Handing over a patient after 16 or 24 hours should not be any different as regards continuity of care. A patient can come at any time during your shift. If a critically ill patient comes an hour before your shift ends (16 or 24 hour shift), you likely will not have time to stabilise them before leaving. Neither would you have to wait for a 5-hour operation to end when it started at Hour-15/23. Rather revise the handing over process than advocate for longer hours.
One problem is that in practice, the day is longer than current residents experience. As an attending, you don't have an option to hand off to someone else at 11 pm. You are on all night. How odd that those in training work less hard than those in practice. There is great value in following a patient throughout a 24 hour period, rather than punching a time clock.
I am not clear about why the problems of handing off patients after 16 hours would be any different than handing off after 24 hours.
I think the thing is that if you have a shorter shift, you are more likely to have your shift end while a situation is still ongoing. True that every shift will end at some point - but a longer shift will include more completed cases, from beginning to some kind of stabilization, before the time comes when you have to leave. I've heard this from nurses, they like to have longer shifts, to see situations through - and then maybe have a long weekend.
1
But residents don't get to have longer shifts and longer weekends-just longer shifts. I am an MD and I love working 4-10s instead of 5-8s because on those other days no one expects me to work...not so residents!
When my daughter was a resident, I thought her experiences closely paralleled army boot camp - grueling hours, not enough rest, and long periods of great danger to the lives of others. Much like handing new recruits loaded guns and putting them through live-fire exercises. She bought in to the indoctrination that this somehow improved her ability to learn. I was, and remain, unconvinced.
Oh, and that 80-hour maximum limit? They enforced that by telling the residents not to record any hours exceeding 80. And the 80 hours don't include the time at home reviewing the next day's cases with the attending physician, which consumed another 60 to 90 minutes per day.
Oh, and that 80-hour maximum limit? They enforced that by telling the residents not to record any hours exceeding 80. And the 80 hours don't include the time at home reviewing the next day's cases with the attending physician, which consumed another 60 to 90 minutes per day.
6
apples to apples. the control group and the interventional group all worked the same hours. there were no checks or balances. it's a sham. the thing not mentioned here is that the number of patients has sky rocketed since the "good ol days" and the number of residents remains unchanged. there is also a vast amount of new data, technology and procedures to master. residents can learn the same amount with saner hours. we just need more residents.
3
So many people who have never worked in a hospital commenting- I would agree that too much pandering to a students wants is bad. Patient care is a continuum, and if you have to leave at 4:00 you are going to miss something important.
Yes, becoming an MD is difficult, and it should be.
Yes, becoming an MD is difficult, and it should be.
3
Aaron,
Actually its well known that surgical residents now are lacking in their training. The surgeons who run fellowships give additional training to general surgery training program residents and they find that the new graduates are often incapable of doing surgery.
http://journals.lww.com/annalsofsurgery/Fulltext/2013/09000/General_Surg...
Politics got involved in surgical training. Politicians puffed themselves up with the idea that they were doing a great thing by protecting the public by making sure that the residents got plenty of rest. Only politicians could believe that less training makes for better surgeons! Its so clear that the five years of training, (after 4 of college and 4 of medical school) is now inadequate that the Board of Surgery is now thinking about making 6 years mandatory.
http://bulletin.facs.org/2014/08/the-five-year-general-surgery-residency...
Actually its well known that surgical residents now are lacking in their training. The surgeons who run fellowships give additional training to general surgery training program residents and they find that the new graduates are often incapable of doing surgery.
http://journals.lww.com/annalsofsurgery/Fulltext/2013/09000/General_Surg...
Politics got involved in surgical training. Politicians puffed themselves up with the idea that they were doing a great thing by protecting the public by making sure that the residents got plenty of rest. Only politicians could believe that less training makes for better surgeons! Its so clear that the five years of training, (after 4 of college and 4 of medical school) is now inadequate that the Board of Surgery is now thinking about making 6 years mandatory.
http://bulletin.facs.org/2014/08/the-five-year-general-surgery-residency...
3
There is so much more to learn now than there was when all the training programs were designed that I wouls support making them longer. Medical school has been 4 years long since the Flexner Report in the 1920s! Isn't there a lot more to learn?!?! The same for Internal Med residencies (which have been 3 years since the 1950s). Either new MDs will have to have more OJT or something is going to have to give. Simply working them more and more hours is NOT the answer.
Medical training is hard. Learning volumes of information and caring for critically ill people and helping their families and maybe having a family yourself, is hard. Commitment is hard; it requires sustained focus, fortitude, compassion for self and others- it requires, commitment. Money and scheduling are extraneous factors which will not fix this. My experience as a resident and fellow at an Ivy League institution, 25 years ago, showed beyond a doubt, easier schedules correlated with increased resident complaints. ...........Our patients and our country need strong self reliant doctors who understand that whining is worse than useless, its destructive. Rather than changing the schedule, change the culture. Promote real changes such as team based care and train our care leaders in mindfulness and mind training techniques which build clarity, self awareness, calm and compassion. introduce regularly scheduled peer discussions where its safe for the care delivery CEOs (the MDs) to share their problem cases, stress, and challenges related to the PTSD-generating experiences which bombard engaged care delivery teams. If we can get to the root cause of provider despair, depression and frustration, we will begin to heal our system. Until then, its becoming increasingly scary to be a patient in this country.
Many of the physicians here write abut how much they learned during their grueling residencies. Sleepy people lose the ability to correctly estimate how sleepy they really are. So who is to say they correctly estimate how much they really learned? Or, put another way, how much more they would have learned had they been awake enough to take it in and remember it?
2
Yeah, if you want to get really good at something you have to devote yourself to it. If its medicine you probably shouldn't do it if rest and time off are more important than putting in the time and effort it takes to learn it very well. Its a joke that we can reduce hours and expect better results. Only people who have never tried to do a difficult thing expertly could believe that.
To me, this study is simple math, Changing the order of the factors does not change the product. Both comparison groups work the same weekly hours, just different schedules and got no significant changes in patient outcomes.
Change weekly hours and THEN you'll see difference, not only on patient outcomes but in training/skills gain.
Change weekly hours and THEN you'll see difference, not only on patient outcomes but in training/skills gain.
1
You want some evidence that the current system is bad for patients and the trainees? How about an Annals of Surgery study looking at graduating surgical residents? The findings are pretty stark... "We identified major deficiencies in the domains of independent practice ability, patient responsibility, and some motor skills..."
General Surgery Residency Inadequately Prepares Trainees for Fellowship: Results of a Survey of Fellowship Program Directors. Annals of Surgery
September 2013, Vol. 258 - Issue 3: p 440–449
As an anesthesiologist who trains this new class of residents, I look around and see residents leaving a carotid endarterectomy because its 4p and the "want to go home." Forget learning, forget doing what's best for the patient. It's all about me, me, me...
And looking across the drape at the surgical residents... Consistently showing up not knowing the patient, the surgery they are going to perform... It's atrocious. An utter lack of accountability and professionalism.
This lack of direct patient care may not matter in the medical specialties, but it sure matters in surgery and anesthesia.
General Surgery Residency Inadequately Prepares Trainees for Fellowship: Results of a Survey of Fellowship Program Directors. Annals of Surgery
September 2013, Vol. 258 - Issue 3: p 440–449
As an anesthesiologist who trains this new class of residents, I look around and see residents leaving a carotid endarterectomy because its 4p and the "want to go home." Forget learning, forget doing what's best for the patient. It's all about me, me, me...
And looking across the drape at the surgical residents... Consistently showing up not knowing the patient, the surgery they are going to perform... It's atrocious. An utter lack of accountability and professionalism.
This lack of direct patient care may not matter in the medical specialties, but it sure matters in surgery and anesthesia.
3
Are residents tested these days for abuse of uppers and downers used to stay alert and to sleep? In the not too distant past this was a rather serious problem.
3
Not a rational argument. Learning doesn't take place when brains and bodies are exhausted. In my two years working for a hospital network as a PhD medical educator, I witnessed the swagger among the surgery residents as they "bragged" about going over their 80 hours. And, according to them, their supervisors approved. If the author is so concerned with surgical residents missing out on learning opportunities, he would recommend increasing the number of years in residency. The argument against this, of course, is that these trainees are being denied their right to full wages as bonafide surgeons. Surgical residents, in case this audience doesn't know it, are paid somewhere between 50-75k. It's true they incur considerable debt in medical school but they are paid much more than a living wage as residents. And they should follow the rules. What the author is condoning here is the "hidden curriculum." And it's not good for the patients, the profession, or the health systems they work for.
4
Not sure why a Surgical Resident could not stay on longer to see
the last critical steps in a surgery - it not like they are assembly line
workers and the assembly line stops when the whistle blows. Then can;t
the Resident and their Supervisor re-adjust their schedule ?
the last critical steps in a surgery - it not like they are assembly line
workers and the assembly line stops when the whistle blows. Then can;t
the Resident and their Supervisor re-adjust their schedule ?
4
Good point - it seems like there could be some flexibility for staying to finish up an operation, or one last ongoing patient-care situation if it was critical - but then, the incoming people would probably want to get started with their shifts, so it could get complicated. I guess it's that the longer shifts reduce the number of transition periods, with all the issues those involve.
80 hours a week is irresponsible.
Finding a 9% harm rate, why did no one ask, What can we do to PREVENT that 9% from happening over and over again to other patients.
Do patients not deserve someone to even ask if they could prevent known harm from being repeated...?
Are patients really that frivolous to the medical industry?
Finding a 9% harm rate, why did no one ask, What can we do to PREVENT that 9% from happening over and over again to other patients.
Do patients not deserve someone to even ask if they could prevent known harm from being repeated...?
Are patients really that frivolous to the medical industry?
7
I work in health care, and I wouldn't want any member of my family to be treated by a resident who's been up for 24 hours. The hours limitation was originally adopted because ACGME realized that if they didn't place limits on training loads, state legislatures were going to do so. It's also worth considering how training volume affects who goes into medicine. How many people who might be great doctors are deterred from even going into medicine (especially in surgery) by the utterly crazy and demeaning ordeals which constituted residency training for many decades?
8
Like with many, often very fundamental "issues", our societal system of "representative democracy". i.e. representing, above all, interests of the ruling class (top 0.1% and 1%) which can afford to pay politicians the required millions for the current election campaign, more millions to retire debt from the previous campaign, and offer a lucrative job when a politician can't no longer "serve the country" ... issue of grossly overworked medical residents is a repeated "issue" in mainstream media ... yet - inevitably - besides increasing readership never leads to any real change and real solution.
Our health care system is a racket, a shameful evidence of the supposed "free market" inefficiencies where we spend twice as much money and twice as many per cents of GDP than other 30 OECD countries which all (except of the post-apartheid South Africa) enjoy cost-efficient, the same and even often better outcomes. And the hard-fought "Obamacare" is, in the end, with Joe Lieberman killing its "public choice", a bonanza and giveaway to mighty insurance industry (thus premium increases).
With medical residents, the economic model of our teaching hospitals works on the premise that $45K a year earning residents produce billable hours allowing attending and other physicians make killing as the average American physician's compensation is about 5-times the average wages while in other developed countries is only 2 to 3 times the average wage.
There can't be any bona fide change.
Our health care system is a racket, a shameful evidence of the supposed "free market" inefficiencies where we spend twice as much money and twice as many per cents of GDP than other 30 OECD countries which all (except of the post-apartheid South Africa) enjoy cost-efficient, the same and even often better outcomes. And the hard-fought "Obamacare" is, in the end, with Joe Lieberman killing its "public choice", a bonanza and giveaway to mighty insurance industry (thus premium increases).
With medical residents, the economic model of our teaching hospitals works on the premise that $45K a year earning residents produce billable hours allowing attending and other physicians make killing as the average American physician's compensation is about 5-times the average wages while in other developed countries is only 2 to 3 times the average wage.
There can't be any bona fide change.
3
The issue is not the hours, it's the abuse. Too many attending physicians in the academic world of medicine are slightly psychotic and extremely egotistical. I have too many memories of medical school in the late 80's and residency in the early 90's that make me cringe now, remembering behavior that was unethical at best. We can all remember difficult and strenuous rotations when we might have worked more than 80 hours a week but it was still rewarding and valuable because we had a good leader and good team at the time.
Stop perpetuating the institutional abuse in medical schools by rewarding research-oriented physicians over clinically-oriented ones. Give tenure to docs that are well-rounded and team oriented. Stop looking the other way when an abusive physician brings in big bucks in grants but acts like Henry the 8th.
Stop perpetuating the institutional abuse in medical schools by rewarding research-oriented physicians over clinically-oriented ones. Give tenure to docs that are well-rounded and team oriented. Stop looking the other way when an abusive physician brings in big bucks in grants but acts like Henry the 8th.
15
As someone who had family member go through residency program, I have to say that your points are very much on mark. Thank you.
6
One purpose of the formerly long work weeks was for the physician in training to see more of different case presentations in order to build up experience. A few years ago I attended a seminar on risk to patients. When a patient is handed off at end of shift, there is a certain increased risk of a physician error. What the report found as described in this news account was that for surgeons, no such signal was observed. The next speaker at the seminar described the error rate when physicians were presented with a patient whose issues they had never seen before. The error rate for diagnosis and treatment more than doubled. Thus, residents who see fewer patents will later be presented with patients with a disease or syndrome that they had not seen and will be more likely to make an error.
Rather than looking at surgeons, it would have been better to look at Internal Medicine residents and determine their error rates in diagnosis and treatment decisions. That will probably give a stronger signal.
Rather than looking at surgeons, it would have been better to look at Internal Medicine residents and determine their error rates in diagnosis and treatment decisions. That will probably give a stronger signal.
3
A study of the same design is currently ongoing with Internal Medicine residency programs nationwide. It's called the iCompare study. Unfortunately, assessing accuracy of diagnosis and treatment is outside the scope (and likely feasibility) of this study. Primary outcomes will include mortality and complications in patients, and secondary outcomes will include resident satisfaction and reported well-being.
1
I don't believe the conclusions drawn from the mortality statistics in this study stand up to careful analysis. The program's studied were "surgical' ones. It would stand to reason then that mortality in both groups would probably be related to the surgical outcomes. Residents are supervised in their training programs and the surgeries are assisted by senior staff members. This study only shows that the surgical outcomes for a large group of patients are probably a reflection of each institutions mortality and that I f residents fall asleep during surgery there are experienced and alert surgical present.
