What do you log as work hours?

[PMRMD2B]

I was wondering what hours, other than direct, clear-cut work hours do you log. My programs seems to go back and forth on what is considered work hours. According to my interpretation of ACGME rules, journal club (if "strongly suggested"), resident interview (outside of normal hours), and being on residency councils (again, outside normal hours) should all be logged.

The point is this.. we are an ethical, rule following profession.. correct? If we are encouraged to bend the rules that our accrediting body institutes, then why no bend all the rules? Either we do what is right and correct, or we don't.

Any comments or thoughts?

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[NotAProgDirector]

You should review the ACGME duty hour site, where many questions like this are answered. Specifically, look at the links labeled "Frequently asked questions about the common program requirements" and "Specialty specific duty hour definitions and FAQ". Read them in that order.

Specifically from the FAQ:

What is included in the definition of duty hours under the requirement “duty hours must be limited to 80 hours per week.”?
Duty hours are defined as all clinical and academic activities related to the residency program. This includes inpatient and outpatient clinical care, in-house call, short call, night float and day float, transfer of patient care, and administrative activities related to patient care such as completing medical records, ordering and reviewing lab tests, and signing verbal orders. For call from home, only the hours spent in the hospital after being called in to provide care count toward the 80-hour weekly limit. Hours spent on activities that are required by the accreditation standards, such as membership on a hospital committee, or that are accepted practice in residency programs, such as residents’ participation in interviewing residency candidates, must be included in the count of duty hours. It is not acceptable to expect residents to participate in these activities on their own hours; nor should residents be prohibited from taking part in them. Duty hours do not include reading, studying, and academic preparation time, such as time spent away from the patient care unit preparing for presentations or journal club.

Even with this, there's some flexibility. If the resident class decides to have their own Journal Club at the local pub at 8PM, even if you really do talk about an article, that doesn't get logged IMHO. If I make it mandatory, then it does.

 

[hamstergang]

If we are encouraged to bend the rules that our accrediting body institutes, then why no bend all the rules? Either we do what is right and correct, or we don't.

No. Such black and white thinking isn't required to function in this world.

That said, I wouldn't recommend lying about duty hours. But if you do, that doesn't justify killing someone since you're on a rule-breaking spree.

 

[Raryn]

You should review the ACGME duty hour site, where many questions like this are answered. Specifically, look at the links labeled "Frequently asked questions about the common program requirements" and "Specialty specific duty hour definitions and FAQ". Read them in that order.

Specifically from the FAQ:



Even with this, there's some flexibility. If the resident class decides to have their own Journal Club at the local pub at 8PM, even if you really do talk about an article, that doesn't get logged IMHO. If I make it mandatory, then it does.

The only gray area I have is what to do with the hours where I went home and then catch up on progress notes from there.

Like, especially intern year, it wasn't unusual for me to finish a workday, go home, have dinner, watch some TV, then spend a couple hours to wrap up clinic notes or discharge summaries or whatever. If I were to log those as one continuous shift, which a strict reading of the rules might suggest, I was breaking duty hours pretty much every day I did that. I just ended up logging the hours I was physically in the hospital.

 

[PTPoeny]

The only gray area I have is what to do with the hours where I went home and then catch up on progress notes from there.

Like, especially intern year, it wasn't unusual for me to finish a workday, go home, have dinner, watch some TV, then spend a couple hours to wrap up clinic notes or discharge summaries or whatever. If I were to log those as one continuous shift, which a strict reading of the rules might suggest, I was breaking duty hours pretty much every day I did that. I just ended up logging the hours I was physically in the hospital.

In our duty hour software there is an option to log two separate times but list them as a single work unit with strategic napping. That way you don't break the restriction on enough time between shifts. We do that for similar situation

 

[Raryn]

In our duty hour software there is an option to log two separate times but list them as a single work unit with strategic napping. That way you don't break the restriction on enough time between shifts. We do that for similar situation

I think the whole continuous period would still count towards 80 though. At least the way our program interprets the rules.

I just don't log anything after I get home though.

