Resident work hours

15

Category : Medical Rants

 

One of the first hot issues on Medrants (over 6 years ago) was the change in residency work hours.  Recently the IOM has had a committee looking further at this issue.  The report is out with some surprises and some new problems.  Expert Panel Seeks Changes in Training of Medical Residents

The experts’ report, issued by the Institute of Medicine on Tuesday, focused on the grueling training of medical residents, the recent medical school graduates who care for patients under the supervision of a fully licensed physician. The medical residency, which aims to educate doctors by immersing them in a particular specialty and all aspects of patient care, is characterized by heavy workloads, 80-hour workweeks and sleep deprivation.

So the author paints residency as "grueling."  As usual they focus on sleep deprivation.  As usual they do not ask if current training produces well trained physicians.

So of course the panel has solutions to the problem they declare.

But the expert panel said those reforms were not enough. Caps on work hours are often not enforced, and many residents still do not get enough sleep, putting doctors and patients at risk for fatigue-related mistakes. While the new recommendations do not reduce overall working hours for residents, the report says no resident should work longer than a 16-hour shift, which should be followed by a mandatory five-hour nap period.

The committee also called for better supervision of the doctors-in-training; prohibitions against moonlighting, or working extra jobs; mandatory days off each month; and assigning chores like drawing blood to other hospital workers so residents have more time for patient care.

The idea of 16 hour shifts makes some sense, but it will put great strains on education.  The mandatory 4 days off each month (recommended to increase to 5 for unknown reasons) has a serious untended consequence.  When making rounds daily with a team, often I am the only person providing continuity.  When I give "chalk talks" someone is always absent. 

Now I do understand the need for days off.  I do believe in sleep.  However, we must understand that changing these rules often have negative impacts on education.  We have residents who cannot attend noon conference because their "shift" is over.  How does that help the resident? 

I suspect that many residents will balk about the moonlighting rules.  We saddle our students with unreasonable debts, and then we will handicap their ability to make some extra money during residency.  I remember the importance of moonlighting money in buying my first house and a new car.  I see residents moonlight so that they can have some semblance of a decent quality of life.

The 16 hour shift will stretch our ability to provide good education. 

On the positive side, the committee did not back off from the 80 hours.  They recommend more strenuous enforcement, and I agree with that plan.  I do hope that they do not penalize residents and programs when the infractions are totally voluntary and associated with educational desires.

More on this subject as others comment.

 

 

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Comments (15)

If we can figure out how to train airline pilots, cargo ship/tanker captains, air traffic controllers, and other high stakes professionals, then we can figure out how to train modern doctors. The current system benefits only hospital stake-holders who exploit cheap labor in order to provide care.

I completely agree with Oskie.

The only residents that tend to suffer from ridiculously long hours with no sleep breaks are the junior residents – usually the intern, and 2nd year in some surgery residencies (and once in awhile, senior residents but only on some rotations).

Any anyone who went through residency training knows the junior years have little to do with education, and any exposure to continuity of care is most definitely certainly on accident. At least 50% of one’s time is occupied with navigating the bureaucracy, paperwork, scut, etc. While these are things every attending will have to deal with, let’s be honest and acknowledge that there is plenty of fat in the system that could be cut out -while maintaing an outstanding training environment – if not for the prized cheap labor.

I’m a fourth year student who wants to go into a surgical specialty. I obviously don’t cheer my future workload as a resident but I figure such a necessary part of becoming a physician. I watched my parents go through the ordeal of residency and along with my own exposure during my clinical years I figure I don’t speak entirely without context.

I don’t support work hour restrictions but that isn’t the issue I want to discuss. Instead I want to raise this question: who is this panel to be making these recommendations?

I understand the impressive credentials of the panel members and the process they used to solicit stakeholder input. All that said, it remains that the 17 member panel included 8 NON-PHYSICIANS and just a single surgeon. That doesn’t seem proper. The panel’s perspective (or lack thereof) invalidates their conclusions as far as I’m concerned.

As many major stakeholders (surgical specialty societies and boards, the AAMC, the AHA, etc) have said this is a process that requires further input and study from those who work hour restrictions actually effect. Whatever the debate over residency work hour restrictions the IOM report is inadequate.

I want my sleep too. I’m requesting eight hours a night on my 12 hour night shift. That’s how much I need to feel refreshed to go get ’em.

There is this belief that time off means time to sleep. Why is that realistic?

Do we force residents to not go to homes where infants may need care during the night? What about homes with a demented relative who needs help with ADLs?

I have never understood why a resident can’t take overnight call but he can work, moonlight at an LTAC facility, and then come to work (in the same scrubs) for 4 days in a row.

