What do you make of this piece on duty hour restrictions?

[TulipsAndSunscreen]

http://www.slate.com/blogs/the_drift...ight_have.html

I'll be honest, I don't buy the "doctors are having to switch out more often" reason that the duty hours haven't improved patient outcomes. Obviously I have a limited perspective or dataset but I've NEVER heard of a resident having to leave in the middle of a surgery because of duty hours. And even if they did, it would be the most junior residents or interns who are often not even scrubbed in. If the junior resident needed to leave, the senior and the attending (or a scrub tech/circulator) would still be there so the quality of care shouldn't change. I can't speak to the ICU issue whether maybe management of those complicated cases being handed off matters but the surgery piece just rings false to me.

What do you guys think?

[SoonerTexan]

^Exactly

: While doctors might have been better rested, the new rules prevented them from overseeing their patients’ care from start to finish. Sanghavi wrote:

Shorter shifts mean doctors have less continuity with their patients. If one doctor leaves, another must take over. Work-hour reductions lead to more handoffs of patients, and the number of these handoffs is one of the strongest risk factors for error. As a result, many hospitalized patients are at the mercy of a real-life game of telephone, where a message is passed from doctor to doctor — and frequently garbled in the process.

If there truly is an issue with this, I'm going to call it a problem that can be fixed without extending duty hours. Nurses hand off every 12 hours. I heard DH call the next resident on and give an overview of the patients all the time last year.

Also--time off is more than just getting more sleep. You just need some mental rest too. Downtime.

I do think the intern restrictions weren't that helpful for DH. He said he would have rather had the upper level resident's schedule. More time on in a row, but allowed for more downtime. It wasn't uncommon for him to get home at 10 pm and have to get up at 4 the next morning because of how the schedule was parsed out due to the hour restrictions were parsed out.

And finally, yes we all know the hours aren't being followed. BTDT, thankfully not this year.

[corn poffi]

Just skimmed the article and posting on the fly, but I know that there is scientific research that handoffs have started to become an issues with the new work hours. Many interns start residency without not knowing how to properly hand-off or sign-out their list to the next resident, which can affect continuity, but not necessarily quality of care. There's a difference between a handoff and a good handoff.

Nurses are usually better trained in that aspect of patient care, and are often smarter than junior residents. However it just takes a few hours (if that) at the end of M4 or before starting PGY1 rotations to bring them new residents up to speed on a proper handoff.

[corn poffi]

Also I feel like I saw somewhere that residents actually get LESS REM sleep than in the good old days, so you still have tired residents treating patients.

In general, I think the 80-hour work week is a load of crap. I don't believe that residents are getting the proper training anymore. If something improved with the new restrictions means that something else suffered. Don't know what the answer is, but this wasn't it!

[TulipsAndSunscreen]

I don't believe that residents are getting the proper training anymore.

Why? Based on what? It didn't say the rates had gone up, did it? It just said it hasn't improved?

Also, we should be able to teach a proper handoff. If nurses can do a good handoff, why can't doctors? Seems like they should be equally capable.

[corn poffi]

Based off of residents graduating and not knowing how to do anything by themselves. That was my own opinion of the work hours based off of years of working in medical education and seeing residents choose fellowship because they don't feel they have the proper training. (Obviously the majority of them want to do fellowship because they specialize but I had heard "I didn't feel comfortable on my own", more that a few times, and that's scary.) I could go on, but there's no point. There are too many stupid hour rules based on arbitrary numbers.

And you'll see that I said that handoffs are easily taught, it just takes the initiative of the medical school or residency program to teach proper handoffs.

Do I think there should be work hours rules? Absolutely. Do I think the current ones work? No. Do I have a solution? Hell no, there's I reason I left medical education after 10 years.

