have much impact, but disagree with your assessment here. You still have a stake insofar as folks who go through training now will be your partners, consultants, colleagues and committee co-chairs a few years down the road. The public and jury perception of doctors impacts you, and any failures in training will dog you just like every other physician. And if failures in training open the doors further for midlevels, certainly you will be losing patients to the cheaper DNPs just as likely as someone coming through residency now. As a profession we are bound together in lots of ways. It only takes a few rotten apples to taint the flavor of the whole barrel.

 

[JackADeli]

I too am past the point when duty hours will have much impact, but disagree with your assessment here. You still have a stake insofar as folks who go through training now will be your partners, consultants, colleagues and committee co-chairs a few years down the road. The public and jury perception of doctors impacts you, and any failures in training will dog you just like every other physician. And if failures in training open the doors further for midlevels, certainly you will be losing patients to the cheaper DNPs just as likely as someone coming through residency now. As a profession we are bound together in lots of ways. It only takes a few rotten apples to taint the flavor of the whole barrel.

I appreciate and also generally agree with the few bad apples point.... However, if sweeping rules cause the general graduating population to be undertrained, it is far more then a few bad apples. The press/media will definately start focusing on the lack of training. I am not afraid a DNP or PA will take my job... especially if those supposedly residency trained in my job are underqualified to do my job. If my future colleagues have trouble competently removing difficult gallbladders or colons with 5 years of 40hrs/wk training... I am certain a DNP with a couple hundred hours of book work is not going to fare any better.....

There will be a stratification of who the public views as qualified. As it stands, the public often worries about "how young" their surgeon appears. This may be a trend with even more reality if the "young" surgeon not only lacks the experience of the "old" but also lack years of training....

Again, yes, I have a stake in the quality of over all healthcare. Yes, I do NOT want patients suffering under less competent care. Yes, I do NOT want to be cleaning up the mess of complications from poor clinical judgement and less qualified physicians, PAs, NPs, DNPs... Yes, their malpractice will effect my premiums. But, from a purely market standpoint, the stream of clients will shift towards those trained before year "199x" or "200x", etc.... I also suspect just as with car insurance and young drivers equals higher premiums, as the significant shift in training starts to give data of complication rates, so too will it be more costly to insure new grads from programs with demonstrated shorter hours of training, etc... Insurance companies may also start looking at program board cert pass rates... if they are not already.

Again, the point is not that I ~just don't care. I actually do. The point is the fight is "yours". It is first and foremost "your" education. These organizations, AMSA, etc.... are in theory representing "you". So, it is up to "you" to steer their efforts towards education reform and not misguided punch card hours reform. It is your education.....

...From a purely selfish standpoint, it could potentially have great benefit to my pocket book if all the young, hotshot turks coming out of residency after me are actually under trained.... i.e. 30-40hrs/wk training vs my past experience...

It really is your training and your future. I have consistently argued that the education needs reform. However, focusing on "hours" is simplistic and ...It would be very, very sad if you go through happy, kinder residency and are unable to get a job or keep a job because you have been heavily sued for lack of training (i.e. incompetence)...

PS: the issue of no dog in the fight is specific to me not having a conflict of interest in so much as I do not have med students or residents as ~servants. I am not conflicted because I use cheap labor residents and thus fear having to work, etc.... because I do NOT use them. thus my point of no dog in the fight.

 

[danielmd06]

SLEEP
VOLUME 33, ISSUE 08
EFFECTS OF REDUCING RESIDENT WORK SHIFTS OVER 16 HOURS—A REVIEW
Effects of Reducing or Eliminating Resident Work Shifts over 16 Hours: A Systematic Review
Adam C. Levine, MD, MPH; Josna Adusumilli, MD; Christopher P. Landrigan, MD, MPH