 

[tiedyeddog]

I just log whatever time I am physically in the hospital.

 

[evilbooyaa]

6am - 5pm, M-F.

I've worked the exact same schedule every month for the last four years.

Don't wanna be over work hours.
Ortho right? I've found Ortho and NSG at my hospital are most likely to do this, followed by Gen Surg residents.

 

[Mirp]

I think there are a lot more that log those magically consistent hours than don't. Was just discussing this with my senior resident last week. She's been consistently over work hours for several weeks and nobody seems to care. We were wondering why. Checked the ACGME guidelines and it seems that there is significant leeway for patient care requiring extra work hours when you're a senior resident (3rd year FM). So.... you can log accurately and rock the boat or you can log Tired's hours because it doesn't matter anyway. Just another layer of bureaucracy.

 

[RadOncDoc21]

I think there are a lot more that log those magically consistent hours than don't. Was just discussing this with my senior resident last week. She's been consistently over work hours for several weeks and nobody seems to care. We were wondering why. Checked the ACGME guidelines and it seems that there is significant leeway for patient care requiring extra work hours when you're a senior resident (3rd year FM). So.... you can log accurately and rock the boat or you can log Tired's hours because it doesn't matter anyway. Just another layer of bureaucracy.

Totally agree, the first time I was honest, I had a meeting with the PD which was held ironically outside of my duty hours, making me really go over my duty hours.

 

[gutonc]

6am - 5pm, M-F.

I've worked the exact same schedule every month for the last four years.

The system that my program used pre-populated your duty hour log with the hours you were theoretically supposed to work. Everybody just clicked "Log Hours" and that was that.

 

[laconfidential]

We're able to log our hours up to two weeks in advance. Definitely promotes honesty!

 

[Doctor Bagel]

I reached a point in later residency where actually correctly logging my work hours would take a ton of time because I would work multiple sites in one week (and sometimes in one day). I never came remotely close to violating work hours anyway and consequently got a bit lax in my logging. Luckily they switched it to where we could just click something saying we didn't violate hours in a time period rather than log each specific hour of work.

 

[PMRMD2B]

I also had questions about logging hours for working from home, i.e. doing notes. I looked at it this way, IF.. IF I one was getting paid hourly for work, like if you were an attending, would you log that time or just say, nah... those two hours doing notes at home is just donated time? We don't have to worry about that in my program now, since they instituted that all residents are to finish all their notes before leaving the hospital.

Either way, it doesn't really matter. Programs will report whatever hour they want and they have the ability to alter whatever we log, so I just focus on working. I just wanted to hear some people's opinions and experience. Thanks for any responses.

 

[Smurfette]

I also had questions about logging hours for working from home, i.e. doing notes. I looked at it this way, IF.. IF I one was getting paid hourly for work, like if you were an attending, would you log that time or just say, nah... those two hours doing notes at home is just donated time? We don't have to worry about that in my program now, since they instituted that all residents are to finish all their notes before leaving the hospital.

Either way, it doesn't really matter. Programs will report whatever hour they want and they have the ability to alter whatever we log, so I just focus on working. I just wanted to hear some people's opinions and experience. Thanks for any responses.

Most attendings are not paid as hourly employees, but are effectively paid by what they bill during their time at work (i.e. RVU system based on number of patients seen, procedures done, etc.) or are salaried.

 

[tiedyeddog]

Don't wanna be over work hours.
Ortho right? I've found Ortho and NSG at my hospital are most likely to do this, followed by Gen Surg residents.

Ha, I do the same.

 

[Law2Doc]

I know a colleague who dutifully logged hours that showed he was about to exceed duty hours one month. The program gave him an extra day off to get him somewhat back on track, but he had to meet with multiple attendings during that day to understand why it was that he was so slow and inefficient and couldn't get his work done within the duty hours "like everyone else". He took the hint.

 

[blebb]

PGY3, I have yet to log any hours

 

[smq123]

I log those hours so that people leave me alone. I just want to operate. I could care less about that ACGME nonsense, because in a very short period of time, I'm going to be taking people to the OR on my own credit card. I don't understand how anyone can contemplate that reality and then worry that they're not spending enough time at home.

