Favorite Quotes
"For every complex problem, there is a solution that is simple, neat, and wrong." - HL Mencken
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"I hear and I forget. I see and I remember. I do and I understand." - Confucius
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"The good physician treats the disease; the great physician treats the patient who has the disease" - Sir William Osler
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" The best test of a person's character is how he or she treats those with less power." - Bob Sutton
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"Those are my principles, and if you don't like them - well, I have others." - Groucho Marx
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"The difference between genius and stupidity is that genius has its limits." - Albert Einstein
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"It is hard enough to remember my opinions, without also remembering my reasons for them" - Friedrich Nietzsche
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"Anyone can make the simple complicated. Creativity is making the complicated simple." - Charles Mingus
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"Not everything that can be counted counts, and not everything that counts can be counted." - Albert Einstein
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"A foolish consistency is the hobgoblin of little minds, adored by little statesman and philosophers and divines. With consistency a great soul has simply nothing to do." - Ralph Waldo Emerson
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"This ain't no party, this ain't no disco, this ain't no fooling around." - Talking Heads, Life During Wartime
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"What is hateful to you, do not do to your neighbour. This is the whole Torah; all the rest is commentary. Go and learn it." - Hillel, Talmud, Shabbath 31a
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"You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing." - Thomas Sowell
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"An idealist is one who, on noticing that a rose smells better than a cabbage, concludes that it will also make better soup." - HL Mencken
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"If you only have a hammer, you tend to see every problem as a nail." - Abraham Maslow
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"A great teacher is one who realizes that he himself is also a student and whose goal is not to dictate the answers, but to stimulate his students creativity enough so that they go out and find the answers themselves." - Herbie Hancock
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"There are no facts, only interpretations." - Nietzsche
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"An education isn't how much you have committed to memory, or even how much you know. It's being able to differentiate between what you do know and what you don't." - Anatole France
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"In character, in manner, in style, in all things, the supreme excellence is simplicity." - Henry Wadsworth Longfellow ====
Nov - 15
Dec - 19
Jan - 21
Feb - 8
Mar -
Duty hours, patient safety and resident education
6 Oct2009
Excellent article in AMNews – Resident duty hours: Does more sleep mean safer care?
Over the past 10 years I have worked with residents using multiple call systems. First, we instituted an 80 hour work week prior to ACGME guidelines. We included 4 days off each rotation.
I thought that this was a very reasonable advance. The housestaff were clearly happier. The only problem occurs when one resident is off (a common happening) and the other 2 residents do not pick up the slack. Often the attending physician represents the continuity of care with housestaff coming and going. However, having those off days is reasonable and worthwhile.
Next we added a night float system. This decreased the number of nights that residents stayed “in house”. The big improvement came from the night float intern who did all the cross cover work over night. I often say that admissions never kill you, but cross cover does. The interns especially were brighter, even when they spent the night. Education receptiveness improved. The cost for residents is one miserable month – night float.
In our family medicine program this year, we have instituted a 14 hour max schedule. This “advance” is receiving very mixed reviews. Most residents believe they are working harder than when they averaged a 30 hour shift every 4th night. The total number of hours is the same, but the new schedule is actually more tiring.
Residents with infants have a special dislike for this schedule. One assumption of the IOM is that when the resident leaves the hospital, they can relax. That may or may not be true. I have worked with several women with infants who found their 4 straight nights miserable. They could not get much sleep during the day.
On average, residents prefer the 30 hour shift with one recovery day and two humane days prior to another 30 hour shift. I believe that the 30 hour shift is neither as dangerous as some would like to portray, nor inhumane.
As one resident told me, with 14 hour shifts, he had little time to relax. With the 30 hour shift, there was always some relaxation time.
The new schedule makes teaching more difficult. I will make rounds this morning @ 7:30 a.m., and must get the resident out by 9:00-9:30 a.m. This negatively impacts my ability to give positive or negative feedback on his care.
I would like to see the ACGME develop focus groups with interns and residents to determine the best balance here. Medicine is a difficult, rewarding profession. Sometimes we all work hard, long hours. I believe that the IOM committee must not have really understood the unintended consequences of their report. I hope that someone will start thinking about the big picture.
Related posts:
- Adapting to work hour restrictions
- Duty hours – no easy answers (h/t @FutureDocs)
- Reform residency but intelligently
- A guest post
- Duty hours, the ACGME and the surgeons
Related posts brought to you by Yet Another Related Posts Plugin.
- In: Medical Rants
2 Responses to Duty hours, patient safety and resident education
Michael Kirsch, M.D.
October 6th, 2009 at 5:47 pm
It is self-evident to any thinking individual that reform of residency training is in order. I didn’t buy in to the specious arguments that working 36 hrs straight was necessary training and preparation to face emergencies at odd hours as a practicing physician, or to follow the natural history of acute disease,. The reasons that this inhumane system has survived has much more to do with $$$, machismo and perpetuating a tradition of abusive training, than is does with actual medical education. As a gastroenterologist, I’m awakened to attend to patients and hope that I perform well on these occasions. I doubt that my training years when I was somnambulating through the hospital corridors was necessary preparation for what I need to do now as a practicing gastro. Did we really need Libby Zion to determine that a physician, an airline pilot or a truck driver performs better when rested? http://www.MDWhistleblower.blogspot.com
Erik
October 6th, 2009 at 10:09 pm
I hope Dr. Kirsh has done a few endoscopies at ungoldy hours – in my hospital no one seems to hemorrhage during the daytime. I’d just as soon his training (and mine) included caring for sick people when tired, stressed, and upset about some personal issue.
Dr. Centor brings up a good point – residents don’t sleep when they leave the hospital. They care for young children and elderly parents. I had a resident who lived with his mother, who was on hospice for end stage lymphoma – his time at home was quite stressful and rarely relaxing.
We cannot legislate or force people to relax. There is a point where staying the hospital becomes ridiculous and accomplishes little for the patient or the doc, but every single case does not hit that point when the clock strikes 14, or 24 or 30.
Very few jobs as attendings allow for time off after call. If the goal of residency is to make sure doctors are ready to practice without any supervision in their community, then part (but not all) of their training has to include working past the point of exhaustion.