Study Objectives: The Institute of Medicine (IOM) has called for the elimination of resident work shifts exceeding 16 hours without sleep. We sought to comprehensively evaluate the effects of eliminating or reducing shifts over 16 hours.
Design and Outcome Measures: We performed a systematic review of published and unpublished studies (1950-2008) to synthesize data on all intervention studies that have reduced or eliminated U.S. residents' extended shifts. A total of 2,984 citations were identified initially, which were independently reviewed by two authors to determine their eligibility for inclusion. All outcomes relevant to quality of life, education, and safety were collected. Study quality was rated using the U.S. Preventive Services Task Force methodology.
Measurements and Results: Twenty-three studies met inclusion criteria (κ = 0.88 [95% CI, 0.77-0.94] for inclusion decisions). Following reduction or elimination of extended shifts, 8 of 8 studies measuring resident quality of life found improvements. Four of 14 studies that assessed educational outcomes found improvements, 9 found no significant changes, and one found education worsened. Seven of 11 identified statistically significant improvements in patient safety or quality of care; no studies found that safety or care quality worsened.
Conclusions: In a systematic review, we found that reduction or elimination of resident work shifts exceeding 16 hours did not adversely affect resident education, and was associated with improvements in patient safety and resident quality of life in most studies. Further multi-center studies are needed to substantiate these findings, and definitively measure the effects of eliminating extended shifts on patient outcomes.

(1) Basically, when you look at fluffy, subjective scales like "quality of life," or "fatigue," residents from radiology, EM, IM, OB-GYN, and General Surgery reported better scores when they worked less hours. Seriously, what did everyone expect? And there is always room for bias in self-reported measures.

(2) Education neither worsened nor improved with the groups that worked less hours. Residents didn't study more with the extra time off, and didn't perform better on in-service examinations with lighter schedules. Neither did they perform significantly better with the longer hours or "more experience." Basically, medical education appeared unchanged. BUT..."long term educational outcomes were not assessed."

(3) Most importantly, patient safety/quality of care appeared to improve with the shorter schedules. Unfortunately, the data wasn't as overwhelming as the article words it. BUT, care didn't appear to worsen with shorter schedules for anyone.

Not exactly bearing on the original post...but in-line with arguments being made regarding "less is more" versus "more is more."

I was always pretty good with hierarchy and a military-esque structure of the higher you rank, the more perks you get. It had the benefit of letting residency get physically easier as you went along.

I think the biggest problem with resident education (as someone who just completed it) can be summed up in three words: lack or ownership. Lack of ownership of the patients from the residents. Working fewer hours will only exacerbate that with more hand-offs and more pious excuses about why no one seems to have a clue what's going on with a patient.

How many times on-call did I hear this: "Sorry, I don't know. That's not MY patient."

You learn more when you take full responsibilty for the patients...whether anyone here wants to really admit that or not. And you tend to take full responsibility when you are personally present more...not less. Whether it happens at night or during the day. Whether night float is implemented or not. And it doesn't matter how much time off you have or how much you read (as this study actually seems to indicate).

Anyway. Others can convey this mind-set more eloquently.

 

[Arcan57]

NEJM just published (12/01) a survey of residents regarding their expectations in regard to the ACGME regulations. To summarize most residents thought their well-being would improve, but that patient care, resident education, and their readiness for senior roles would be negatively impacted.

Interestingly, residents also predicted that the new regulations would emphasize service obligations over education. My guess is that the lack of didactics on night float will need to be addressed, especially for programs (surgical sub-specialties and smaller OB residencies especially) whose residents will spend a significant portion of the year on NF.

 

[Neuronix]

Only 22% of residents responded to the survey. "A free-response item elicited thoughtful and often lengthy commentary from nearly half the respondents."

To me there seems to be a clear selection bias among the respondents. They likely represent the minority who feel strongly against the work hour rules and who had an axe to grind.

Never mistake the vocal minority for the majority. I'm surprised NEJM published this with such a poor response rate. Considering what they have chosen to publish and not publish regarding resident work hour rules, I'm beginning to wonder if the editorial board there has its own bias against work hour rules reform.