Small lol at the thought of a PGY3 being a "senior resident".

What would you prefer that a Family Med or IM PGY-3 be called?

 

[smq123]

I don't think you really want to hear his answer...

Honestly, it was more out of curiosity. Laughing because a FM PGY-3 (or peds, or IM) calls themselves a "senior resident," when, well, they are relative to everyone else in their program, just seems a little dumb. Because what else do you call them? Well, besides Kiddo or Pumpkin, I suppose.

I don't personally care; I haven't been a PGY-3 in over 3 years now. But I would actually agree that calling yourself a "senior resident" when you're a PGY-2 is a little silly.

 

[Raryn]

"Kiddo" or "pumpkin".

Only thought of this because I happen to be at a place where peds PGY2s call themselves "senior residents" and the PGY3s say they are "the chief of the service."

They get super irritated when I laugh.

*Shrug*. Our PGY2s are seniors. As are our PGY3s. Some places the terminology is intern/junior/senior for IM/peds pgy1/2/3s, others it is just intern/senior. Regardless, the ACGME considers the 3 year specialties to only have interns and "residents in their final years of training", and explicitly says that they do NOT consider any IM residents to be "intermediate year residents" when it comes to the duty hour rules.

And those who stay as PGY4s are chiefs... and junior attendings at that. If you laughed at that, I'd just smile at the thought of you being a PGY7 resident when I'm an attending.

 

[Law2Doc]

These titles are irrelevant. Who cares if someone in a short residency calls themselves a senior in their second year. Nobody is going to bow down to them if they aren't working under them. What matters is the years of experience. When I was an intern, I witnessed a pretty intense dispute between a sixth year "resident" and a newly minted (i.e. 4th year) IM hospitalist "attending" over a patient care matter. The hospital higher ups got involved (at the request of/complaint filed by the hospitalist, actually) and in no uncertain terms let that attending know he should have more deference to those with years more experience. He did not last long there. Often the titles are irrelevant when you look across specialties. It's the years logged (the PGY) that matters.

 

[22031 Alum]

in no uncertain terms let that attending know he should have more deference to those with years more experience.

The difference between a newly-minted 6 and a new IM hospitalist is exactly two years, and not even in the same specialty. Physicians in other fields with many more than two extra years experience defer to my expertise in my specialty all the time. Literally every day. I'm not commenting on how appropriate the argument was, but that hospital policy sounds really dumb when you think about it.

 

[Law2Doc]

The difference between a newly-minted 6 and a new IM hospitalist is exactly two years, and not even in the same specialty. Physicians in other fields with many more than two extra years experience defer to my expertise in my specialty all the time. Literally every day. I'm not commenting on how appropriate the argument was, but that hospital policy sounds really dumb when you think about it.

I am not going to go into the specifics of the dispute but both parties were involved in a patients care and pulling in competing directions. The dispute involved a component of care within both individuals scope of practice, so specialty differences were not the issue. I didn't state the deference comment as one of "hospital policy" (and I actually can't see where you drew that from my post) but to point at that one's title is meaningless if the knowledge base/experience isn't there. Which was both the "hospital higher ups" and my point.

 

[22031 Alum]

I didn't state the deference comment as one of "hospital policy" (and I actually can't see where you drew that from my post)

From when you said "hospital higher ups" got involved. In my experience when that happens it means policies are getting invoked. I recently had a colleague who felt pressured into doing something that didn't jive with our specialty standards because the consulting doc was an intimidating guy who had taught her as a student. It didn't turn out well, and that made me read too much into what you wrote!!

 

[Law2Doc]

From when you said "hospital higher ups" got involved. In my experience when that happens it means policies are getting invoked. I recently had a colleague who felt pressured into doing something that didn't jive with our specialty standards because the consulting doc was an intimidating guy who had taught her as a student. It didn't turn out well, and that made me read too much into what you wrote!!

Nope. The attending in my scenario filed a formal complaint against the resident, which is why the "higher ups" got involved -- I actually mentioned that in my post. He lost. Was the talk of the hospital...