8
As a long time medical spouse, I disagree with the author. Residents should not be pushed to the point of chronic misery and exhaustion or to a point where stress becomes so overwhelming that it negatively affects the quality of patient care or the long term well being of the residents' lives, but they should not be coddled either.
Medicine, like military service, IS a very very stressful, serious business that requires enormous skill and stamina. Patients' lives are at stake and the doctors who treat them need to build up reserves of endurance and confidence they can draw on to meet the demands of this very difficult job.
Medicine, like military service, IS a very very stressful, serious business that requires enormous skill and stamina. Patients' lives are at stake and the doctors who treat them need to build up reserves of endurance and confidence they can draw on to meet the demands of this very difficult job.
2
"Some physicians equate “suffering” with “commitment”..."
some people equate suffering with commitment and commitment with productivity. why do humans do this?
it's 21:30 and i am still at the office.
some people equate suffering with commitment and commitment with productivity. why do humans do this?
it's 21:30 and i am still at the office.
5
I lived through a "Big 10" (Ohio State) internship, and was about to volunteer to go back to Viet Nam after months of 110 hr weeks. Then into rural general practice, another sled ride. Now I am in a 30-40 hr/wk practice. Maybe a little less money (not sure about that) and have a life outside of medicine. I still have time to spend with patients, (half-hour visits one hour with new patients). I suggest you think of working for the VA or as a civilian MD for the military. Before that, it was daily and every weekend day making rounds at the hospital, and fighting with insurance companies to get paid. You can have private practice.
5
"Further, asking the residents what they think may not be the best way to determine if that’s the case. Residency programs have a way of indoctrinating new recruits into believing that misery is somehow noble." so true... the culture that would promote work life balance is absolutely nil, the idea is that post-graduate doctors simply sacrifice everything to accommodate everybody else... not the best balance and it produces very scarred and bad doctors who are unable to effectively take care of others.
4
As an orthopedic surgeon in practice for 15 years I count myself and my patients very lucky to have trained before residency hour restrictions were imposed. There is simply far too much to be learned--physically and mentally--to adequately accomplish it under normal working conditions. Is it hard? Yes. But most programs had months (rotations) that were really tough and others that were not nearly so bad. Others have mentioned how multifaceted this problem is: how true! I have been involved training residents for years and the commitment to completing the job of patient care--seeing the patient through to the end--is almost a lost art. It's not the resident's fault; they are simply responding to the expectations put before them. But medicine used to be about pride in "solving problems" for patients and doing the right thing--no matter how hard it was. We were held to a higher standard and we responded in kind.
I should mention that I strongly believe the generation before us did so at an even higher level!
But patients want competency and compassion. You can't do this with shorter hours and yoga because there's simply too much to know! Perhaps having longer programs would help, but I did;t get a real job until I was 34 after surgical training and fellowship.
The author is right--there's insufficient data--and probably dead wrong--my experience and many many other patient experiences suggest that the quality of the training is suffering mightily.
I should mention that I strongly believe the generation before us did so at an even higher level!
But patients want competency and compassion. You can't do this with shorter hours and yoga because there's simply too much to know! Perhaps having longer programs would help, but I did;t get a real job until I was 34 after surgical training and fellowship.
The author is right--there's insufficient data--and probably dead wrong--my experience and many many other patient experiences suggest that the quality of the training is suffering mightily.
10
Agreed. There are no shortcuts to mastery, not even talent. Some surgeons may have more dexterity just as other specialists may have superior critical thinking skills, but there is no substitute for learning by doing something over and over a thousand times over again.
2
I work with surgeons right out of residency. They know and I know their skill set is quite limited due to the cutback in hours. If you are not there you are not going to see the surgery or do it. That is why so many are now subspecializing in smaller and smaller areas of surgery. Hospitals are looking at case lists when making privileging decisions. You can't generate a big case list if you are not on duty.
Agreed. Unfortunately, residents have less continuity, and as a consequence, less commitment to patients. I see this less in surgical residents but much more in medical residents (the exception is the outstanding medical program, where medical residents often have PhDs). I agree with previous comments that this study would have been better suited to internal medicine.
Additionally, medicine has always been self selective. Those that could not stay up all night, work the extra hours, and demonstrate "over drive," did not go into surgery. IM physicians and Pediatricians often had a different focus. In deciding between IM and Surgery during medical school, my IM chairman told me that if I did internal medicine I would have time to fix my own car, rather than bringing it into a service shop (little did he know that with computer driven cars, everything goes into the shop!).
I assume the author of this column, a pediatrician, did not have the same "overdrive" as his classmates who went into surgery. There is no judgment here--everyone is different and everyone has a purpose--but I do not think it is appropriate for one personality type to tell another type what he/she should act like and be like.
If surgeons want to work extremely hard to perfect their craft, so be it. I know I will appreciate their efforts on the back end. I do not think we should strive for mediocrity for all.
Additionally, medicine has always been self selective. Those that could not stay up all night, work the extra hours, and demonstrate "over drive," did not go into surgery. IM physicians and Pediatricians often had a different focus. In deciding between IM and Surgery during medical school, my IM chairman told me that if I did internal medicine I would have time to fix my own car, rather than bringing it into a service shop (little did he know that with computer driven cars, everything goes into the shop!).
I assume the author of this column, a pediatrician, did not have the same "overdrive" as his classmates who went into surgery. There is no judgment here--everyone is different and everyone has a purpose--but I do not think it is appropriate for one personality type to tell another type what he/she should act like and be like.
If surgeons want to work extremely hard to perfect their craft, so be it. I know I will appreciate their efforts on the back end. I do not think we should strive for mediocrity for all.
1
Today's residents are whiners- but that goes without saying. The Doctors Who Know should control residency programs and hours and NOT the unions, lawyers, and politicians.
One remark on the marriage "problem," in a lot of cases the spouse were motivated to marry the future doctor for the wrong reasons- which were unmasked when the realities of training set in. Another aspect is that many residents- especially the women- enter medical training with "pre-existing" spouses who ultimately become incompatible with the dedication required in medicine.
One remark on the marriage "problem," in a lot of cases the spouse were motivated to marry the future doctor for the wrong reasons- which were unmasked when the realities of training set in. Another aspect is that many residents- especially the women- enter medical training with "pre-existing" spouses who ultimately become incompatible with the dedication required in medicine.
4
A diverse and occasionally derisive group of comments here. As a physician Anesthesiologist in practice for twenty nine years I have a certain perspective. Grueling hours of training can no doubt be harmful. The material must be mastered. Residency may need to be lengthened in order to get in enough experience without harmful hours. The slave labor that is the resident trainee allows large institutions to provide care and make profit. New surgeons out of training? Horribly unprepared to deal with the gamut of cases that come their way. Those trained in second-rate institutions show it. Even those new surgeons from highly regarded University programs need more training than they have. There is so much more to this discussion than meets the eye...
8
I'm a 50 yr old MD w/Long hrs, often working between midnight and 6 am & work the next day. I am grateful the "old days" prepared me for reality. Arguments for extended work hours are valid - continuity of care, thinking and performing while sleep deprived, etc. Ideally, residency should prepare one for the responsibilities expected once training is complete & the safety net is gone. I have zero work/life balance & sleep deprivationmiss common & neither are good. maybe restricting hrs will allow for clearer thinking, life balance & reduce burnout & depression. to evaluate effects of reduced hours would require study post residency measurement of multiple, hard to define variables. Being a "good MD" depends on definition of "good" Ask patients, RN, MD, insurance comp, the government & hospital administrators to define "good" and the answers will be vast & varied. Being a physician requires commitment & is rewarding. Being a pt is frightening each should expect excellent care & time with MD - a real human that genuinely cares & follows up, makes eye contact, leaves the computer at The desk & engages in conversation. Being "good" from all the different perspectives is virtually impossible & and patients lose out. Would be nice for patients to have a properly educated, compassionate happy, well rested MD with work/life balance & predictable hours but restricting work hours while training is unlikely is not going to make that happen in real life.
4
Residents paid are paid, aren't they? How about requiring overtime pay after 40 hours, the way other businesses do. Boy, would you see some pencil-sharpening in the office!
11
Now that would have been nice! I calculated during residency that I was making half the minimum wage.
8
Nice try, but try finding a salaried white-collar professional in any other field who makes overtime. The government has written the rules to favor businesses such that they don't have to do it for the more "professional" middle class, so that they can get worked to the bone.
1
The U.S. military has done a fair bit of research about how long people can function without sleep. I have never seen any evidence that the people who train doctors have read it. In particular you basically start having ten second lapses in attention and/or micronaps if you have been awake more than twenty four hours. Amphetamines can push that out but with a much harder and longer crash later, not to mention the long term problems. So why on earth does anybody schedule doctors more than twenty hours on ten off? It is just the reasonable physiological maximum if you want the guy with the big needle to be able to pay attention.
15
Because sometimes, especially in primary care, there are days and nights when a physician is on-call after office hours, and your patient needs to be evaluated in the ICU at 3 AM, another patient needs Q 3 hr blood gas results reported to you during the night, a nursing home patient falls out of bed or has gross hematuria at 1 AM and the call comes through.....And a nurse practitioner group opens up a 9-5 walk-in next door to see the easy stuff that used to help meet over-head or your staff bonuses/retirement plans.....Children, don't go to Medical School! Unless you really enjoy solving problems, engaging in people's lives, caring for the entire person, helping people find peace in life and in death, don't mind that the only reading material you'll pick-up for 40 or so years of active practice will be medical or scientific journals. Then apply.
2
i think there has to be a balance -- should residency be tough? sure. should it be so tough that it drives an increase in mental illness (depression/anxiety) or substance abuse? no. and, above all else, residency should well serve the patients who are at the core of all we do.
8
The issue isn't just the functioning of residents based on shift hours. The issue is what type of people are drawn to a hypercompetitive field. Often it is narcissistic and even sociopathic people who are drawn to such fields. I have observed over the course of my life that an extremely large percentage of physicians lack empathy and interest in other people. Yet helping people is supposed to be their job. And yet we're surprised that medical errors kill tens of thousands and thousands more become addicted to randomly prescribed medications, or destroyed in other ways. More than half the people I know have been victims of medical malpractice.
11
My Intensive Care Fellowship (post residency sub-specialty training) was in the period of 2003-2006 when limitations on resident work hours were being phased in. This transition created an enormous shift in workload. The ramp up in the number of mid-level staff such as Physician Assistants and Nurse Practitioners that we have seen over the past decade had not yet happened. And senior faculty had paid their dues and were not going to return to their training lifestyle. While a necessary change in resident work-hours was being worked out somebody had to take care of patients, and it ended up being the junior faculty and sub-specialty trainees. Exempt from duty hour restrictions, I worked ten months of 14-16 hour shifts and every third night call (a 36 hour shift). Occasionally every other night call was required to spring a colleague for a conference or vacation. Average hours per week were well over 100, with one particularly grim and memorable week that topped 120. The cohort of post residency trainees and new attending faculty of the mid 2000's deserves some recognition and thanks.
14
Yes, the ICU fellows I worked with during that time frame did every other night call during their first year. I work with a graduated one now at my current hospital and he still talks about how horrible it was 10 years later. I was a resident and I was "lucky" to be on every third night.
2
If changing shifts and transferring responsibility does indeed result in poorer patient care, then shouldn't we be focused on teaching residents how to do it better? There are always going to be residents leaving their rotations, nurses ending shifts, medical personal being called to an emergency elsewhere, weekends, days off etc. If good care relies on continuity of care by the same person, aren't we in trouble?
18
Continuity of care with the same person is a thing of the past in hospitals. A cast of interchangeable hospitalists provide roving patient care and require redundant interviews.
1
I've been in medical practice 25 years and I can make two observations. Every one of the residents who commented here fought long and hard to achieve their current position. No one ever hid from them how hard it would be. Second, I can tell an attending physician who trained seriously and who did not by the complexity of care they manage and thoroughness of their thoughts. Stop whining and do the job you signed up for.
2
That sounds empathic...I hope you are not my doctor.
12
All this study shows is that when two groups working the same number of average weekly hours are compared, there is little difference in outcomes for them or their patients. That does not seem like a surprise. What is needed is a significant difference in the working hours of the two groups. If there is no difference in outcomes between a group working 60 hours a week and one working 80 hours a week, then a conclusion may be drawn that patient outcomes and resident training are not affected by the residents working 33% harder, at least at hours of 60 a week or more.
5
I can only give you anecdotal evidence from watch our grandsons fight serious illnesses last year. My wife (a pediatrician who did a hem/onc fellowship in the 90s) was appalled by the lack of clinical skills some of the senior residents and fellows had, even at top facilities.
One surgical fellow palpated the wrong quadrant of the abdomen to check the liver. A senior resident could not hear obvious coarse breathe sounds. Several could not answer basic medical questions my wife posed intentionally, since she likes teaching. None could do certain tasks my wife considered routine as a chief resident. Surely schools are not admitting less-qualified people to learn medicine.
Our only conclusion was that these "kids" simply were not getting the hours necessary to master all the tasks that make good pediatricians. To their credit, however, when looking at the charts, their computer skills were impeccable.
One surgical fellow palpated the wrong quadrant of the abdomen to check the liver. A senior resident could not hear obvious coarse breathe sounds. Several could not answer basic medical questions my wife posed intentionally, since she likes teaching. None could do certain tasks my wife considered routine as a chief resident. Surely schools are not admitting less-qualified people to learn medicine.
Our only conclusion was that these "kids" simply were not getting the hours necessary to master all the tasks that make good pediatricians. To their credit, however, when looking at the charts, their computer skills were impeccable.
20
is that because they are not working ridiculous hours? Or because they are not getting enough training? Is the watch once, do once, and teach formula deeply flawed? That is a rhetorical question.
7
It's surprising that there is no reference to how physician training is done in other developed countries. Do Germany, Sweden, France, Japan, etc., put their residents through this kind of system? If not, what kind of system do they use and what are the observed pros and cons? Is it simply impossible to believe that we can learn anything from other countries or is this system of training the world-wide norm?
It was also disturbing to see little evidence of innovative thinking about physician education in the 21st Century. EMRs are a problem, complexity is a problem, proliferating drugs with sometimes little recognized (or at least acknowledged) side effects and interactions are a problem. New discoveries about nutrition, various biological processes, exercise, and a variety of other things should be having an impact on the practice of medicine, but there was no indication that addressing any of these issues is taking place.