We do ask pilots, military commanders, and even politicians to work without sleep. And since when does being an attending take away scut? Ever heard of pre-approval, prior authorizations, FMLA paperwork, home health forms or disbility forms? Scut by any other name.

I guess at some point all of residency will be learning about proper hand offs because off all medical care will be shift work.

Maybe some day our enlighted society will allow firefighters, and police officers and air traffice controllers to be allowed to stop working and go home for a nap after exactly 480 minutes of being “on shift”?

“I guess at some point all of residency will be learning about proper hand offs because off all medical care will be shift work.” – Erik

There’s a ‘proper’ hand off? That seems to imply you think we can make hand offs fool proof. Hand offs will ALWAYS be, inherently, detrimental to patient care. There are things we can do to lessen the chance of errors but continuity will always be first.

Residency work hour restrictions, in increasing the number of hand offs, will always have that against them. That despite best QI efforts.

I am an intern. I would say 20-80% of my time day by day is spent doing paperwork and assorted scutwork. Some of it is medically useful (pt notes, informed consent, advanced directive stuff). Notes take up the majority of my time. We are not allowed to dictate inpatient notes (I have been told) at the main hospital, as it would overwhelm the transcription services, and a second training hospital offers no transcription services at all. There is plenty of room to train physicians in less hours without sacrificing medical competency.

The current post-graduate medical training system and medical education industry is nothing short of corrupt. The hospitals and employed attending physicians who train them only view house-officers as “RVU multipliers” for the organization they serve.

In turn, most resident physicians are treated with contempt by their trainers, by senior nursing and allied health staff, and hospital administrators. This basic contempt is evident at all levels of the medical education industry. The ACGME “core competencies” are designed to promote “followership” in resident physicians not leadership. Ideas like “systems-based learning” are a thinly concealed vehicles for indoctrination. House-staff have no legitimate due process, grievance, or formal mechanisms for dispute resolution in most health care facilities. It is harder to fire the unionized hospital janitor than it is a resident physician.

Moreover, residents are often asked to be complicit in fraud and inappropriate billing practices by the hospitals who employ them. Again, limiting work hours and promoting an organizational culture where resident physicians are treated with respect is what is needed. The first step in this process is meaningful work hour reform.

Yes, the hours in private practice may be longer than in residency, but the income is very likely well above that of a resident; this is often not mentioned/lost in the discussion when attendings are often quick to say current residents who view medicine as shift work are screwed when they go out into the real world.

I do what it takes to get my work done; if that means 12+hrs. on a non-call day, so be it. If I have to stay over 30hrs. on a call day, same story.

However, those of us in residency don’t have much of a choice when it comes to 30(+)hr. calls & 80(+)hr. workweeks because it is considered “part of our medical training.”

Pay residents what they are truly worth and get rid of the 24+6 farce (how about 24hrs); at the very least put some real teeth in the hours regulations.

I am a third year OB/GYN resident and I have to say bravo to Oskie for saving me the time of writing more because his/her posts were exactly what ran through my mind reading some of the comments.

With regard to my so-called ‘education’, here’s some food for thought. Last year, our program had 2hours of protected ‘lecture’ time per week, that is 52 x2 or 104 lecture hours. Of those ‘lecture’ hours, 32 of those were dedicated to how to fill out the latest inane paperwork required by the hospital and how to ‘behave’ when JCAHO arrived. 12 of those hours were spent with REAL lectures by faculty. TWELVE. The rest was a combination of resident meetings, interview time, an occasional visiting professor,and people who were supposed to lecture cancelling.
Education and ‘teaching’ aside from hands-on technique is a veritable joke in the United States. The average day is much more accurately:
A whole lot of scut even as a senior…including private attendings throwing you under the bus to do their admissions and H&Ps even though they are very aware that they are required to do it themselves. A whole lot of redundant paperwork in order to cover his, her, the nurses, the administrators’ butts in the medicolegal realm. Unreasonable wait times for the OR cases to go due to the unionized nurses not wanting to turn over rooms at certain times of the day. Arguing about bureaucratic crap that is in the ‘policy’ but also painfully detrimental to patient care. That is my work day…with some interesting surgery squeezed in between and an amazing group of co-residents with which to work…which is obviously my solace.

The US residency system has been broken for a very long time. The teaching is abyssmal, the work hours often violated and scoffed at by older attendings, and the pay is laughable. It is like taking intelligent motivated people and crushing them like roaches under a dirty workboot. We are kidding ourselves if we think that our pain and suffering are making better doctors when the evidence undeniably proves that judgement fails and apathy rules with the 24-30hour shifts. I would never go to the hospital on a weekend between 3am-8am in the morning…EVER. Even in labor. Nor would I allow a surgeon to operate on a loved one after working more than 16hours.