 

[Arcan57]

Only 22% of residents responded to the survey. "A free-response item elicited thoughtful and often lengthy commentary from nearly half the respondents."

To me there seems to be a clear selection bias among the respondents. They likely represent the minority who feel strongly against the work hour rules and who had an axe to grind.

Never mistake the vocal minority for the majority. I'm surprised NEJM published this with such a poor response rate. Considering what they have chosen to publish and not publish regarding resident work hour rules, I'm beginning to wonder if the editorial board there has its own bias against work hour rules reform.

Given their population size and response rate, there is a 95% certainty that the results are within +/- 1.9% of their findings. This figure is derived from an estimate of the number of residents in the US (~100k) and 2561 residents responding using the 95% confidence interval. Using the 99% CI broadens the error level to +/- 2.5%. So your argument regarding inadequate response rate doesn't hold up.

 

[Neuronix]

To use those confidence intervals, once must assume random sampling. i.e. You are assuming that those who responded to the survey were random representatives of all residents nationwide. What I clearly proposed in my post was that the respondents were not random, but self-selected to respond because they were particularly unhappy with the changes.

My belief is that those residents who are ambivalent or happy with the changes don't have the strong impetus to quickly respond to this survey. While those who did respond were much more likely to be unhappy with the changes. Thus, I believe this is a skewed sample, and your statistical analysis does not apply.

This is the same sort of issue one has in interpreting reviews of restaurants. Those customers who are dissatisfied are vocal, however the majority who feel ambivalent or satisfied are not vocal. Or to put it another way, to put a survey out there and just allow people to choose to answer it or not, is the equivalent of posting a survey on foxnews.com or slashdot.org. Those who choose to respond to the survey have a skewed, strong point of view in some direction. This is not representative of the population at large.

 

[Arcan57]

To use those confidence intervals, once must assume random sampling. i.e. You are assuming that those who responded to the survey were random representatives of all residents nationwide. What I clearly proposed in my post was that the respondents were not random, but self-selected to respond because they were particularly unhappy with the changes.

My belief is that those residents who are ambivalent or happy with the changes don't have the strong impetus to quickly respond to this survey. While those who did respond were much more likely to be unhappy with the changes. Thus, I believe this is a skewed sample, and your statistical analysis does not apply.

This is the same sort of issue one has in interpreting reviews of restaurants. Those customers who are dissatisfied are vocal, however the majority who feel ambivalent or satisfied are not vocal. Or to put it another way, to put a survey out there and just allow people to choose to answer it or not, is the equivalent of posting a survey on foxnews.com or slashdot.org. Those who choose to respond to the survey have a skewed, strong point of view in some direction. This is not representative of the population at large.

Restaurant reviews still tend to give high marks to good restaurants and low marks to bad restaurants. The written responses tend to be skewed because of the effects you just mentioned, but the average rating still tends to be accurate (as it takes no more effort to fill in a bubble for a 4 than a 1). So I don't think your comparison to restaurant reviews holds up.

In terms of foxnews or slashdot, their surveys probably are fairly accurate at depicting the views of the people that view those websites. And if they DID collect demographic data, I'm sure that data would show that the survey respondent's demographics differed significantly from the population mean. The survey respondents demographics were similar to the US resident population as a whole.

If the responses were as systemically biased as you suggest, I would expect that all the questions would favor keeping the old rules. Instead residents did think their well-being would improve, and like this forum they were all over the board on the issue of improved patient safety.

 

[Neuronix]

All your points come down to a matter of opinion and perspective. I will let the reader decide whether or not there is sampling (self-selection) bias in the responses to this survey. The following is a better description:

Self-selection bias, which is possible whenever the group of people being studied has any form of control over whether to participate. Participants' decision to participate may be correlated with traits that affect the study, making the participants a non-representative sample. For example, people who have strong opinions or substantial knowledge may be more willing to spend time answering a survey than those who do not. Another example is online and phone-in polls, which are biased samples because the respondents are self-selected. Those individuals who are highly motivated to respond, typically individuals who have strong opinions, are overrepresented, and individuals that are indifferent or apathetic are less likely to respond. This often leads to a polarization of responses with extreme perspectives being given a disproportionate weight in the summary. As a result, these types of polls are regarded as unscientific.