 

[rokshana]

These titles are irrelevant. Who cares if someone in a short residency calls themselves a senior in their second year. Nobody is going to bow down to them if they aren't working under them. What matters is the years of experience. When I was an intern, I witnessed a pretty intense dispute between a sixth year "resident" and a newly minted (i.e. 4th year) IM hospitalist "attending" over a patient care matter. The hospital higher ups got involved (at the request of/complaint filed by the hospitalist, actually) and in no uncertain terms let that attending know he should have more deference to those with years more experience. He did not last long there. Often the titles are irrelevant when you look across specialties. It's the years logged (the PGY) that matters.

was the hospitalist the primary? seems to me that the end decision of pt care should be with the primary responsible for the patients care...if the resident was part of a consulting team, then really their ideas are recommendations and it is up the primary team...afterall if the case were to go south and lawsuits filed, the primary is going to have to explain why he went a different way than what his specialist recommended...

but to get into a heated dispute with a resident when you are an attending is poor form...he should have just said that he would discuss it with the resident's attending and shut it down.

 

[Law2Doc]

was the hospitalist the primary? seems to me that the end decision of pt care should be with the primary responsible for the patients care...if the resident was part of a consulting team, then really their ideas are recommendations and it is up the primary team...afterall if the case were to go south and lawsuits filed, the primary is going to have to explain why he went a different way than what his specialist recommended...

but to get into a heated dispute with a resident when you are an attending is poor form...he should have just said that he would discuss it with the resident's attending and shut it down.

The hospitalist was covering that patient that night. His service was the primary. Doesn't mean the hospital is fine sinking with that ship. My point though was that at the end of the day the "titles" of the parties involved were meaningless.

 

[Raryn]

These titles are irrelevant. Who cares if someone in a short residency calls themselves a senior in their second year. Nobody is going to bow down to them if they aren't working under them. What matters is the years of experience. When I was an intern, I witnessed a pretty intense dispute between a sixth year "resident" and a newly minted (i.e. 4th year) IM hospitalist "attending" over a patient care matter. The hospital higher ups got involved (at the request of/complaint filed by the hospitalist, actually) and in no uncertain terms let that attending know he should have more deference to those with years more experience. He did not last long there. Often the titles are irrelevant when you look across specialties. It's the years logged (the PGY) that matters.

I don't know the specific situation, but I completely disagree with your interpretation. It's true, the definition of junior/senior/chief is irrelevant.... but in the case of attending vs resident, the years logged (the "PGY") isn't at all what matters, but the title is. The newly minted hospitalist attending, especially if he's primary, is where the buck stops. He is the physician of record, and it doesn't matter if he has one day of experience as an attending or forty years. On the other hand, a resident in a different specialty, even if it's a PGY10 surgical fellow, is not only a consultant, but also not completely trained in his field. He makes recommendations (not the definitive plan), is not the primary MD on the service, and if there's any sort of dispute should get his attending to (cordially) discuss the matter with the other attending. If there is then a reasonable disagreement with regards to patient care, you can have a pissing contest and eventually hash it out with the higher ups via peer review, but that should never be an attending (of any level) hashing it out with a resident/fellow (of any level).

The fact that the higher-ups at your hospital disagreed with that interpretation is bizarre to me, because everywhere I've ever been an attending is an attending. And when it comes to disputes, the two fully trained physicians with their own hospital privileges are the only ones that hash it out.

Edit: And just to clarify just in case since you refer to the IM person as a resident in one of your later posts: Even if it was a PGY4 Chief Resident, they are attendings. It's an optional year after the completion of your residency as a junior faculty member. They practice fully independently, and the same principles apply: In any disputes, the attending talks to the attending. PGY years irrelevant.