It's also rather ironic that there was so much concern with "handing off" patients even as the use of hospitalists is increasing. Communication between hospitalists and a patient's long-time physician are, in my experience, absymal. If the trend toward use of hospitalists is going to continue, then the medical field needs to come to grips with how to better manage communications--"handing off" would seem to be part of this larger issue. The same is true when hospitalized patients are seen by numerous specialists who do not communicate either.
It was also disturbing to see little evidence of innovative thinking about physician education in the 21st Century. EMRs are a problem, complexity is a problem, proliferating drugs with sometimes little recognized (or at least acknowledged) side effects and interactions are a problem. New discoveries about nutrition, various biological processes, exercise, and a variety of other things should be having an impact on the practice of medicine, but there was no indication that addressing any of these issues is taking place.
It's also rather ironic that there was so much concern with "handing off" patients even as the use of hospitalists is increasing. Communication between hospitalists and a patient's long-time physician are, in my experience, absymal. If the trend toward use of hospitalists is going to continue, then the medical field needs to come to grips with how to better manage communications--"handing off" would seem to be part of this larger issue. The same is true when hospitalized patients are seen by numerous specialists who do not communicate either.
22
Medicine is not the only field that the licenses and internships have been abused for generation after generation. Architecture is another Prime one. You are required to have three years of work experienced under a Registerd Architect before you can take your RA exam. Only one year working for as a construction Manager under a Contractor can count and often only for six months. ( this is the best work experience and should be what is required. Working out in the field with the construction guys. Try explaining to them what the mystery lines are on the drawings. It can't be built, it is a stray line. You learn the most expensive and ridiculous detail is to chapfer columns that will be covered in drywall.)
Attorneys to partnership, CPA candidates and Engineers. Then the Electrical and Computer Science degree effort is being destroyed by Paul Ryan and the Visa gRab based on false data. Their is no shortage just people that don't want to work 80 hrs for 50k and work under rude sexist Indians and Arabs!
Attorneys to partnership, CPA candidates and Engineers. Then the Electrical and Computer Science degree effort is being destroyed by Paul Ryan and the Visa gRab based on false data. Their is no shortage just people that don't want to work 80 hrs for 50k and work under rude sexist Indians and Arabs!
7
The guild-like ordeals of entry into the American medical profession seem to be more focused on restricting the number of physicians and keeping compensation high than on quality of medical care. The complaint about hand-offs is a case in point. Quality assurance programs focus attention on hand-offs because it is widely recognized that disproportionate numbers of errors occur there in most systems. Improved processes that protect patient welfare at the point of hand-off can effectively address the issue. The system wide results of American health care lag all the European countries and do not even outshine the outstanding health care system in a very poor country like Cuba. We do not need to put young doctors through the ordeals of American residency. A system with more humane work conditions and expectations will require more doctors, but it does not have to be more expensive as the Europeans demonstrate. Sometimes it is easier to see the irrationality of a system from the outside. Looking at the big picture, we can certainly do better.
15
Bob,
You have just made every Internist, Pediatrician, Family Practice physician snort, laugh, guffaw, blink, look amazed..... They really didn't know they were on the gravy train!
You have just made every Internist, Pediatrician, Family Practice physician snort, laugh, guffaw, blink, look amazed..... They really didn't know they were on the gravy train!
1
Tell me about it. I am in a non-procedural (ie cognitive) specialty. I have 14 years of post-high school education, all full time plus, and started "real" (ie attending, > $10/hr) work at age 32. My husband has 6 years post-high school education, was able to get his masters part time while still working full time, and has been working at a competitive salary since the day he graduated from college at 22. We went to the same college, and I had considerably higher grades than he did. He works nights and weekends rarely, once every few years, and I do so regularly. He admits my job is a lot harder than his. I make less money than he does, still, which even he thinks is ridiculous. I could have chosen a lot better ways to get on a gravy train- trust me, I see it every single day!
As a current third-year medical student, I could not agree with this author more. This year is my first year doing clinical rotations and by extension, my first year with these 12-17 hour days, q3-5 call and similar work restrictions as to residents. Some residents really do seem to feel that their long hours are a badge of merit and feel students should prove their merit similarly. Meanwhile, every now and then we are reminded to take care of ourselves. Do yoga, exercise, meditate, get counseling! Hard to do when you leave home before sunrise and get home after sunset 6 days a week (and my hours aren't even as bad as residents'). Unsurprisingly, this has been the worst year ever for mental health for me and many of my classmates. After a lecture on the high rates of physician burnout, depression and suicide, several of my classmates and I confided to one another that it had hit all too close to home.
It was infuriating to see the results of these studies being framed as "it's ok guys! Let's make the residents (read: cheap physician labor) work longer hours just because we can!" Thank you to Dr. Carroll for framing it like this instead.
It was infuriating to see the results of these studies being framed as "it's ok guys! Let's make the residents (read: cheap physician labor) work longer hours just because we can!" Thank you to Dr. Carroll for framing it like this instead.
26
You can't turn the practice of medicine into something it is not; it’s a profession, not a job. I trained at the cusp of the implementation of work hour rules, and those who trained after are very different physicians than those who trained before. As an attending, you will be awoken in the middle of the night and have to make complicated decisions quickly. Depending on your chosen field, you may have to operate at 2am or be woken up many times a night and have to work the next day. Those processes take practice to master.
I believe in self care, but by choosing medicine you are making a conscious choice to take care of a vulnerable human being. Your experience and durability can help the patient, your mistakes can harm. Some of the best times in my career are when I see patient through a particularly rough time in their illness. It frustrates me that medical training has taken on a "punch-in, punch-out" shift work mentality.
Were I ill, I would want my physician to be able to know what I looked like hours before, to have a breadth of experience to be able to think outside the box, and to be able to make timely, smart decisions even when tired.
I think that attempts to manipulate the workload have failed because of the nature of the beast: emergencies can't be planned, illness can't be scheduled and diseases have courses which don't obey work hours.
No one should feel abused or suicidal in their profession, but you don't go into medicine for the sleep, you go in to serve.
I believe in self care, but by choosing medicine you are making a conscious choice to take care of a vulnerable human being. Your experience and durability can help the patient, your mistakes can harm. Some of the best times in my career are when I see patient through a particularly rough time in their illness. It frustrates me that medical training has taken on a "punch-in, punch-out" shift work mentality.
Were I ill, I would want my physician to be able to know what I looked like hours before, to have a breadth of experience to be able to think outside the box, and to be able to make timely, smart decisions even when tired.
I think that attempts to manipulate the workload have failed because of the nature of the beast: emergencies can't be planned, illness can't be scheduled and diseases have courses which don't obey work hours.
No one should feel abused or suicidal in their profession, but you don't go into medicine for the sleep, you go in to serve.
One sad effect of work hour rules is that residents get the mistaken impression that life will improve after residency. If only practicing physicians had work hour rules! With the rise of "factory medicine" and the disaster that is EMR, physicians are locked into running on a treadmill over which they have very little control. I'm very close to a primary care physician who regularly works between 70-120 hours a week (70 hours is a rarity), is continually sleep deprived, has to take up the slack created by residents who have to stop and leave the hospital before rounds are finished due to work hour rules, and when she is at home, is occupied with finishing the electronic "paperwork" left over after a day packed with patient visits and not enough time to finish notes, including checking the notes of residents and mid-level providers. Fortunately for her patients, she is thorough and takes the time to make sure things don't get missed, but I think hers are the fortunate patients.
Medicine (especially in the case of primary care) has been co-opted by insurers minimizing their "loss ratios," large hospital conglomerates, layers of administrators focused on maximizing "productivity," and both the patients and providers have been put in an untenable situation as a result. Work hour rules provide residents a few years of slack before a lifetime of "hazing" with no end besides retirement or death.
Medicine (especially in the case of primary care) has been co-opted by insurers minimizing their "loss ratios," large hospital conglomerates, layers of administrators focused on maximizing "productivity," and both the patients and providers have been put in an untenable situation as a result. Work hour rules provide residents a few years of slack before a lifetime of "hazing" with no end besides retirement or death.
14
Speaking from the perspective of those lying in the bed being ignored, it is deeply disturbing that a profit-oriented medical hierarchy is allowed to define medical education as the deliberate overuse of sleep-deprived trainees who are forced to do an absurdly large amount of mental and physical work for the least possible reward, while they are at the mercy of superiors concerned with greater profits, an easier work day, and increased prestige for themselves.
Here is a suggestion from a non-medical observer, in the interest of humane treatment of medical trainees by their trainers: it's time to dump the brainwashing techniques, folks. Yes, you've proven that with sufficiently heartless institutionalized treatment, you can induce a form of Stockholm Syndrome behavior in many of those trainees. And yes, like you, the survivors of this treatment may end up congratulating themselves on how superior they are... but none of that does anything useful for us, the patients.
Here is a suggestion from a non-medical observer, in the interest of humane treatment of medical trainees by their trainers: it's time to dump the brainwashing techniques, folks. Yes, you've proven that with sufficiently heartless institutionalized treatment, you can induce a form of Stockholm Syndrome behavior in many of those trainees. And yes, like you, the survivors of this treatment may end up congratulating themselves on how superior they are... but none of that does anything useful for us, the patients.
24
Training in an inner city hospital the most difficult part was not the work hours but being abused and threatened by patients after you slogged all night trying to save their lives. My best night was when after 90 grueling hours a little old lady told me, as I was walking out, that she was grateful that I was up all night - She said "I am grateful for what you did last night - if you had slept I would not have woken up this morning!"
11
"Some physicians equate “suffering” with “commitment” and believe that a residency should be grueling and difficult"
A leading physician that I worked with closely believed exactly this. he said he learned because of the long hours and difficulty of his residency. He was bemoaning the new rules for residents that preclude such long hours and believed that they were not learning what they needed to as a result.
A leading physician that I worked with closely believed exactly this. he said he learned because of the long hours and difficulty of his residency. He was bemoaning the new rules for residents that preclude such long hours and believed that they were not learning what they needed to as a result.
1
I do not want my physician working his or her first 36 hour shift unsupervised. I want my physician working those hours during residency when he or she is being supervised by an attending. When you are an ICU or surgical attending, you cannot go home. Maybe there is not another physician to take call because the other physician is on vacation at a small hospital. Maybe the hospital is taking too long to hire a new physician, or to get the physician a medical license in that state. By the time a physician is an attending, the physician should know when he or she is no longer capable of making a good decision and needs to call on a colleague, maybe from another department.
Anyone who thinks that the shorter hours for residents do not make longer hours for attendings is not thinking about the way that hospitals are run.
Anyone who thinks that the shorter hours for residents do not make longer hours for attendings is not thinking about the way that hospitals are run.
7
I was a CPA. I worked very long hours for a portion of the year. There is no doubt that people made more mistakes when they were working 80 hours a week, were tired, and less likely to exercise. I cannot think of a reason why it would be different in the medical world.
11
There's more than a little amiss when doctors are cued or forced to report working 80 hours vs. 100 hours actually worked in a country that spends by far the most per capita on health care.
In my 20s I worked such long hours in a non-medical field that several times I fell asleep while standing. Learning and civility were both compromised. I've had friends and relatives who died in acute care situations due to fatigue-related blunders by doctors.
By my 50s I had learned there was no substitute for constant vigilance by me when a family member was in the hospital. So my teenage son's discharge report reads "The patient's father diagnosed his condition [pericarditis] through research on the internet." (Thank you mayoclinic.com.) A year later the doctor who missed the diagnosis and who always appeared to be surviving on 4-5 hours of sleep retired before age 60.
Medicine is a profession where it's hoped, and mistakenly expected, that the practitioners will be miracle workers. The medical establishment needs to retune its thinking about the effect of fatigue on Doing No Harm.
In my 20s I worked such long hours in a non-medical field that several times I fell asleep while standing. Learning and civility were both compromised. I've had friends and relatives who died in acute care situations due to fatigue-related blunders by doctors.
By my 50s I had learned there was no substitute for constant vigilance by me when a family member was in the hospital. So my teenage son's discharge report reads "The patient's father diagnosed his condition [pericarditis] through research on the internet." (Thank you mayoclinic.com.) A year later the doctor who missed the diagnosis and who always appeared to be surviving on 4-5 hours of sleep retired before age 60.
Medicine is a profession where it's hoped, and mistakenly expected, that the practitioners will be miracle workers. The medical establishment needs to retune its thinking about the effect of fatigue on Doing No Harm.
16
I was appalled to find that life-or-death decisions about my mother were being made by someone who had been up all night. So these sleep-deprived residents are supposed to learn from their mistakes? What if those mistakes include stealing the life of someone I love? Am I supposed to accept that as somebody's learning experience? I would prefer the odds with a resident who was not sleep-addled!
17
Enough rationalization--this is hazing, plain and simple. It's human nature; hazing crops up wherever new members are being admitted to an exclusive group, and it's every bit as stupid--and as tenacious--for medical residents as it is for college freshmen. We only allow it to continue out of deference to anyone in a white lab coat.
29
Hospital outcomes are not about a few minutes of contact with a clinician. Outcomes in people are about behaviors, situations, relationships, and determinants shaping outcomes decades before a hospital encounter, and shaping the encounter, and with impact after the encounter. This is why NP vs MD or Primary Care Medical Home or any study with the same population would show no difference. But if there are differences in populations, there are differences in outcomes such as Hong in JAMA with lesser outcomes for underserved patients or rural hospital outcomes in JAMA (different pop, different payment, different situations)
1
You can "cruise through" residency, if you want too. But that's not what most residents want.
1
As Dr. William Halstead reportedly said, "The only bad thing about being on call every other night is missing half the cases."
1
Considering this is coming from a guy who was addicted to cocaine, I don't think I would take his advice on working hours very seriously.
17
From To Err is Human to the present, studies have been designed to blame medical errors, clinicians, residents, and lack of insurance coverage. The result has been further distraction from important changes in areas that can impact outcomes - changes in the patient, their behaviors, situations, relationships. Instead we focus on the 10% that can be impacted by the clinical intervention or the 1% for digital impact.
3
The purpose of residency is to train physicians. Everyone believes that medical care form an attending is superior to from a resident , so why would current care matter . (specifically, if bad outcomes occur in 9% of either training method, it would be reasonable to assume a lower percentage in well staffed non teaching hospitals of around 6-7%). The only metric that matters (but is certainly difficult to measure) is how these residents function once done their residency. My experience with younger physicians today is that they are much less confidant in their diagnostic and treatment judgement, and as a result, over test and over treat. Find a measure that shows which programs lead to physicians better able to enter the field, not still need training when they get there. My experience in the "bad old days" was that the only real way to learn medicine was to have to make decisions under pressure, and to learn from the mistakes you made.