Take a look at Europe. Longer residencies, yes, but respectful treatment, guided learning, 6wks vacation, better pay, and 50-60hr weeks max. Somehow, Europe makes amazing physicians…hmmm. Maybe we don’t know it all…we are just as broken as health care reform.

Having graduated from a very non-abusive, training centered residency and gone on to an abusive, “system-centered” (for lack of a better word) fellowship (and having watched the residents at my current institution be at least as abused as us fellows), I will not even attempt to suggest that abuses don’t happen in training, and I think that they’re quite common.

The pay, however, is not bad. It’s approximately equivalent to what post-docs make. It is irritating, though to see on my paycheck that I’m being paid for “40 hours” each week. Also, everybody in the hospital has better benefits and more vacation.

I would not want to move to a European system. My understanding is that the Europeans don’t get to operate nearly as much as we do (and that comes from having seen and spoken with several European residents doing second residencies in the US). They also don’t have the income expectations. I wouldn’t mind getting paid less as an attending for less work, but I don’t want it to be an order of magnitude less!

I think that in many ways the US system is pretty good, and when you feed it a good student, it will turn that person into a good doctor. There certainly are abuses, but there are abuses everywhere. And perhaps a better line of attack would be to go after the specific abuses. If a program is abusing a resident’s time on scut, there should be some recourse. Residents should unionize in order to advocate and bargain for themselves effectively.

The European system of training, however, is not a good answer, at least not for surgical specialties. Remember, there is no definitive END to training in most European countries. I like having an END! 🙂

I think the work hours would be more sustainable if work days were less frenetic for residents. I know this would never happen because nobody wants to pay for something they can get for free from residents, but how about hiring more PAs (or RNs) to take over some of the non-medical, non-educational activities we spend so much of our time doing? Have someone else stay on hold for 20 minutes trying to get a follow-up appointment for a patient. Pay somebody to make sure peoples’ blood gets drawn, urine samples and stool samples get sent, and to go to the pharmacy to pick up medications needed urgently (or do something even more renegade…ask the people who are already paid to do these things to actually do them).

Pay somebody to be on call overnight for all the orders for tylenol that need to be put in at all hours. A well-trained PA could answer all the calls and triage them appropriately. Those calls that required an MD’s attention would be directed to the MD. The calls requesting sleep medication, pain medication, and “Mr. X doesn’t want to take his medication tonight, can you come talk to him?” could be taken care of by somebody else while the MD sleeps or rests and is allowed to spend time in more important activities. There would still be some nights when residents got no sleep, but they would be fewer, and the days would be less crazy.

Work hours are changing as a result of a change in the demographics of those entering medicine. Residents have a different way of looking at the world than attendings. It is not wrong, just different. With the new view come the changes in work hours. Attendings don’t like it, but they don’t have a choice. For more go to: http://www.associatedcontent.com/article/1288635/resident_work_hour_restrictions_impending.html?cat=5

So I’m currently a pre-med student, but I have to tell you that the decision to go into medicine was very difficult. Not because of the difficult curriculum because I will deal with it fine, and not because I lack passion because I have plenty of it. However, for the longest time, I’ve been scared of the residency program. Now, I don’t intend to practice surgery, I want to be a family medicine doctor, have my own practice, and run in my own hours, with occasional night time home visits. And I have a history of unable to sleep once I’m sleep-deprived, and I get really edgy, worried, and I would break down. Now to say that 80+ hour residency training with 20-80% things associated with paperwork gives proper training is ridiculous. I don’t even care about the pay, just let me get my proper nights of sleep. I promise you that I will stellar practitioner in the morning if you let me sleep.

And lastly, to be clear, Captains and pilots get 8 hours of sleep. Each cargo ship have usually 3 captains, and 2-4 copilots for long flights. They switch on and off. And moreover, they get 1-2 days break before flying once again. I know because my sister works as a stewardess.

I went through residency when there was no restriction on the hours you could work or be on call. I must tell you that if you go out to practice in a rural area you need all the experience in medical school rotations and residency that you can get. A professor once said discussing rare medical conditions that I would probably never see it again. I have. I deal with patients with mundane common things to ones with strange antibody conditions and genetic conditions. It is all fair game out here. In addition, the hours are a little shorter but not much in practice. It may be the rural area, but I work 80-100 hours a week and go many nights getting a few hours of sleep if I am lucky. There should be a national standard for time off and sleep in medicine like truck drivers and pilots have. Unfortunately, in rural family medicine reimbursement continues to fall and will fall more with Obama I fear. These rural areas cannot afford to hire more docs and stay competitive with urban centers. So I take 1:3 call and am busy on call and its better. For over a year it was me and a PA only in town. Talk about burnout. Get used to the long hours or reform health care so the physicians don’t continually get shafted I feel is the only solution.

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