 

[Law2Doc]

I don't know the specific situation, but I completely disagree with your interpretation. It's true, the definition of junior/senior/chief is irrelevant.... but in the case of attending vs resident, the years logged (the "PGY") isn't at all what matters, but the title is. The newly minted hospitalist attending, especially if he's primary, is where the buck stops. He is the physician of record, and it doesn't matter if he has one day of experience as an attending or forty years. On the other hand, a resident in a different specialty, even if it's a PGY10 surgical fellow, is not only a consultant, but also not completely trained in his field. He makes recommendations (not the definitive plan), is not the primary MD on the service, and if there's any sort of dispute should get his attending to (cordially) discuss the matter with the other attending. If there is then a reasonable disagreement with regards to patient care, you can have a pissing contest and eventually hash it out with the higher ups via peer review, but that should never be an attending (of any level) hashing it out with a resident/fellow (of any level).

The fact that the higher-ups at your hospital disagreed with that interpretation is bizarre to me, because everywhere I've ever been an attending is an attending. And when it comes to disputes, the two fully trained physicians with their own hospital privileges are the only ones that hash it out.

Edit: And just to clarify just in case since you refer to the IM person as a resident in one of your later posts: Even if it was a PGY4 Chief Resident, they are attendings. It's an optional year after the completion of your residency as a junior faculty member. They practice fully independently, and the same principles apply: In any disputes, the attending talks to the attending. PGY years irrelevant.

I didn't ever refer to the resident as IM. Not the case - you misread. The hospitalist was IM. And this was brought up the chain of command by the attending -- the resident presumably would have let it go, once he prevented the lapse in patient care. Without going into details, the attending was out of line and not acting in the best interests of "his" patient, and the higher ups made that clear. And yes, I think the titles mattered a heck of a lot less to everyone involved in the scenario than the knowledge bases involved.

No the buck doesn't stop with the "attending" title, at least not everywhere I've been, when they aren't in the same department/hierarchy. There are places where certain departments have more far more clout than others and frankly Hospitalists providing periodic coverage really don't outrank doctors/teams who have been involved in a patients care more longitudinally.

And for this hospitalist to demand to speak to this residents attending in the middle of the night could have been much more risky than the complaint with the administration he filed the next day. If he followed that advice it could have been much worse for him (and he probably realized that). Attending to attending is only a good idea when you are on solid footing, not the overnight guy who doesn't know the care plan.

 

[rokshana]

I didn't ever refer to the resident as IM. Not the case - you misread. The hospitalist was IM. And this was brought up the chain of command by the attending -- the resident presumably would have let it go, once he prevented the lapse in patient care. Without going into details, the attending was out of line and not acting in the best interests of "his" patient, and the higher ups made that clear. And yes, I think the titles mattered a heck of a lot less to everyone involved in the scenario than the knowledge bases involved.

No the buck doesn't stop with the "attending" title, at least not everywhere I've been, when they aren't in the same department/hierarchy. There are places where certain departments have more far more clout than others and frankly Hospitalists providing periodic coverage really don't outrank doctors/teams who have been involved in a patients care more longitudinally.

And for this hospitalist to demand to speak to this residents attending in the middle of the night could have been much more risky than the complaint with the administration he filed the next day. If he followed that advice it could have been much worse for him (and he probably realized that). Attending to attending is only a good idea when you are on solid footing, not the overnight guy who doesn't know the care plan.

obviously there are things we are not privy to that may have made this decision make sense, but with what is here, it makes little sense...the resident ultimately does not have the medical (or legal) responsibility that the attending does...even if its just the night guy...regardless of how many years he has been a resident...and you know very well that if this were to go to court because of a bad outcome based on what the resident recommended the IM attending is NOT going to be able to say, well the RESIDENT wanted this course of action...everywhere i have been the buck DOES stop with the PRIMARY attending of record...sounds like some sort of surg or surg sub resident...maybe they should have the patient on their actual service if they want to execute the decisions on pt care instead of being a "consulting" service for their patient.

and as an attending, I have NO issue whatsoever in calling up the attending on call (its not like the resident is solo) if I am having an issue with one of their residents especially if that resident is trying to undermine me with my patient's care...and again if the "consulting" service feels so strongly about it...i will be happy to transfer primary care to their service (that usually has them back off).

 

[Law2Doc]

I recommend you reduce the fracture and place a cast on it.