1
I'm sure learning from mistakes was great for your medical education. Let me ask, how great was it for your "mistakes"?
Do you even realize how terrifying your last sentence sounds to those of us who read it from a patient's perspective?
Do you even realize how terrifying your last sentence sounds to those of us who read it from a patient's perspective?
11
Younger physicians today compared to when? What other factors have changed between that time and now, both in medical education and in education other than medical? What changes have occurred in treatment options? How much more complex has medicine become? How many new drugs have been added? How large is your sample size of "now" and "then"? And how reliable is your memory of what young physicians were like "then"?
5
How funny. Quoting studies from NEJM as if its sacrosanct. residency is not supposed to be benign, it is inherently imbalanced- there is simply no way around it, should you choose a traditional residency. Programs vary in quality of teaching and patient load. Residency is short term- there is always an end in sight and as the years go by, one gains a certain amount of respect- becoming a senoir resident. It isnt easier, but the nurses depend on you more, consults are not as difficult and you have help- a team of junior residents and med students. Personally, I wanted a demanding difficult program, I wanted maximum exposure to everything- this was it- my training. I did a med peds residency- slept in converted closets when on call, would leave at 7 pm after being on call all day/ previous night. Getting 2 hours of rest in the early morning was a luxury. I distinctly remember that icky queasy feeling of being called at 4 am and having to get up after maybe 30 min horizontal. Surgeons are a different breed, I distinctly remember being told- if I was sick/vomiting nauseated- go to the ED and get some compazine- so you can continue to work. Regulating hours is not going to make better doctors or safer patients and anyway- how would we know? Depend on all these various studies? Until they are refuted?
2
It is somewhere between an insider joke and a tragic coverup that a small percentage of attending physicians on call who are awakened in the middle of the night give incoherent orders. How many potential medical errors due to sleep deprivation and stress are rectified by experienced nurses or other staff who carefully guide such an impaired physician - or resident, or fellow - into making a reasonable choice about care, or who find another way to avoid implementing erroneous and perhaps dangerous orders?
Might I suggest that if there is "no evidence" that patient care is harmed by a brutal call schedule when a physician in training is in the least competent time of their career and under the most stress, the problem needs to be assessed in another way?
Might I suggest that if there is "no evidence" that patient care is harmed by a brutal call schedule when a physician in training is in the least competent time of their career and under the most stress, the problem needs to be assessed in another way?
16
Although I was a Professor and trained medical students for many years the problem newly minted MDs have finding resident training only became clear recently. A highly trained MD friend bounced around from volunteer medical research and part-time nursing home jobs, bathing the elderly for two years following graduation before she finally landed a residency. Why? the shortage of residency position is in part due to a lack of Federal money that hospitals use to pay residents. This shortage is a major road block to licensure and the much needed increase in doctors on the street.
4
I find that hard to believe that they couldn't find any job, clinical of course not without a residency, but there are many pharmaceutical and insurance companies out there who are just chomping at the bit to have MDs working for them.
@Durham MD - At least some prospective physicians would consider working for either the insurance industry or a pharmaceutical company to be like a stint in hell.
5
Not saying it is ideal, but it sure would pay better than $0 (volunteer research) and minimum wage (aide in a nursing home) and probably would look better on a CV if you were interested in applying to residencies.
My complaint is that nurses are taking over medical care: taking histories before the patient has even met the doctor, "prescribing" drugs with no doctor in sight to get consent for treatment, and so forth.
4
Nurses DO NOT prescribe drugs. A nurse practioner does prescribe under medical protocols. Nurses are trained and skilled at taking histories and have more time than most doctors to do it thoroughly. Without time, many things are missed. When a nurse does a complete history before the patient sees a doctor, the doctor can then spend her/his time concentrating on treating the patient.
13
You got it. Now multiply that by 100x to know the damage being done by run-away midlevels (NP)
2
Being young, I simply accepted the long hours, night call etc. during my training. A beneficial effect, in my opinion, was that I learned that illness and patients' concerns did not "respect" 9-5 hours. I had to be available at any time for any problem. There was some benefit in seeing patients at 4 in the morning and being able to manage their care efficiently.
Obviously there is a limit- what my neurosurgical friends told me that they endured was brutal and not beneficial in my mind. There should be a common sense approach.
Obviously there is a limit- what my neurosurgical friends told me that they endured was brutal and not beneficial in my mind. There should be a common sense approach.
7
Not one word about what their patients thought...
11
One patient told me what he thought.
As a second-year resident I was on a schedule in CCU with two other residents, during which we all started Day 1 at 8:00, stayed through Day 2 until 16:00, usually staying up much of the night, and then had one day off.
One night before my Day 2 was particularly rough, and I was observed by one light-sleeping patient to be running all night. At three in the afternoon of the next day, he had chest pain and I went over to assess him. He asked me politely if he could have "the new one" and I laughed and agreed readily.
As a second-year resident I was on a schedule in CCU with two other residents, during which we all started Day 1 at 8:00, stayed through Day 2 until 16:00, usually staying up much of the night, and then had one day off.
One night before my Day 2 was particularly rough, and I was observed by one light-sleeping patient to be running all night. At three in the afternoon of the next day, he had chest pain and I went over to assess him. He asked me politely if he could have "the new one" and I laughed and agreed readily.
3
When I was a fellow I had MULTIPLE patients express worry about my well-being, asking when I got days off and such. When I was visibly pregnant, even more so. Many of them were very kind people, with family members who were very ill, and I did appreciate their concern for me as a person.
1
My son is a third year resident at a hospital in Chicago. Even with the so-called improved hours/schedules, he is frequently so exhausted that it is impossible for me to believe that this does not affect the ability to deliver care safely and appropriately. Is this the only profession that can work trainees to death without a compromised outcome? If senior doctors think so, they should get out of the hospital more. As a patient, the first question I would have when I saw an exhausted resident would be, "How long have you been on duty?" Depending on what he/she said, I might have to get up and run out of the hospital asap.
15
Residency training is inherently difficult. Adding unnecessary hardship is a way to indoctrinate elitist attitudes and an illusion of superiority. It encourages a sense of entitlement to higher pay and martyrdom. It distracts from the mission to keep the patient at center stage where they belong.
10
or it teaches you that even when you don't feel your best that patients lives are on the line and you have to learn how to do the right thing no matter how you feel. Listen, make training a regular 40 hr 9-5 job, a non elite if you like, but you go to that doc, I'll go to one who has had to make difficult decisions in the middle of the night, and learned from his mistakes.
1
Alan, studies have shown that drowsy drivers are like slightly drunken ones. Each individual may have a different level of tolerance, but I think you are fooling yourself that you'll make the right decision after nearly two days awake. How would you like to step on a small plane with a solo pilot who had been awake 40 hours?
Repetition and practice make any learned activity more automatic, but where is the study showing that practicing while massively sleep-deprived improves proficiency? I'll go to the doctor who is self-aware enough to acknowledge her/his own human limitations.
Repetition and practice make any learned activity more automatic, but where is the study showing that practicing while massively sleep-deprived improves proficiency? I'll go to the doctor who is self-aware enough to acknowledge her/his own human limitations.
7
During my medical internship (first year of hospital training after medical school graduation) I worked 38 hours on and 10 off throughout almost the entire year, together with my fellow interns. I was young (26) and strong, and did not find the experience enervating or depressing. In fact, it was exhilarating; it was the first time that I experienced the opportunity and responsibility of taking primary care of patients. While I would not have wanted to keep up this rigorous schedule through all the years of my residency training (which were less arduous), it was the year that made me into a real doctor.
I am not aware of any mistakes or lapses in judgment that I or my colleagues made due to fatigue or sleep deprivation.
****A Connecticut physician
I am not aware of any mistakes or lapses in judgment that I or my colleagues made due to fatigue or sleep deprivation.
****A Connecticut physician
3
Of course you weren't aware of any errors. That's kind of the point -- impaired people are usually too impaired to realize their impairment. If you wanted an accurate assessment, you should have asked the nurses on the shift -- the ones who have quietly corrected the errors of many exhausted new doctors.
Would *you* want a virtual zombie taking care of you at the most vulnerable moments of your life?
Would *you* want a virtual zombie taking care of you at the most vulnerable moments of your life?
6
This whole argument is garbage. At the same time this discussion started many years ago, a similar study in the NEJM , the sacrosanct arbiter of medical care and research, published an article proving that it was dangerous for long hours of long distance truck driving. Laws changed to protect us on the highways.
When I and many others wrote letters to the editor comparing the two issues, we eere rebuffed by the establishment of medical education. Lay in a hospital bed and look up at the neurosurgical resident who had not slept for 24 hrs, as I have done; I promise that you will be on the side of a more humane treatment of residents when you see him stumble in the room unable to focus on your wound and forget what he was supposed to order.
The other side of the story is that residents save hospital systems fortunes. The attending MDs make money on the system by charging for the work done by residents even in their absence. This argument of continuity of care must cease; the educational advantage of long hours is pure garbage, or why do parents make their children go to bed before a long day of school. Stop the exploitation and move on.
When I and many others wrote letters to the editor comparing the two issues, we eere rebuffed by the establishment of medical education. Lay in a hospital bed and look up at the neurosurgical resident who had not slept for 24 hrs, as I have done; I promise that you will be on the side of a more humane treatment of residents when you see him stumble in the room unable to focus on your wound and forget what he was supposed to order.
The other side of the story is that residents save hospital systems fortunes. The attending MDs make money on the system by charging for the work done by residents even in their absence. This argument of continuity of care must cease; the educational advantage of long hours is pure garbage, or why do parents make their children go to bed before a long day of school. Stop the exploitation and move on.
47
Whether trained under the old system or under the new system, so far I have never met a physician to whom I would comfortably entrust the health of anyone I love. Both systems foster nonintellectual, incurious, poorly read, robot-like nonthinkers who are now unable to bring modern medicine into the 21st Century where it belongs. In general they make poor parents to their own children, and poor spouses. 100% are unfit and underexercised, eat poor diets, and 30% of my entering class at Yale Medical School were smokers. And yet physicians spend their lives telling other people what they are supposed to do. The economics of our medical system make fixing this very difficult. But in general the nurturing of the human mind requires both sleep and quiet time for reading, learning, and reflection. This simple fact is known by every intelligent person on our planet, but apparently not by anyone in the medical profession.
35
Dr. Lewis, I am thankful that you are not my physician.
This study was not designed to gather good data-- objective physiologic data-- on the actual performance of the surgical residents who were required to participate. Data could have easily been collected on subgrops of residents who work in hospitals with Clinical Research Centers funded by NIH-- where sleep EEG data plus cognitive, manual and mood instruments could have been administered. Or driving data could have been extracted from devices installed on residents' cars-- for deceleration and sharp braking, for instance.
instead a large data based was mined for trends that will be applied to particular residents each wth individual biological situations of sleep-wake needs, mood, family requirements, and particular training situations that vary in intensity and idiosyncracy. I fear that important policy decisions will be made based on this deeply flawed study. With 40 years of sleep research seemingly ignored, so many aspects of this study deeply perplex and disturb me.
instead a large data based was mined for trends that will be applied to particular residents each wth individual biological situations of sleep-wake needs, mood, family requirements, and particular training situations that vary in intensity and idiosyncracy. I fear that important policy decisions will be made based on this deeply flawed study. With 40 years of sleep research seemingly ignored, so many aspects of this study deeply perplex and disturb me.
21
Many surveys of mid-career doctors show that over 50% of doctors complain of burnout. Doesn't burnout start during grueling residency training? Like smoking, the injuries inflicted on young doctors don't manifest themselves until much later.
15
How on earth is America going to find enough doctors when getting through a residency is insanely difficult? Should A Bernie plan come to pass and a quarter or more of our doctors bail, it's not going to be pretty here even though the airlines will do a brisk business.
4
Perhaps you'd like to list the countries where doctors are more highly paid than in the U.S. and have more freedom from regulation?
2
I stayed in Canada rather than going back to the US where I came from because, most pertinently, I could not tolerate the thought of being micro-managed by insurance clerks, and secondly, they weren't going to pay me as much as I was earning in Canada.
5
Of course training is important, but we're being wildly unimaginative if we're saying that there isn't a better way to accomplish this without such strenuous work conditions for the residents. They're doctors, after all -- motivating their patients to lead healthy lifestyles, get good sleep, enjoy proper nutrition, and yet they're supposed to function on something less than all of that?
Being a health care provider is already innately difficult; I don't understand why it needs to be exacerbated further.
Being a health care provider is already innately difficult; I don't understand why it needs to be exacerbated further.
28
I graduated medical school in 1972 & went through the "old school" training regimen. In my internship, for at least half the year I was on every other night, not merely q3. This entire discussion seems like it occurs in a vacuum. There are voluminous data on the deleterious effects of sleep deprivation. Are we to believe that by attending medical school for 4 years we become immune to the effects, unlike other humans? What proponent of the old system would volunteer to ride in a plane piloted by someone who hadn't slept in 24 hours? Does the fact that no harm came to the patients, in the quoted study, who were cared for by relatively sleep deprived residents mean that they were not exposed to potential harm? Airlines demand that their entire flight crew, not merely pilots, get a certain amount of sleep. The issues, I believe, are ego & economic. This article opened with doctors bragging that they are martyrs to the medical profession. That is the ego part. The economic part lies with the hospitals where the training occurs. If a resident works fewer hours, who picks up the slack? The answer is someone else who now must be paid. We were not paid overtime as residents. Fewer hours on call means another person needs to be hired AND paid. It is true, on the other hand, that continuity of care is compromised with shorter work hours. The solution to that seems to be better communication. The only solution to sleep depravation is sleep.
71
I am in a surgical specialty with 35 years in practice. Last week I saw in my office a young lady, a college student. I asked her what her career goal was. and she replied, "certified registered nurse anesthetist." Such a well-defined goal at such a young age is unprecedented in my experience, but it made perfect sense. Interested in medicine, she had followed doctors around in the hospital and their offices, and every one had advised her not to go to medical school. She grew up on a ranch and is unusually mature with a highly developed sense of responsibility. She will graduate with a nursing degree, spend a year or two as a clinical nurse, earning at least as much as a resident after four years of medical school, then go on to nurse anesthesia school for another two years. She will earn nearly as much as an MD anesthesiologist, not have a huge debt, and have less malpractice risk because she will not be doing the risky cases. Most of all, she will have a life outside of medicine.