I just wanted to comment on the following point.

If the responses were as systemically biased as you suggest, I would expect that all the questions would favor keeping the old rules.

Not really. Nobody can argue that resident well-being will decline with increased protections. It just makes no logical sense. Even those against the work hour rule changes must concede that point.

 

[Arcan57]

While this study was online, it was not the type of on-line poll mentioned in the Wiki article. Examples of that type of poll would be the foxnews.com or even SDN polls that frequently crop up. This study could very well have been conducted twenty years ago using mail, and I haven't seen data to indicate that this form of survey suffers significantly in comparison to traditional mail based surveys.

My point in posting regarding the survey was that the attendings and residents that have concerns over changing ACGME rules without convincing data are not alone. That concern appears to be shared by a significant percentage of current residents, for many of the reasons brought up in this thread. If your belief is that the study is so biased that it has no generalizability (ie it only represents pissed off residents with an ax to grind against the ACGME), I doubt I'll be able to convince you otherwise. But just because you don't like the results doesn't mean they are incorrect.

In regard to your statement about no one being able to argue that it improves resident well-being, I would say you are correct if you substitute intern for resident. For the PGY-4 and PGY-5 that used to be able to take home call but is now doing q3 in-house call with the interns, I would say that has a large negative effect on their well-being.

 

[ilubmedicine]

Was there ever a decision on this?

 

[GreatSaphenous]

Was there ever a decision on this?

Sure I have decided to wish everyone in favor of further cuts well in their 6-10 year residencies.

All for now, go back to your chili Mac.
I am the Great Saphenous!!!!

 

[jbcarlso]

Esteemed colleagues,

As a current PGY1 nearing the end of PGY1 in a surgical subspecialty I'll offer the following brief thoughts:

Interesting thread littered with a glut of level 5 evidence with a sprinkling of higher levels.

1) I agree that time spent on call is when I learned the most. I started internship determined not to kill anyone (successful so far). I now near the end trying to actually help people and protect my seniors from middle of the night bull**** as appropriate rather than simply do no harm. Edit: I should clarify as follows. I have done a number of months with close to q3 call. I have never done night float. I am of the opinion that knowing the pt from presentation to hand-off the next am was absolutely in the pt's best interest. Subtle things (from an intern's perspective - possibly better described as 'things not anticipated to be important from my perspective') would come up on rounds the next am and I can't imagine a hand-off covering these subtleties as I didn't recognize them as vital to pt care.

2) I fear the reduction of work hours as a PGY2 and beyond. If I didn't sleep on call then I'll go home post-call. However, if I did and there are cases, I'd prefer that the decision to stay and operate the following day be left to me and my staff rather than dictated from afar by some regulatory agency.

3) While a great deal of what I learned as a PGY1 "prelim" will be worthless in my eventual career, I acknowledge my inability to accurately assess the value of these experiences given my own obvious lack thereof. I'm tempted to support restricting intern year hours, as I think interns are largely abused as warm bodies who have an MD and can deal with floor scut cheaper than a PA or NP could with little actual educational benefit.

4) For the students in this thread, welcome to the debate. You definitely have a spot in the debate as all of this will affect you. That said, the transition from student to intern is marked. Please respect the opinions of those who have come before you. We all stand on the shoulders of giants.

I'll end with this:

No one who went into a surgical specialty or GS did so blindly. We all knew what we signed up for and that hours would be long. We could have done a more lifestyle-friendly residency, but we decided that we wanted to combat disease with cold steel (and power tools in my case); and that comes with a cost and a significant reward. I would hope we weighed those choices before matching into such a specialty.

Best,
jb