I recommend you place three cannulated screws in the hip under general anesthetic.

I recommend you amputate the leg as it is no longer viable.


I could get used to this...

Yes. That's my point. The hospitalist is the "tourist" here. These "consultants" in many cases are the ones actually treating the patient longitudinally, not just floating ideas.

 

[Law2Doc]

obviously there are things we are not privy to that may have made this decision make sense, but with what is here, it makes little sense...the resident ultimately does not have the medical (or legal) responsibility that the attending does...even if its just the night guy...regardless of how many years he has been a resident...and you know very well that if this were to go to court because of a bad outcome based on what the resident recommended the IM attending is NOT going to be able to say, well the RESIDENT wanted this course of action...everywhere i have been the buck DOES stop with the PRIMARY attending of record...sounds like some sort of surg or surg sub resident...maybe they should have the patient on their actual service if they want to execute the decisions on pt care instead of being a "consulting" service for their patient.

and as an attending, I have NO issue whatsoever in calling up the attending on call (its not like the resident is solo) if I am having an issue with one of their residents especially if that resident is trying to undermine me with my patient's care...and again if the "consulting" service feels so strongly about it...i will be happy to transfer primary care to their service (that usually has them back off).

The resident has his own attending and that's where HIS buck stops. His attending would tear him a new one if he didnt hold his ground. I think you aren't appreciating who was the one undermining the patient care plan here, and you apparently haven't worked at a hospital where certain departments and attending have a lot more clout than the hospitalist service...

 

[22031 Alum]

I'm sure that example makes sense with full context and to those with similar experiences but I think it's lost on many of us. Calling a fellow attending in the middle of the night is "risky???" Residents having more clout than attendings because one service trumps another?? Does not compute. I'm not sure how common that is but it certainly hasn't applied anywhere I have ever worked.

 

[Winged Scapula]

Small lol at the thought of a PGY3 being a "senior resident".

The worst is when your former medical student is now an attending in another specialty and you're still in training.

 

[gutonc]

The worst is when your former medical student is now an attending in another specialty and you're still in training.

What about when your med school classmate is your attending on your M3 rotation? Hooray for MD/PhD programs.

 

[Law2Doc]

I'm sure that example makes sense with full context and to those with similar experiences but I think it's lost on many of us. Calling a fellow attending in the middle of the night is "risky???" Residents having more clout than attendings because one service trumps another?? Does not compute. I'm not sure how common that is but it certainly hasn't applied anywhere I have ever worked.

Totally computes, but you apparently just haven't seen it in action. There's always a bigger fish. At some hospitals certain entire services are guppies.

Again that's why people calling themselves seniors or other titles isn't that meaningful to anyone not immediately within their service hierarchy.

 

[Raryn]

The resident has his own attending and that's where HIS buck stops. His attending would tear him a new one if he didnt hold his ground. I think you aren't appreciating who was the one undermining the patient care plan here, and you apparently haven't worked at a hospital where certain departments and attending have a lot more clout than the hospitalist service...

The resident, any resident, is welcome to hold their ground. But if it's my patient and I disagree, then yes, I tell my attending, who calls their attending. If I were a hospitalist six months from now, I don't care if it's the hotshot neurosurgeon or the dingus CT surgeon, if it's a question of management I would not be arguing with the resident. And if that's risky, that's that attendings problem, I don't work for them. Hospital administration won't pull anyones privileges for waking up the hotshot, and the resident, no matter their PGY year or specialty, will not trump the primary attending whose name is the one on the bottom line for the patient.

If you want to be primary for the longitudinal care of your patient, you're welcome to have them on your own service, and answer all of the phone calls at night yourself. Hospitalists are not simply there to be your b!tch, no matter how much your attendings have apparently tried to teach you otherwise.

 

[Law2Doc]

...Hospital administration won't pull anyones privileges for waking up the hotshot...

You'd be surprised. As mentioned, this "attending" did not last long there.

 

[22031 Alum]

Totally computes, but you apparently just haven't seen it in action. There's always a bigger fish. At some hospitals certain entire services are guppies.