Daniel Allan, MD, FACS
Daniel Allan, MD, FACS
23
We hung ourselves when Medicare came through and doctors have seen almost annual fee reductions for services, to the point that the lose money on these paperwork-heavy oldsters.
Go check out the 1965 estimates for Medicare spending in the years ahead, such as 1990.
Go check out the 1965 estimates for Medicare spending in the years ahead, such as 1990.
3
The median annual Certified Nurse Anesthetist salary is $168,721 as of 1/31/16.
The median annual Physician Anesthesiologist salary is $352,686 as of 1/31/16.
How will she "earn nearly as much as an MD anesthesiologist"?
I don't have current figures for the student loan debt to income ratio for either group, but some time back there was an article pointing out that, while nursing education costs a lot less than that for a physician, the ratio of debt to income was actually higher for a nurse than for a physician. That obviously varies with specialties and various other factors, and it's possible it's no longer true, but simply stating that she'll have less debt doesn't mean a whole lot without more information.
The median annual Physician Anesthesiologist salary is $352,686 as of 1/31/16.
How will she "earn nearly as much as an MD anesthesiologist"?
I don't have current figures for the student loan debt to income ratio for either group, but some time back there was an article pointing out that, while nursing education costs a lot less than that for a physician, the ratio of debt to income was actually higher for a nurse than for a physician. That obviously varies with specialties and various other factors, and it's possible it's no longer true, but simply stating that she'll have less debt doesn't mean a whole lot without more information.
3
Now compare the out-of-pocket for each group for liability insurance. It can double in a month for doctors.
4
You know what's really changed resident training? It's not the limits on work hours. It's the extraordinary amount of time that residents now spend on computers checking and updating the electronic medical record, or ordering medications or labs. During my internship, writing a note on a medical patient took five minutes and ordering a medication or a lab took less than a minute -- the work was seeing the patients, doing procedures, and figuring out what to do. It usually took longer to find the paper chart than it did to write the note! Now residents spend longer doing paperwork than they do with patients. Even surgery residents are now stuck on a computer after surgery to finish all the note-writing instead of checking on the patient.
I'm not a luddite -- far from it. I love my laptop, iPhone, iPad, and everything else that helps me get through my day, and I'm quite a speedy typist. But every doctor I know, every single one, knows that electronic medical records take far more time than paper charting ever did. So it's not just a matter of hours -- it's a matter of how much time is actually spent on patient care vs writing about patient care, no matter what specialty.
I'm not a luddite -- far from it. I love my laptop, iPhone, iPad, and everything else that helps me get through my day, and I'm quite a speedy typist. But every doctor I know, every single one, knows that electronic medical records take far more time than paper charting ever did. So it's not just a matter of hours -- it's a matter of how much time is actually spent on patient care vs writing about patient care, no matter what specialty.
34
The accountability monster has even made its way to the lives of cops, firemen, and any allied-health professional working in a school system.
But when doctors are stuck doing clerk work people's lives are downgraded - imagine the doc having to count on nurses spotting post-op problems instead of that doctor actually getting by the patient as fast as they used to.
We could use gov't to demand insurance companies reduce this requirement, and tort reform will make ALL the difference.
But when doctors are stuck doing clerk work people's lives are downgraded - imagine the doc having to count on nurses spotting post-op problems instead of that doctor actually getting by the patient as fast as they used to.
We could use gov't to demand insurance companies reduce this requirement, and tort reform will make ALL the difference.
7
"Imagine the doc having to count on nurses spotting post-op problems instead of that doctor actually getting by the patient as fast as they used to." Nurses are the ones who are with patients all the time with doctors coming in when needed. The nurse has always been the one to spot problems, post-op or otherwise, first. Doctors cannot and should not be expected to be beside the patient 24 hours a day.
12
as a physician with a daughter in her last year of medical school, I couldn't agree more.
3
You know what really ruins continuity of care? When your doctor slams herself into a tree after being on call for too long without sleeping. Also, when your doctor blows his head off in a bathroom because he's so burnt out and despondent.
You think those don't happen? Think again. Most doctors are miserable and not just because of work hours. The crippling, humiliating restraints put on them by the government, insurance companies, and hospital CEOs are rapidly dehumanizing the workers. Meanwhile, entitled patients inform doctors they are little better than Google and really should just be replaced by NPs.
No wonder 4% of all doctors are killing themselves every year.
You think those don't happen? Think again. Most doctors are miserable and not just because of work hours. The crippling, humiliating restraints put on them by the government, insurance companies, and hospital CEOs are rapidly dehumanizing the workers. Meanwhile, entitled patients inform doctors they are little better than Google and really should just be replaced by NPs.
No wonder 4% of all doctors are killing themselves every year.
26
Gov't oversight doubled for some doctors two years ago. Like all lawyers, Obama came out of law school convinced that MD's are all overpaid.
8
There is something fundamentally wrong when a truck driver is restricted on the number of hours he/she can drive in a week but when the resident treating you in emergency for your heart attack may have been on straight duty for 36-48 hours straight it is acceptable medical practice. Sorry, I and you should have a problem with that.
43
The NYT has had 2 recent articles about resident work hours, and I've read all the comments on both of them. The comments from those opposed to work-hour restrictions are disturbingly similar to each other and use many of the same phrases and metaphors. A "shift-work mentality" is damaging to the practice of medicine ... Doctors need to "take personal responsibility for their patient" ... Being a physician "isn't a job, it's a profession" ... the doctor/patient relationship is similar to parent/child. Frankly it's obvious that there is a lot of ironclad indoctrination involved in medical training.
Lovely ideals and all, but we're not talking about a small-town doctor in 1910. Modern hospital care is complicated, fast-paced and increasingly dependent on testing. Stays are short, patients have many comorbid conditions and are being treated by many specialists. Let's modernize medical training to reflect that medicine is, in fact, a JOB -- a job to be performed conscientiously and with pride, to be coordinated well with colleagues -- but still a job, not a religion or an identity. Restricting work hours may be a start, but it clearly isn't the whole solution.
Lovely ideals and all, but we're not talking about a small-town doctor in 1910. Modern hospital care is complicated, fast-paced and increasingly dependent on testing. Stays are short, patients have many comorbid conditions and are being treated by many specialists. Let's modernize medical training to reflect that medicine is, in fact, a JOB -- a job to be performed conscientiously and with pride, to be coordinated well with colleagues -- but still a job, not a religion or an identity. Restricting work hours may be a start, but it clearly isn't the whole solution.
38
do you really want a doctor who considers medicine a job? I have worked jobs before, and it is nothing like practicing medicine. when I am in a room, a patient deserves 100% of my attention and concern. don't think I've ever worked a job where i felt that way. Don't think I've met that many people working jobs who I think feel that way as well.
3
As too often happens, egregious actions (in this excessive resident work hours) is often addressed by a response that, although meant to be balanced is not without its own consequences - sometimes anticipated and other times not. Residency training is the only circumstance I can think of off the top of my head where the least experienced is often times the individual who has to first assess a patient. Amongst the challenges in training programs is age old unspoken belief that to ask for help can be viewed as a sign of intellectual 'weakness'. This is all the more apparent when patients are admitted overnight. In nearly three decades of attending at academic medical centers, the number of times I have been called about new admissions or a significant change overnight in a patient's medical status remained disturbingly low - and this occurred despite my expressed desire to be notified. Reduced work hours has not improved patient care nor outcomes. The accreditation bodies for individual training programs need to use attending notification by the admitting resident as a metric in which a program is reviewed and evaluated. Let the attending decide if he/she needs to return to the hospital to evaluate a patient. I use to tell the residents that they are not Harry Truman. Sadly too few knew who he was and only one knew what was on his desk in the Oval Office. There is also now developing a paradigm shift in residency training - it's about the resident and not the patient.
6
Guess what? There are no work hour restrictions in real life.
This has ingrained the shift mentality which carries through to real life
The left has successfully (once again) made hubristic assumptions about their brilliant no fail plan and...it din't make a difference.
Same applies to the global warming--their brilliance will of course bring infinitely complex processes to heel
Understanding human limitations and the fact that we cannot control every aspect of our lives (but the government wants to) or the earth would go a long way to making peace with the fact that life is fragile and we should make the most of it
This has ingrained the shift mentality which carries through to real life
The left has successfully (once again) made hubristic assumptions about their brilliant no fail plan and...it din't make a difference.
Same applies to the global warming--their brilliance will of course bring infinitely complex processes to heel
Understanding human limitations and the fact that we cannot control every aspect of our lives (but the government wants to) or the earth would go a long way to making peace with the fact that life is fragile and we should make the most of it
2
Your rant was is as off topic as it is incorrect. Professional airline pilots have restricted work hours. Any idea why?
17
Truckers too. They don't just log hours in a book afterwards.
8
No one claimed it was "no fail" except in your mind. So you are of the opinion that no new ways should be tested out? OK, then, I'll go back to my firepit and use my fingers to eat the roasting rat that I killed with a stone earlier today.
Surgical residency was the worst 5 years of my life. As an intern, I would be in the hospital on call from Fri morning until Mon night. I was a miserable person. I came out incredibly well trained and have recouped my life. I wouldn't want my kids to ever go through what I did. Would I do it again? Doubt it. Do I love what I do now? Absolutely.
As far as evidence of inadequate training among surgical residents today, look at the number of residents pursuing post residency fellowships. It is reportedly 80%. This, I believe, is proof that they do not feel ready to be independent practitioners.
As far as evidence of inadequate training among surgical residents today, look at the number of residents pursuing post residency fellowships. It is reportedly 80%. This, I believe, is proof that they do not feel ready to be independent practitioners.
12
My concern about limiting medical hours is the impact on dedication of MDs, especially younger ones. I trained prior to these rules but part of my training took place in NY state which implemented limited hours before national reform.
Back when I was in training, my fellow MDs felt it was weak to abandon patients right as the clock hit 5PM, especially if clinical matters were urgent or things were changing quickly. By the time I finished my specialty training -- in the early 2000s -- the first questions we often got from med students and trainees in reference to my internal medicine specialty were how many hours we worked and how much did we make. While these are valid concerns, it caught not only my senior colleague but us "younger folks" (in our 30s-40s) by surprise. Medicine doesn't have to dominate and destroy one's life but at the same time, people need to realize that to become a good, dedicated doctor, you don't/ can't operate on the same time schedule as everyone else and that sickness can happen anytime. Our (My) concern was would future MDs retain that same dedication.
Back when I was in training, my fellow MDs felt it was weak to abandon patients right as the clock hit 5PM, especially if clinical matters were urgent or things were changing quickly. By the time I finished my specialty training -- in the early 2000s -- the first questions we often got from med students and trainees in reference to my internal medicine specialty were how many hours we worked and how much did we make. While these are valid concerns, it caught not only my senior colleague but us "younger folks" (in our 30s-40s) by surprise. Medicine doesn't have to dominate and destroy one's life but at the same time, people need to realize that to become a good, dedicated doctor, you don't/ can't operate on the same time schedule as everyone else and that sickness can happen anytime. Our (My) concern was would future MDs retain that same dedication.
6
While it is certainly important to consider the effects of residents work schedules on patient safety, concluding that a study that shows "no significant difference" in patient outcomes between more or less "humane" schedules misses a huge part of the picture. What about the effect of these schedules on the doctors themselves? Residents are likely not in the best position to evaluate this during their residencies for the reasons stated. However, these patterns and attitudes continue on into practice after residency. The result: 1. Recent studies show that 59% (!) of practicing physicians today report symptoms consistent with significant burn-out adversely affecting their relationships with patients, colleagues and their families, and 2. Physicians have now taken the top spot as having the highest suicide rates of all the professions. Moreover, female physicians are at even higher risk and suffer nearly twice the suicide rate as males. These statistics should seriously concern all of us, they are stunning and cannot be ignored. Many physicians colleagues are retiring at the earliest opportunity and we are losing many younger colleagues to non-clinical work where they can have a better life.
I think that as a profession and as a nation, we need think carefully about training doctors during residency to believe that in order to be good doctors they must essentially become masochists. It's bad for everyone.
I think that as a profession and as a nation, we need think carefully about training doctors during residency to believe that in order to be good doctors they must essentially become masochists. It's bad for everyone.
22
Beware of the law of unintended consequences.
I'm a physician. My mother was at a prestigious university medical center having undergone an aortic valve replacement. On her second postoperative night she went into an abnormal heart rhythm, which is easily treatable. I was surprised when the nurses gave her a series of less effective medications first, and asked why she wasn't given the definitive anti-arrhythmic medication right away. The response was, "Well, we can give these medications through a protocol, but if we want to use that more expensive medicine we have to speak to the resident on for cardiac surgery. We haven't had to call him yet tonight, and if we let him sleep for six uninterrupted hours we don't have to count those hours towards his week's total. So we'll try these other meds first."
So, in order to abide by the resident work hours limitation, my mom was in rapid atrial fibrillation for hours longer than she needed to be.
When you start making rules like this, there are workarounds that you haven't even thought of. And of course the irony is that the result is exactly the opposite of the intent.
I'm a physician. My mother was at a prestigious university medical center having undergone an aortic valve replacement. On her second postoperative night she went into an abnormal heart rhythm, which is easily treatable. I was surprised when the nurses gave her a series of less effective medications first, and asked why she wasn't given the definitive anti-arrhythmic medication right away. The response was, "Well, we can give these medications through a protocol, but if we want to use that more expensive medicine we have to speak to the resident on for cardiac surgery. We haven't had to call him yet tonight, and if we let him sleep for six uninterrupted hours we don't have to count those hours towards his week's total. So we'll try these other meds first."
So, in order to abide by the resident work hours limitation, my mom was in rapid atrial fibrillation for hours longer than she needed to be.
When you start making rules like this, there are workarounds that you haven't even thought of. And of course the irony is that the result is exactly the opposite of the intent.
50
Maybe the hospital should hire more doctors at night to cover the shift so that your mom wouldn't be in afib with RVR
12
That's not the fault of the schedule, but a fault of its interpretation. The nurses should have woken the resident for the consult and he/she would have worked less later that day/week. If something needs to be done, then it needs to be done.
12
You cannot practise medicine by the clock. It doesn't work that way in the ER or in OB/GYN for example. In such clock-watching situations I have seen doctors who've started to treat a haematemesis case but hand over at 5PM before they have even got an iv line in let alone wait for the blood to arrive. I have seen junior anaesthetists hand the bag over to more senior personnel half way through a case as 5PM has arrived and the case has gone over.
What ever happened to devotion & commitment?
What ever happened to devotion & commitment?
2
This problem is always present. There are always surprises, problems, and crises. Eventually doctors have to leave; we're only human, and we need to eat and excrete and sleep, to say nothing of maintaining families and friendships. The basic problem is that if you don't decide that you're willing to leave you never leave.
The five o'clock patient dump is a problem. But staying an extra two hours and making it a seven o'clock dump doesn't help. What would make sense is an overlap of shifts so that doctors would have reasonable time to complete cases and hand them off to the covering docs while not taking on new work. A good idea, maybe, but it would require hours of double coverage, which would mean either more hours out of the residents or more residents to go around.
The five o'clock patient dump is a problem. But staying an extra two hours and making it a seven o'clock dump doesn't help. What would make sense is an overlap of shifts so that doctors would have reasonable time to complete cases and hand them off to the covering docs while not taking on new work. A good idea, maybe, but it would require hours of double coverage, which would mean either more hours out of the residents or more residents to go around.
10
When I used to work in the emergency room, there would always be at least a one hour overlap. It worked great. The new MD on took the new patients, giving the outgoing person another hour to concentrate on finishing up the remainder of the work and to chart, and then any outstanding issues could be signed out on a much smaller number at the end of the hour or so. Much easier to sign out when you are just concentrating on finishing up and don't have any new issues to address at the end of shift.
9
@Durham MD - This seems like a common sense and highly logical solution to some of the problems cited in other comments. I imagine that the main reason it's resisted has to do with money. It's kind of mind-boggling that as the country with the most expensive health care in the world per capita that we have so many of the problems that we do. Wouldn't you think that the most expensive care would mean sufficient staffing to alleviate some of these problems? And a lot of other ones as well.
3
i have always supported limits on residency hours, and it was a major factor in my decision to seek an internal medicine residency in a community medical center that already had such limits before they were mandated.
Nonetheless, I recall visiting a physician friend in Stockholm in the 1980s and him lamenting that Swedish limits on resident hours resulted in junior doctors leaving during Code Blue events and during emergency surgery.
I believed that such absurdity would never befall our profession in the U.S. I was wrong. Even more sadly, that shift behavior has now pervaded the profession far beyond its trainees.
Let's hope that the current research will bring us back to a place of more common sense. Residency is about learning both the technical skills of medicine and a sense of service inherent to the profession. It should cause suffering neither of the learner nor the patient.
Nonetheless, I recall visiting a physician friend in Stockholm in the 1980s and him lamenting that Swedish limits on resident hours resulted in junior doctors leaving during Code Blue events and during emergency surgery.
I believed that such absurdity would never befall our profession in the U.S. I was wrong. Even more sadly, that shift behavior has now pervaded the profession far beyond its trainees.
Let's hope that the current research will bring us back to a place of more common sense. Residency is about learning both the technical skills of medicine and a sense of service inherent to the profession. It should cause suffering neither of the learner nor the patient.
3
If you are facing a potentially life-threatening illness and require a procedure, would you rather have someone perform the procedure who has done 100 or 10 of them before? As a practicing surgeon who teaches residents, I can tell you that the reduced work hours result in a reduction in experience for these residents, and the anxiety they feel at the end of their training is acute.
14
Marc D writes, "would you rather have someone perform the procedure who has done 100 or 10 of them before?"
I sure wouldn't want to be operated on by a surgeon who'd done 90 of these procedures while half-asleep from exhaustion, was stressed out by divorce related to the abysmal treatment of residents, and having a nervous breakdown for which he/she had never dared to get treatment...
I sure wouldn't want to be operated on by a surgeon who'd done 90 of these procedures while half-asleep from exhaustion, was stressed out by divorce related to the abysmal treatment of residents, and having a nervous breakdown for which he/she had never dared to get treatment...
37
MLChadwick, you're oversimplifying. There is a better way. Starting when I was an Ob/gyn resident 20 years ago, we at my institution did a night float call system, where the night team did 6 nights of 12 hr shifts ( sleeping in the day), and the rest of my resident colleagues did days only, except for a Weekend that was 32 hrs straight from Saturday morning until Sunday evening. It was sane, and it taught us continuity of care. Now, my residents in my teaching hospital are working and learning less. They don't study any more despite the huge difference in work hours.
I am concerned about the face of medicine in 10 years. We older doctors will be gone, and we will be left with inferior trained physicians.
Incidentally, all the practicing private doctors I know routinely take 24 hour call during the week, and 48 hr weekend call. It's not as bad as it sounds- we all get sleep here and there, and can always sign out to the laborist- much like the hospitalist, it is a doctor managing the labor floor.
If hours stay the way they are, we need to extend training in many specialties. Many residents are simply not getting the volume of training I got. So, to answer your question, the literature shows that in many cases, it is better to have the guy with 90 cases under his belt, even if he's tired.... manual skills are not as diminished after long hours as cognitive skills!!
I am concerned about the face of medicine in 10 years. We older doctors will be gone, and we will be left with inferior trained physicians.
Incidentally, all the practicing private doctors I know routinely take 24 hour call during the week, and 48 hr weekend call. It's not as bad as it sounds- we all get sleep here and there, and can always sign out to the laborist- much like the hospitalist, it is a doctor managing the labor floor.
If hours stay the way they are, we need to extend training in many specialties. Many residents are simply not getting the volume of training I got. So, to answer your question, the literature shows that in many cases, it is better to have the guy with 90 cases under his belt, even if he's tired.... manual skills are not as diminished after long hours as cognitive skills!!
4
A 12 hour shift still allows for four hours to eat, unwind, converse with people outside of work, etc. plus eight hours of sleep. The problem is that it frequently goes beyond that, and not in any kind of sensible fashion.
It is a manageable problem, President Eisenhower was known to work 2 shifts a day with a nap in between and real sleep at night; he had essentially two sets of staff.
It is a manageable problem, President Eisenhower was known to work 2 shifts a day with a nap in between and real sleep at night; he had essentially two sets of staff.
1
The humane treatment of medical residents is not measured in work hours. My first residency was a morass of institutional abuse, meted out by senior doctors, nurses, administrative suits, etc. who all contributed to a prevailing idea that residents were some sort of grunts unworthy of responsibility, compensation, minimal respect or basic human kindness. My second residency, admittedly in a different field but more importantly at a different institution, was run by doctors and administrators who taught us well and valued our contributions, while appropriately recognizing that we still had much to learn. Work hours were more or less the same, but (surprise!) duty hours were not resented at the second residency by any of us the way they were, bitterly and by all of us, at the first. Resentment does not a good physician make.
My point should be clear: stop fiddling with hour restrictions as if they're the problem and the solution. Instead, create schedules guided by common sense and circumstance, and influence the culture so that residency becomes what it should be -- an extraordinarily tough job that still feels like a calling and a privilege.
My point should be clear: stop fiddling with hour restrictions as if they're the problem and the solution. Instead, create schedules guided by common sense and circumstance, and influence the culture so that residency becomes what it should be -- an extraordinarily tough job that still feels like a calling and a privilege.
57
Something no one ever seems to talk about when they discuss the hours in residency and how lessening the hours has not improved patient care is that they have not looked at the downside of the shortened hours. When I did my residency, I often worked 80-100 hour weeks, and I was pretty tired and miserable. However, I had a complete sense that the patient under my care was MY responsibility and mine alone. Even when I left for the night and signed out my patient to the night float, I still felt that patient was mine and anything that happened to that patient was on ME. My sense with shift work happening is that the care is more fractured and the house staff do not have this strong sense of responsibility toward their patients. They don't feel they need to spend a little extra time to make sure the patients under their care are truly "tucked in for the night" before they go home. And they also don't seem to realize that when they are attending physicians there is no safety net for them if things go wrong, and they will be ultimately responsible for their patients. This has led to newly trained doctors who are looking for jobs whose first questions to prospective groups looking to hire them are: "How much vacation time?" I'm a doctor, but I'm a patient, too. It frightens me that doctors like this will be taking care of me when I'm old.
6
I find this expressly false and as a physician trained under the duty hours, frankly, this is insulting. Never once did I sign out a pt who wasn't tucked in, or leave in the middle of a procedure. Everyone in these comments act like you turn into a pumpkin when the clock strikes, but don't realize that it is we residents who track our own duty hours and that "violations" can be explained away, only turning to consequences if a program at large has repetitive infractions. I had my 90 hour weeks too, we just AVERAGE 80 over 4.
I also would like to point out that the amount of medical knowledge that has been gained, and that we new physicians are expected to master, has exploded in the years since most of you have trained. Not to mention the litigious atmosphere, no wonder why new grads are anxious to practice alone without fellowship. It is not inferior training, it is shifting environments. And tack on the administrative duties that lands squarely on the backs of residents, and you have a recipe for burnout. I'm going to postulate that this is most largely to blame for what you all perceive as "inferior training" and lack of exposure.
I agree a flexible, logical schedule beats a one size fits all any day, but out of necessity to control the malignant programs (which very much still exist) I believe that it is important to continue with these regulations. And how about valuing residents fairly? Any comments focused on vacation, pay, mat/paternity leave, help with wellness?
I also would like to point out that the amount of medical knowledge that has been gained, and that we new physicians are expected to master, has exploded in the years since most of you have trained. Not to mention the litigious atmosphere, no wonder why new grads are anxious to practice alone without fellowship. It is not inferior training, it is shifting environments. And tack on the administrative duties that lands squarely on the backs of residents, and you have a recipe for burnout. I'm going to postulate that this is most largely to blame for what you all perceive as "inferior training" and lack of exposure.
I agree a flexible, logical schedule beats a one size fits all any day, but out of necessity to control the malignant programs (which very much still exist) I believe that it is important to continue with these regulations. And how about valuing residents fairly? Any comments focused on vacation, pay, mat/paternity leave, help with wellness?
12
Isn't the research pretty solid in establishing that cognition is hurt by sleep deprivation? Maybe we should extend residency beyond a year, or continue the training once someone is in practice, like they do in some school systems (ongoing training or mentoring for teachers in their first couple years). There's more and more research on the health problems associated with lack of sleep (like increased cancer rates and Alzheimer's down the road, not just immediate-term fuzzy thinking). There's something philosophically unsettling to have such an INCREDIBLY unhealthy habit expected and even required of people who profess to care about HEALTH. It's like requiring doctors to smoke or something as a condition of being trained. They should be encouraged to develop and model HEALTHY habits.
21
Residencies are generally 3-4 years or more. They are already beyond a year.
2
3 years for internal medicine, family medicine, or most emergency medicine residencies; 7 years for neurosurgery. The other residencies fall somewhere in the middle.
But then many residents do go on to do fellowships--effectively extending residency a few more years for even more specialized training.
Keep in mind that this is all after 4 years of college and 4 years of medical school. It's important to actually have fully trained and licensed physicians who can practice independently for a while before they retire!
But then many residents do go on to do fellowships--effectively extending residency a few more years for even more specialized training.
Keep in mind that this is all after 4 years of college and 4 years of medical school. It's important to actually have fully trained and licensed physicians who can practice independently for a while before they retire!
4
After residency and fellowship, I was 32 years old before I got to be in independent practice. And I only took one year off from schooling in between, so even if I had gone straight through training from preschool to end of fellowship, I would have been 31. Imagine if I had started when I was older, as many students do now. I actually don't have to, as I know a fellow who is well into her 40s, with young children.
What this article fails to mention is that the 80 hour rule is based on residents' self-reported time sheets. Because the residency programs do not want to be flagged by ACGME(Accreditation Council of Graduate Medical Education), they often put the burden on the residents themselves to report only 80 hours a week. In other words, there are some residency programs that frown upon residents putting down more than 80 hours a week in their time sheets, even though they may have worked 100+ hours a week. Instead of encouraging more time off, there are some malignant residency programs that "yell" at residents for "working too much" and encourage to work "only 80 hours a week". To the lowly resident, this means that he can only log 80 hours but still works 100+ hours. I have seen this too many times and I'm surprised that no one is bringing this up.
39
Many programs actually use logins in and out of the computer to track times now, which is much harder to falsify, esp if double logons are not allowed (ie making it difficult for post call doc to use someone else's). Post call residents can stay for things like education but cannot place orders (or it's noted if they did) past a certain time cutoff.
I think the work hour rules have both positive and negative effects. I saw instances in which unequal work load distribution (caused by disparities in #s of admissions & discharges or patient acuity) led sometimes to interns/residents still in the hospital at 5 or 6 PM on the post call day, so sleepy they were unable to complete their remaining administrative tasks, but then not having "signed out," being called to take care of an emergent issue at a time when they were clearly impaired. I've seen more teamwork among residents once the 80 hour workweek rules came into being...what comes around goes around. However, signout procedures in many places are still much more casual than among nurses and is a clear area for improvement.
I think the work hour rules have both positive and negative effects. I saw instances in which unequal work load distribution (caused by disparities in #s of admissions & discharges or patient acuity) led sometimes to interns/residents still in the hospital at 5 or 6 PM on the post call day, so sleepy they were unable to complete their remaining administrative tasks, but then not having "signed out," being called to take care of an emergent issue at a time when they were clearly impaired. I've seen more teamwork among residents once the 80 hour workweek rules came into being...what comes around goes around. However, signout procedures in many places are still much more casual than among nurses and is a clear area for improvement.
5
More hospital staff. Less or no med school debt. Longer residencies with decent pay, reasonable hours (80/week is plenty), and ongoing primary-care service during training.
Universal health care.
Fat chance.
Universal health care.
Fat chance.
28
Every time I read this I think of one thing: why not add more staff to the hospitals so that there is continuity of care and enough coverage so that nurses aren't spread so thin and residents and doctors do not have to work overtime? Just because it's always been that way doesn't mean it should stay that way. We have enough problems in hospitals without adding to it. And if the CEOs want more money ask them what's more important: their BMWs or the health of the patients after they've been in their hospital that's not well staffed.