Again that's why people calling themselves seniors or other titles isn't that meaningful to anyone not immediately within their service hierarchy.

I didn't think the "for me" after "Does not compute" was necessary... I've never seen it happen, nor ever heard of anything like it throughout my entire time in medicine until this very conversation. I don't doubt that it's true where you are and where you've been, but it's not universal.

Although to be fair, over half the hospitals I've worked at have been dedicated women's hospitals so that could be one reason the concept of a specialty being a "guppy" is so foreign to me! I wouldn't last very long at any hospital where I was expected to consider it "risky" to initiate an attending-to-attending discussion if I had some issue with the resident.

 

[rokshana]

I recommend you reduce the fracture and place a cast on it.

I recommend you place three cannulated screws in the hip under general anesthetic.

I recommend you amputate the leg as it is no longer viable.


I could get used to this...

how about surgical patients go to the SURGICAL service and if there are medical issues, then there can be a MEDICINE consult...

 

[rokshana]

Yes. That's my point. The hospitalist is the "tourist" here. These "consultants" in many cases are the ones actually treating the patient longitudinally, not just floating ideas.

so maybe...they could actually be on the correct service...if the primary issues are surgical but the pt happens to have high blood pressure or diabetes (and these are not the reason the pt was admitted) then maybe...MAYBE...they should go to the appropriate service and not just dumped onto the hospitalist service...

again if the consulting team feels oh so strongly about implementing their recommendations, then they should be on as the primary team...that would take care of any issues.

 

[Law2Doc]

so maybe...they could actually be on the correct service...if the primary issues are surgical but the pt happens to have high blood pressure or diabetes (and these are not the reason the pt was admitted) then maybe...MAYBE...they should go to the appropriate service and not just dumped onto the hospitalist service...

again if the consulting team feels oh so strongly about implementing their recommendations, then they should be on as the primary team...that would take care of any issues.

Hospitalist services are dumping grounds for a certain comorbid demographic of patients everywhere. That's just the reality at many hospitals. I am not debating whether the patient was admitted to the right or wrong service, but saying it's not at all unusual for some specialties to care for some of a patients multiple problems but be perfectly happy not to assume the others. But as mentioned by our ortho colleague above, his team is not there to give "recommendations" -- he is going to take the patient to the OR, do very significant things to her, and return the patient to the hospitalist with a very specific post-operative plan of care. And God help the overnight person who wants to F with that.

So yeah, a person might stay on a Hospitalists service for his/her diabetes and hypertension issues, while at the same time other services are driving the train on other more acute and significant diagnoses. You can argue that such s person shouldn't end up on the Hospitalists service in the first place, and I might agree, but I would say it happens this way everywhere I've ever been, and it's not up to me, even if I agreed with you.

 

[rokshana]

The resident has his own attending and that's where HIS buck stops. His attending would tear him a new one if he didnt hold his ground. I think you aren't appreciating who was the one undermining the patient care plan here, and you apparently haven't worked at a hospital where certain departments and attending have a lot more clout than the hospitalist service...

I have worked at many places and frankly have never seen where a resident's medical opinion trumps an attending...even on the red headed step child service...i get that this situation must have been unusual, but as it has been said...i wouldn't want to be at a place where some attending feels that they are so above other ones that they would be upset if a peer felt the need to speak with them...and a place that feeds the arrogance of a resident to feel that he is superior to an attending in another service that he thinks is inferior to his own specialty.

I've been at places where there is co-managing of ortho pts (old people with hip fractures) and ortho writes the orders related to pre and post op care...that's fine since their attending is just as liable for the pt and the ortho issues don't come under medicine's responsiblities.

 

[Law2Doc]

...and a place that feeds the arrogance of a resident to feel that he is superior to an attending in another service that he thinks is inferior to his own specialty...

Um I think you are reading something in here I didn't actually say. The resident wasn't being arrogant, he was protecting his patient. A hospitalist, who didn't know the patient, was the one being arrogant and thought his title trumped the resident (who was more senior) and the ongoing plan of care. Turns out this attending was wrong. (And his title didn't matter a darn. It's not a right to kill your patients).