32
Adding more staff decreases patient and procedure exposure necessary to become competent. The only way to compensate would then be a longer training period. General surgery is already a 5 year committment AFTER four years of medical school and four,years of undergraduate school. Subspecialty training would make this even longer. This would be untenable
5
I hear this complaint a lot, but compare the time in medical school to the time it takes to train to be a research scientist, which includes the time to PhD plus, typically, a couple of post-docs. One can easily spend 10 years post-BA before getting one's first academic position.
8
We could change the way we do medical education in this country. Instead of 4 years of college and 4 years of med school we could do a 6 year program and drop some of the stuff that is truly superfluous. After all, we don't doctors to think too much do we? And 8 years of college is pricey.
First define what it means to be a good doctor (surgeon, pediatrician, neurologist, etc.) in measurable terms. Then determine what is the best way to train someone to be a good doctor, in measurable terms, while assuring patient safety and trainee well-being, in measurable terms. Neither the medical profession or society as a whole has been able to accomplish step 1, yet we are trying to accomplish steps 2 and 3.
The stress of medical training is only partially the result of long hours. Much of it comes from the emotional difficulty of dealing intimately with illness, death, and the emotions of patients and families while balancing professional and personal life. Helping trainees to manage that is as important as limiting work hours.
The stress of medical training is only partially the result of long hours. Much of it comes from the emotional difficulty of dealing intimately with illness, death, and the emotions of patients and families while balancing professional and personal life. Helping trainees to manage that is as important as limiting work hours.
10
Really important point, maybe the most important point. We seem to always be tinkering with medical education without the ability to rationally or rigorously assess our outcomes.
As a physician, I also wonder why the public doesn't question the idea that we can essentially cut the duration of training (which is what we did) and get the same outcomes. Certainly things have been lost and things have been gained within the context of work hours reforms. I hated working 36-40hrs at a stretch and it did not make me a better person, but I have no doubt that I saw a lot more medicine when I trained than the residents I am training now. Its curious that nobody has taken the suggestion to add time to residency more seriously. Why is the duration of residency fixed? Sure, it would cost money, but so do medical errors, both those committed due to fatigue and those due to lack of experience and lack exposure to cases.
As a physician, I also wonder why the public doesn't question the idea that we can essentially cut the duration of training (which is what we did) and get the same outcomes. Certainly things have been lost and things have been gained within the context of work hours reforms. I hated working 36-40hrs at a stretch and it did not make me a better person, but I have no doubt that I saw a lot more medicine when I trained than the residents I am training now. Its curious that nobody has taken the suggestion to add time to residency more seriously. Why is the duration of residency fixed? Sure, it would cost money, but so do medical errors, both those committed due to fatigue and those due to lack of experience and lack exposure to cases.
8
One consequence of reduced hours for young residents is longer hours for older doctors. I'm a recently retired surgeon and I can tell you it is much harder to work on one or two hours sleep when you are 60 than when you are 30. I was always appreciative when I had a younger person reduce some of the time I had to spend awake in the middle of the night.
6
Maybe you should retire and leave it to the younger guys! Maybe they should be out in the rural areas, instead of all the foreign graduates filling the less desirable positions, because they don't make the large incomes their city brothers do. After going through residency programs in the late seventies, I felt abused and used by most rotations. The 32 -34 hour shifts every third night were the rule. In the second residency, I was illegally forced to transfer to was just a abusive the one that profited from my abuse. (They took three general surgery residents in a two resident program I was on the losing end of that deal!) Watching most surgical procedures as a third year resident did nothing to improve my abilities, either. If I had not fought to get scheduled for useful cases, I would have been ill prepared for practice in a rural hospital. The abuse did nothing to improve my abilities. And being chastised for not standing beside a post-operative patient;'s bedside during my 12 hours "on call" seems to be the worst! That is a day in my life that will never be erased from my memory. Having broken my back and injured my spinal cord, leaving me disabled, makes me glad I don't have to swim with the sharks that are united to harass the physicians, unwilling to sacrifice patient care for politics. It never prepares one for the petty non-surgeons, who are constantly biting at your ankles, like a bunch of chihuahuas crossed with piranhas!
3
As a physician that went through medical school, residency and fellowship in the 90's, I wouldn't trade it for anything! I had many nights of 1-2 hours of sleep but learned so much. I had a medical school experience that allowed me a lot of hands on experience that I could only get by being available during the nighttime (less populated) hours. During residency, I was pregnant my 1st and 4th years and still enjoyed most of the experience at a very academic, busy institution. The nurses were a tremendous help. These are life lessons in how to be a great doctor...allow the nurses with years of experience to guide you, treat your patients with dignity and respect regardless of how you personally feel at that moment and be ready for anything at anytime. While I do agree with the point behind limiting the long hours for trainees, I love that I trained under the old system. I never hated it, I enjoyed it. Were there times I would rather stay home? Of course. But I knew that training was short-lived and when it ended I became responsible. The final say. That is a responsibility that is HUGE and bigger than deciding what car you are going to drive.
Training for this job is serious business because people's lives are literally in your hands, regardless of specialty. Making time to "have a life" outside of the hospital can come later. This is the time to learn how to be a doctor, and its short, so use it wisely!
Training for this job is serious business because people's lives are literally in your hands, regardless of specialty. Making time to "have a life" outside of the hospital can come later. This is the time to learn how to be a doctor, and its short, so use it wisely!
12
The hours are not the issue as much as the Attending physician and the nursing staff is. If the resident is working for an attending that rants & raves about everything, belittles the residents, the learning is diminished because the resident is just trying not to get yelled at during rounds. This type of residency also teaches the residents to throw each other under the bus to keep the attending's focus off of them.
The other huge factor is the nursing staff the residents deal with day in and day out. The resident that has an older, more experienced nursing staff seems to do better regardless of the hours worked. If the nursing staff knows their stuff and the resident learns to lean on that nursing staff, then the resident actually gets some sleep when they are covering the ICU. The ICU nurses that are very experienced know more than most of the residents to begin with. When the resident puts their trust in that staff, they are usually rewarded with a much easier rotation. The resident that comes into the unit with a god complex has a very long stay and will be completely worn out after each shift. Now that nurses are not being paid a real wage these days, more and more of your experienced nurses are leaving that intense clinical setting and the residents don't have anyone to support them in their various rotations within the hospital. Ask any doctor and they will tell you that the nurses can make life much easier or they can make your one month stay a nightmare.
The other huge factor is the nursing staff the residents deal with day in and day out. The resident that has an older, more experienced nursing staff seems to do better regardless of the hours worked. If the nursing staff knows their stuff and the resident learns to lean on that nursing staff, then the resident actually gets some sleep when they are covering the ICU. The ICU nurses that are very experienced know more than most of the residents to begin with. When the resident puts their trust in that staff, they are usually rewarded with a much easier rotation. The resident that comes into the unit with a god complex has a very long stay and will be completely worn out after each shift. Now that nurses are not being paid a real wage these days, more and more of your experienced nurses are leaving that intense clinical setting and the residents don't have anyone to support them in their various rotations within the hospital. Ask any doctor and they will tell you that the nurses can make life much easier or they can make your one month stay a nightmare.
54
A quick look reveals that ICU nurses average a little over $68,000 a year, plus benefits - that's not a real wage?
2
Edward,
No, it isn't. My mother was making about that much as a nurse in the early 80's.
No, it isn't. My mother was making about that much as a nurse in the early 80's.
3
Pierre. Good for your mother. Other people with a similar amount of education make do with far less. I work with nurses every day. I wouldn't call them overpaid but to say they don't make a "real wage" is to be totally out of touch with the rest of workers across the the US and elsewhere.
2
I don't get the argument for long hours, if you can preform the job while sleep deprived or after working 14 hours I really can't consider it a job that requires a high level of cognitive ability - from personal experience as a physicist who designs medical equipment - many doctors spend way to little time thinking about what they are doing, they are more concerned with just doing something - practically every time I go to a hospital to observe doctors I see a screw up - also why do residents only have to work 80 hours if it is so critical to care - why not all of them? Really, if you don't have to be overworked and sleep deprived you shouldn't.
14
It has always seemed to me that one of the virtues of such gruelling residencies has been to reinforce the "green zone - red zone" view of the profession: "We went through all this grief to get where we are, and we don't have to listen to you."
4
I've never heard of a physician recommending that a patient perform a critical occupational function or learning function when sleep deprived. It's odd to me that they would find it an acceptable part of their own training. I have to believe there are workflow solutions to concerns about loss of experience and/or quality (overlapping hours, exceptions for surgeons already in procedures, recaps of cases etc.). There are of course compensatory and clinical factors that influence/inhibit certain workflow changes, but I'm glad the discussion is occurring. Having just experienced a critical care situation in a hospital with a family member, I think that many sides of the discussion have merit.
28
I agree with the author that the residency trial by fire can create a long lasting pernicious attitude that "misery is somehow noble." It can also turn MD's into "the chosen few," "the elite," "the entitled." This can become toxic on a multi-disciplinary team. I have had the experience of MD's routinely looking down on non-MD's who bring up issues, such as work/life balance and on-call duties (for no extra pay). Their residency experience reinforces a haughty arrogance to mere mortals who aren't willing to go the distance. Then they get in their Lexus/BMW/Mercedes and drive away.
21
The truth that is overlooked here is that residents routinely do work over 80 hours a week ( both groups were capped at 80). No matter what they report, 100 hours are the reality for many. That is what the study should really be looking at.
9
I found training in the 70s was really exhilarating and enjoyable. I am convinced there is less acumen developed currently upon graduation due to less complex cases managed during residency. I have seen the "training" then continue after the benign schedules because of the lack of experiences and they are mentored by senior partners in their practices.
The most important issue not mentioned in this piece is the effect on patient care and loss of continuity which leads to handoffs and results in well publicized errors of near misses. Our communication and better attention to continuity must be addressed for the patient's safety.
The outcome is a lagging indicator. The input and process are leading indicators.
We need to devise better processes to educate while balancing the patient care (satisfaction and continuity both in hospital and discharge planning). The system is undergoing a slow overhaul because the leadership needs a well-structured analysis of the process. Remember despite this "benign" training more doctors are leaving the area of direct patient care which will exacerbate the shortage.
I believe this is primarily due to culture changes over the past two decades and poor exposure to real expectations. Also the new generation feel their entitlement. As such we must psychologically support the trainees
The most important issue not mentioned in this piece is the effect on patient care and loss of continuity which leads to handoffs and results in well publicized errors of near misses. Our communication and better attention to continuity must be addressed for the patient's safety.
The outcome is a lagging indicator. The input and process are leading indicators.
We need to devise better processes to educate while balancing the patient care (satisfaction and continuity both in hospital and discharge planning). The system is undergoing a slow overhaul because the leadership needs a well-structured analysis of the process. Remember despite this "benign" training more doctors are leaving the area of direct patient care which will exacerbate the shortage.
I believe this is primarily due to culture changes over the past two decades and poor exposure to real expectations. Also the new generation feel their entitlement. As such we must psychologically support the trainees
4
Learning to hand off patients should be part of the residents' training. It is often missing now, in continuity of care, as you say. The government and hospital accrediting agencies make countless rules to arrive at the better outcomes you mention. But changing the culture, starting with residency, is just as important.
5
Dr. Carroll, your interpretation of this data is similar to the editorialist in the NEJM, however several points are in order. 1) when residents are protected, more senior trainees and faculty do the work. Just ask the editor of the NEJM who was in the work hours study at BWH. When it is no longer done at the junior level, someone else has to do it.
2) It is not uncommon for surgeons to work overnight and do surgery. You have to teach them to know when not to operate. In fact, outcomes are the same when surgeries are performed the day after night work (http://www.nejm.org/doi/full/10.1056/NEJMsa1415994#t=abstract) 3) The lack of harm in the change in work hours is actually a marker of worse patient care. Over the time period described, mortality rates from surgery decreased significantly. http://www.nejm.org/doi/full/10.1056/NEJMsa1010705, The fact Stable surgical outcomes indicates worse care. 4) The problem with the idea that training should be easier if patient outcomes are similar is that patient outcomes aren't dispositive of the impact of the training method. Patient safety was a flag flown by those who studied sleep. In fact, this short-term view is the problem. I have seen a significant degradation in the skill set of graduating resident and, worse, a similar reduction in confidence resulting in more consultation for less ill patients. The real metric here is how do these residents do AFTER training. We need to measure consultation requests at 1 year after training.
2) It is not uncommon for surgeons to work overnight and do surgery. You have to teach them to know when not to operate. In fact, outcomes are the same when surgeries are performed the day after night work (http://www.nejm.org/doi/full/10.1056/NEJMsa1415994#t=abstract) 3) The lack of harm in the change in work hours is actually a marker of worse patient care. Over the time period described, mortality rates from surgery decreased significantly. http://www.nejm.org/doi/full/10.1056/NEJMsa1010705, The fact Stable surgical outcomes indicates worse care. 4) The problem with the idea that training should be easier if patient outcomes are similar is that patient outcomes aren't dispositive of the impact of the training method. Patient safety was a flag flown by those who studied sleep. In fact, this short-term view is the problem. I have seen a significant degradation in the skill set of graduating resident and, worse, a similar reduction in confidence resulting in more consultation for less ill patients. The real metric here is how do these residents do AFTER training. We need to measure consultation requests at 1 year after training.
19
When i was a medical resident back in the 1970's, we were on "only" every 3rd night, and it was grueling, to be sure. But the surgery residents were on every other night, and they used to say/?joke," the only problem with being on every other night was that you missed half the great cases". We would constantly be regaled with stories of the "good old days", when men were men, to impress upon us how good we had it/how lucky we were to be on "only" every third night. Some things never change, but the more humane work schedules for residents represent a change for the better.
10
WEhen an acutely ill patient is admitted to hospital, the first 24 hours are the most crucial. It is then that the important tests are performed, decisions made, diagnoses established and treatments started. After that, it's usually routine. To have residents scheduled in a way that they are not able to follow their patients through this process, but rather 'hand them off,' reduces the value of their education.
2
Too much chance for error after a 24 hour shift. I have friends who were residents who fell asleep waiting for red lights, had a resident neighbor who TWICE fell asleep filling his bathtub and flooded my apartment. You can't convince me there's much learning going on in such a state of exhaustion. IQ drops rapidly with sleep deprivation. Medcine should make doing handoffs part of the training, and part of normal routine, along with record-keeping. If a student needs to know what happened to a patient while they were on a needed sleep break, then they can refer to the records and logs that other doctors should be keeping. If there is no written record, and they are relying on memory alone, there is a problem with the system.
29
How many physicians are in the hospital for the first twenty-four hours, as you suggest?! None do! One should be trained how to take care of patients, from home, not during 34 hour shifts, as I did during my abusive general surgery residency. It was not too uncommon, to have those shifts every other night! It was definitely not for my benefit!
5
So only attending physicians, who have no restrictions on their work hours should make decisions after an extended on call shift? How does one learn to work when fatigued and in discomfort as we have all had to do in our profession? I have seen too many you g attending who request consults merely to avoid taking care of their patients after "normal" hours.
2
For those of us who, as patients, wonder why finding a compassionate doctor who's actually willing to listen to us is often so hard, wonder no more. Here's your answer, and it's not Obamacare. It's the ongoing zombification that's euphemistically called 'post-graduate- or 'residency' training. While the picture may be improving somewhat, to the point where (hopefully) we don't have too many resident physicians ending up in the road accident, suicide or divorce statistics, it's not good. Forget the baloney about how long hours somehow build character and 'We were giants in those days' ('Those days' being not only before computers but even beepers and direct-dialing long-distance phone calls). Sleep-deprived people simply don't learn very well, let alone actually do the thinking that's really required to figure out what's wrong with their patients and how best to help them.
Granted, the increasingly complicated nature of medicine and today's electronic record-keeping might end up lengthening residency training by a year or so in many specialties, but that's still preferable to going back to the days of forced sleep deprivation due in part to misplaced macho pride (and the LACK of compassion for the ill it so often causes). Zombies can make for great entertainment, but would you want to trust your life to one?
Granted, the increasingly complicated nature of medicine and today's electronic record-keeping might end up lengthening residency training by a year or so in many specialties, but that's still preferable to going back to the days of forced sleep deprivation due in part to misplaced macho pride (and the LACK of compassion for the ill it so often causes). Zombies can make for great entertainment, but would you want to trust your life to one?
83
Exactly right. People who go through this sort of torture learn one thing: we endured, and that makes us better than you. No matter what else you know, you don't know what it's like to "work" when you've been awake for 36 or 48 hours. Or even 72 hours. YOU, non-physician, are less than we. You are mere mortals, WE are... Most could readily fill in that blank with unflattering words. Medicine may be one of the most respected of the professions, proving only one thing: you can respect people you really just can't stand to be around.
It's irrelevant as to whether or not the captives believe they are being tortured. It's a special form of Stockholm syndrome that the article mentions, "Residency programs have a way of indoctrinating new recruits into believing that misery is somehow noble." Indeed.
Are the patients harmed during these residencies? Perhaps not, but subjective reports are too confounded to be properly analyzed. patient harm and physician satisfaction are not the most important criteria. Far more important to consider is that those who go through this process come out believing they are superior to the rest of us - and behave as such when they begin to practice outside of a studied environment. The harm caused by physician bravado may be impossible to measure, but someone should give it a try.
It's irrelevant as to whether or not the captives believe they are being tortured. It's a special form of Stockholm syndrome that the article mentions, "Residency programs have a way of indoctrinating new recruits into believing that misery is somehow noble." Indeed.
Are the patients harmed during these residencies? Perhaps not, but subjective reports are too confounded to be properly analyzed. patient harm and physician satisfaction are not the most important criteria. Far more important to consider is that those who go through this process come out believing they are superior to the rest of us - and behave as such when they begin to practice outside of a studied environment. The harm caused by physician bravado may be impossible to measure, but someone should give it a try.
14
the reason you can't find a compassionate doctor is because the conversations and interactions that fostered that behavior was often after hours "in those days"
1
Residency is actually the easy part of the carrier of of Professional physician. The resident is not ultimately in charge, they are learners. Once out of training either as academic faculty or practioner in private or group practice, the chain of command changes. The "attending" physician is in charge and responsible, the pressure is on. There are no rules, or even good studies to evaluate the effect work hours after training on patient safety or other outcomes of practice. Unless one is a physician doing shift work, the hours including being on call are often more grueling than those during training. Isn't training after all supposed to prepare one for the real world life of a committed practicing physician? Do you want your doctor to be on a time clock? When the practice of medicine becomes a job rather than a profession, the result can be very bad indeed
22
Amazing. It seems to me, in a hospital setting, that surgeons and other physicians were on more of a time clock (i,e, unreachable most of the time) than the residents (who made a few god-awful errors when I was taking care of my husband)
6
Agreed. I moonlighted as a fellow (allowed by my program) and learned early on that outside of residency, there are no rules on hours, except perhaps as dictated by the practice you join. Found myself once reading an x-ray from a very sick patient at 3AM on a Saturday night in the same room as a much older physician doing the same. He gave me an acknowledging nod and noted that when things happen, you have to be there regardless of the time.
2
More time spent communicating patient status to the oncoming resident and " healthcare" team, more time spent treating the medical record, that is documenting care in order to enhance hospital revenue. It all means less clinical time, less surgical time, a less meaningful training experience. There is one highly skilled, highly educated and highly intelligent person responsible for a patients life- it's a doctor. I
6
Only in very rare and extreme cases is one single person responsible for saving anyone's life, and far more frequently that person is NOT a physician.
But thank you for exemplifying my premise that physicians believe themselves to be saviors of us all, due partially to their training, but also apparently to the attitude that they, and they alone, can "save" us. If only life, and death, were so easy.
But thank you for exemplifying my premise that physicians believe themselves to be saviors of us all, due partially to their training, but also apparently to the attitude that they, and they alone, can "save" us. If only life, and death, were so easy.
11
As a young physician, sitting in church, I could hear a strange muttering- it was like the sound of a hurt animal. Looking back, I could see a mother and her two sons- identical twins about 7 or 8 yrs old. They were beautiful children but they couldn't talk- only that strange pathetic murmuring. Their mother would try to quiet them. Years passed and when the boys were 11, they were to make their first communion. As the two handicapped boys struggled with each step to walk that long long distance to the altar, there was not a sound in the entire church. It was agony to see those two children struggle. Could their mother's pregnancy and the children's birth been handled differently? Many times at 3 am when I left my own family to attend the labor of a patient it was with the thought that I am there to protect that child and mother, to protect them from catastrophe. It's not a feeling like a "savior" but it is most definitely a paternalistic feeling- a concern, a responsibility, a self sacrificing love for fellow man. The welfare of the patient is always first. And about those two boys, time passed and a group of women including their mother gathered for a bible study. The subject was heaven. Each person would voice their opinion of what heaven would be and then the question was posed to the mother of the two handicapped children. " I KNOW what heaven is," the mother said. The room fell silent. " Heaven is when my two boys can say that they love me."
2
That's not what Jeff said. The responsibility is a legal one. Nobody else gets punished so severely for errors or omissions: especially not the hospital management that understaffs the various units or picks an unusable electronic records system.
It doesn't mean that the doctor is the sole contributor to the outcomes, and I doubt that many doctors feel that way about their role. Some clearly do.
It doesn't mean that the doctor is the sole contributor to the outcomes, and I doubt that many doctors feel that way about their role. Some clearly do.
1
I trained under the "old" rules working 90-100 hours a week in a Unuversity run metro hospital setting. Yes it was ridiculously hard. Residents now say "I don't want to hear about how hard you trained" so I don't talk about it. But here are two examples that make me pause:One of my residents was married to a surgical resident. She mentioned that they frquently meet at home for lunch and to walk the dog. Another team I had spent more time talking about which BMW to buy than cases.
Honestly, what do they do with all those hours? We had no cap on the number of admissions or patient load and we drew our own blood, transported patients after 4PM, placed our own IVs and central lines and early on mixed our own TPN. I know- I'm ranting.
I am fine with changing the structure somewhat, but you must learn to take full responsibility for people's lives and that comes from long, often difficult, demanding training.
Honestly, what do they do with all those hours? We had no cap on the number of admissions or patient load and we drew our own blood, transported patients after 4PM, placed our own IVs and central lines and early on mixed our own TPN. I know- I'm ranting.
I am fine with changing the structure somewhat, but you must learn to take full responsibility for people's lives and that comes from long, often difficult, demanding training.
17
You are clearly delusional. There is NOTHING redeeming in working 36 out of every 48 hours, as we did in the intensive care units. It resulted in burn-out, loss of compassion and depression. There is nothing dictating that having a more humane schedule is less demanding. I would have welcomed the opportunity to have had more than one Sunday off each month. I wasn't even able to buy postage stamps to pay my bills (no internet in those days). I left clinical medicine because the return (satisfaction) on my investment (my time) was clearly not worth it. Getting reamed out in the morning in front of the entire team by the attending, who was not reachable during the night and would likely yell and scream if he/she WERE reachable, was not either merited or helpful to learning. Residency was an ordeal to be survived, but I never considered the torture to which we were subjected conducive to more complete learning.
63
BA, This is mainly about you. Consider the loss of patient continuity and most importantly the exposure to as many cases as possible when you get out of residency. You will only appreciate it once you are out for years and realize how much you depend on the total residency experience, Granted this servitude can be improved, but do not forget how you are now consumed with EMR, documentation and the like which just reduces patient face time and your actual "treating" . There were good things about spending those residency years in extended and maximum experience .
2
Thank you RB! As a physician married to another physician (cardiovascular surgeon) this is exactly what we are seeing with residents in training today. We both trained at excellent programs under the old rules and yes it was hard...particularly for my husband...but we still managed to have two children and an intact marriage! My husband is a superb surgeon who still talks about the excellent (albeit arduous) training that made him the physician he is today.
6
9% deaths or serious complications for both groups? This is acceptable?
Perhaps the real conclusion is that BOTH of these schedules are inappropriate for best patient care.
Perhaps the real conclusion is that BOTH of these schedules are inappropriate for best patient care.
3
No, the real conclusion is that people eventually die, and there's nothing we can do about that.
When doctors and patients have to choose between a 100% likelihood of death, and a 91% likelihood of death, they usually choose 91%.
They're not building microchips in clean rooms. They're treating human beings in a real-world environment.
Sometimes, even after a technically perfect operation with the best care, a patient declines and dies. Sometimes this is because they started with high risk factors, like lung and kidney function, and they accepted the risks. Sometimes this is because they got bad reaction to a standard drug. Sometimes this is because of reasons nobody understands.
There is no institution or surgeon anyplace in the world, under any system, at any price, that has a zero risk of death or serious complications for major surgery. 9% can be quite reasonable.
When doctors and patients have to choose between a 100% likelihood of death, and a 91% likelihood of death, they usually choose 91%.
They're not building microchips in clean rooms. They're treating human beings in a real-world environment.
Sometimes, even after a technically perfect operation with the best care, a patient declines and dies. Sometimes this is because they started with high risk factors, like lung and kidney function, and they accepted the risks. Sometimes this is because they got bad reaction to a standard drug. Sometimes this is because of reasons nobody understands.
There is no institution or surgeon anyplace in the world, under any system, at any price, that has a zero risk of death or serious complications for major surgery. 9% can be quite reasonable.
27
@Norman
You are ignoring the estimates that up to 440,000 Americans die each and every year needlessly from preventable mistakes in healthcare settings - a number that is stunningly higher than the "terrorism threat" on which we waste so much money each year.
Hygiene failures alone (think lack of hand-washing and lack of following best practices) kill 70,000 or more each and every year and account for 10 times that in serious infections costing an extra week in hospital, despite being a major target for improvement. (This outcome apparently has shown substantial improvement in the last ten years, since it used to be, by the CDC's count, 100,000 each and every year + one million serious infections, but there are still a huge number of needless deaths and serious injuries, all low hanging fruit for saving American lives, no bombs needed.)
You are ignoring the estimates that up to 440,000 Americans die each and every year needlessly from preventable mistakes in healthcare settings - a number that is stunningly higher than the "terrorism threat" on which we waste so much money each year.
Hygiene failures alone (think lack of hand-washing and lack of following best practices) kill 70,000 or more each and every year and account for 10 times that in serious infections costing an extra week in hospital, despite being a major target for improvement. (This outcome apparently has shown substantial improvement in the last ten years, since it used to be, by the CDC's count, 100,000 each and every year + one million serious infections, but there are still a huge number of needless deaths and serious injuries, all low hanging fruit for saving American lives, no bombs needed.)
12
Those who see the most learn the most.
16
If they'e alert enough to understand what they're seeing.
16
Kate: Alert? When BIS brain monitors were placed on anesthesia residents after taking night call, they registered in the 70s on a 100 point scale, a level compatible with light to moderate sedation. The rationale was anyone can give an anesthetic when they are wide awake. What will you do when awakened at 3 in the morning to give anesthesia for a life or death emergency? You must be able to function in your sleep. Maybe things have changed since I trained in anesthesia in the mid 1970s. For sure we did not even have pulse oximeters then.
Visit the non-profit Goldilocks Foundation for more information. The mind you save could be your own.
Visit the non-profit Goldilocks Foundation for more information. The mind you save could be your own.
3
Very interesting. Dr. Carroll reads a well designed study, and comes to the wrong conclusion.
As a surgeon with 35 years of experience, I know how hard training was back in the 70s. I see the residents that have been recently trained.
Surgeons are a little like navy seals. We have to perform at a moments notice under severe conditions, to save lives. Not being used to working under difficult conditions is a negative.
The new surgeons often have limited training in certain procedures because of their minimal training under the new system of resident protection.
Libby Zion changed everything, but, according to this recent study in the NEJM, not for the better. Long overdue.
As a surgeon with 35 years of experience, I know how hard training was back in the 70s. I see the residents that have been recently trained.
Surgeons are a little like navy seals. We have to perform at a moments notice under severe conditions, to save lives. Not being used to working under difficult conditions is a negative.
The new surgeons often have limited training in certain procedures because of their minimal training under the new system of resident protection.
Libby Zion changed everything, but, according to this recent study in the NEJM, not for the better. Long overdue.
15
Libby Zion most likely had serotonin syndrome - a condition not even recognized until years later. The work hours regulations were a reaction to the media. The major quality studies of our time from To Err is Human to the present are flawed and continue to distract our nation from real improvements.
Libby Zion didn't change everything. The doctors who did or didn't treat her properly because of how they were treated changed everything. Since hospitals continue to try to be too lean in order to pay their CEOs lavish salaries perhaps those CEOs could contribute to the betterment of everyone's life by doing some work in the hospital to understand why more people are needed or they could admit that they don't need such lavish salaries. Patients needs should come first when thinking about nursing staff, doctors, orderlies, infections, etc.
5