 

[22031 Alum]

thought his title trumped the resident (who was more senior)

Setting aside your specific example, and blatant issues of patient safety -where I think we all agree titles don't matter- the issue some of us are having is with what I've quoted above. For some of us, like me and @rokshana, an attending does trump a resident (again, speaking generally, not when one is doing something obviously wrong/dangerous, etc.) And the idea of a hospital where some attendings don't trump residents just because they belong to a "lesser" specialty is hard to grasp. Just like it's hard for you to grasp that our hospitals/systems aren't like that.

 

[rokshana]

Setting aside your specific example, and blatant issues of patient safety -where I think we all agree titles don't matter- the issue some of us are having is with what I've quoted above. For some of us, like me and @rokshana, an attending does trump a resident (again, speaking generally, not when one is doing something obviously wrong/dangerous, etc.) And the idea of a hospital where some attendings don't trump residents just because they belong to a "lesser" specialty is hard to grasp. Just like it's hard for you to grasp that our hospitals/systems aren't like that.

^ what he said...

the "arrogance" is in the resident thinking that he is at the same level (or even better) that the attending...i know hierarchy is not as strong as it used to be, but there one is a physician and the other is a physician IN TRAINING...one is licensed and credentialed by the hospital and the other is on a training license and can make no decisions on his own...

as i did say, there must be things that we are not privy to (and yes, pt safety is always the more important issue) but when I was a resident and if I somehow had a concern about how another service (or even an attending) treatment of a pt, I would call my attending to discuss it with said attending...but then I had attendings that wouldn't hold it against me that I called them...even on christmas eve (true story)

 

[Law2Doc]

Setting aside your specific example, and blatant issues of patient safety -where I think we all agree titles don't matter- the issue some of us are having is with what I've quoted above. For some of us, like me and @rokshana, an attending does trump a resident (again, speaking generally, not when one is doing something obviously wrong/dangerous, etc.) And the idea of a hospital where some attendings don't trump residents just because they belong to a "lesser" specialty is hard to grasp. Just like it's hard for you to grasp that our hospitals/systems aren't like that.

I never used the phrase "lesser specialty". I think that reflects a sensitivity some of you guys are carrying. I expressed it in terms of a different specialty and hierarchy. And yes, in some places it matters and the title one carries in another specialty just doesn't matter as much as the two of you guys seem to think or want.

Whatever. Obviously your hospitals do it differently and let's leave it at that.

 

[rokshana]

Um I think you are reading something in here I didn't actually say. The resident wasn't being arrogant, he was protecting his patient. A hospitalist, who didn't know the patient, was the one being arrogant and thought his title trumped the resident (who was more senior) and the ongoing plan of care. Turns out this attending was wrong. (And his title didn't matter a darn. It's not a right to kill your patients).

its not the title per se...it the level of responsibility that he has that in the end should count in the general ways of things...if the resident had screwed up, the responsibility would not have been his...it would have fallen to HIS attending...on the other hand, if the attending screwed up (which apparently is the case in your example), it is only his responsibility...and speaking from experience, I would rather defend how I came to my medical decisions and not try to explain how i let other people make decisions for my patient...

 

[Law2Doc]

^ what he said...

the "arrogance" is in the resident thinking that he is at the same level (or even better) that the attending...i know hierarchy is not as strong as it used to be, but there one is a physician and the other is a physician IN TRAINING...one is licensed and credentialed by the hospital and the other is on a training license and can make no decisions on his own...

as i did say, there must be things that we are not privy to (and yes, pt safety is always the more important issue) but when I was a resident and if I somehow had a concern about how another service (or even an attending) treatment of a pt, I would call my attending to discuss it with said attending...but then I had attendings that wouldn't hold it against me that I called them...even on christmas eve (true story)

Um residents are licensed, in most cases after their first year. No trainee licenses.

Someone with more years of training and has logged more years in the hospital simply knows more. The only arrogance I'm hearing is the person with two years less experience who thinks their title in and of itself makes them know better..