[Sheherezade]

As an "old timer" I always hesitate to wade in to any of these discussions, because they always go badly. I have to lend some support to corn poffi though. We are pre-80 hour people. My husband trains residents now. I can tell you that he has concerns abut the level of surgical training they receive. He is always trying to find ways to increase their time in the OR. The idea of adding years to residency comes up frequently if we have to reduce the total number of training hours (for safety reasons) of the existing years. I wonder if people aren't doing that themselves already by tacking on fellowships at a higher rate then they used to do. I wonder if the number of residents pursuing fellowship has increased post-80 hour work week. I wonder what that does to the whole field of medicine, with everything tilting towards more specialists, less generalists.


Angie

[TulipsAndSunscreen]

But haven't newly minted attendings in every era thought that? Maybe it wasn't voiced so openly 20 years ago when doctors were still infallible but I'd imagine that was always the case. It's akin to your first day at your first real job - it's scary!

I don't know what the solution is either. But I don't think we can dismiss that fewer residents feel burnout. So if it was neutral for the patients but the residents feel better, isn't that a win? I'd argue that a stressed and burned out resident isn't a good resident just like an exhausted resident isn't a good resident.

[PrincessFiona]

In Europe, resident hours are strictly controlled, but residencies are extended. For example, IM is 5 years, not 3. You also get 6 weeks vacation/yr.

Things have definitely changed. We see more of an entitlement attitude. Med students are literally picking up their purses to leave at 4:55. The knowledge base and skills are weaker. For example, our OB/GYN dept has had to start having experienced docs do call with the recent grads. The new grads just were in over their heads. They also consult specialists for everything. It's a new thing that docs coming out of training aren't competent to do the job.

Kris


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[MrsC]

DH did residency under the 80 hour rule (not that they adhered to that much, he averaged 90) and it worked out fine for him. A couple of the other residents went on to do fellowship right after but most went into private practice. He was nervous about being out on his own but felt like he got adequate training. Then again, he was the work horse of the group.
I think one you approach the 100 hour mark and over, you're getting into dangerous territory with the level of sleep deprivation that's going on.
The 16 hour rule is of a bigger concern I think. It has resulted in a lot more hand holding with second year residents. Their clinical skills are not what they should be.

I think the attitude varies a lot depending on the med school or program too. Some do too much babying. Some produce excellent academics but they're lacking in clinical skills.
There was this story during fellowship of a resident calling the fellow at 7am asking if there was anything to do before she went home. The fellow had no idea she had even been on call because she slept all night in the call room. This would have been a serious issue in DH's residency program. At this place, they let it slide. So yes, entitlement is a big issue with some.

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[corn poffi]

The 16 hour rule is of a bigger concern I think. It has resulted in a lot more hand holding with second year residents. Their clinical skills are not what they should be.

I think the attitude varies a lot depending on the med school or program too. Some do too much babying. Some produce excellent academics but they're lacking in clinical skills.
There was this story during fellowship of a resident calling the fellow at 7am asking if there was anything to do before she went home. The fellow had no idea she had even been on call because she slept all night in the call room. This would have been a serious issue in DH's residency program. At this place, they let it slide. So yes, entitlement is a big issue with some.

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Yeah that 16 hour rule needs to be the first to go. That hasn't done anybody any favors, except for maybe the senior residents who can send a whiny intern home due to hours. Haha

I also think entitlement is a huge problem. The lack of professionalism and basic etiquette of so many students and residents is ridiculous.

[WolfpackWife]

Knowing that drowsy driving is as dangerous as drunk driving (a HUGE fear of mine) I just can't reconcile the idea of having doctors practice with that level of prolonged sleep deprivation. It seems reckless, but what do I know. I also don't know an answer. I selfishly am not looking forward to the toll prolonged years of exhaustion and sleep deprivation will take on my husband at the expense of his career and I can't imagine wanting to receive care from some of these residents with the levels of exhaustion I've heard described. More residents? That's not going to happen. Maybe Europe is doing it right. Strict rules, more years. At least they seem to have some value for the mental and physical health and personal lives of their physicians. The US does not. At all.

[OrionGrad]

What do you make of this piece on duty hour restrictions?

I also think entitlement is a huge problem. The lack of professionalism and basic etiquette of so many students and residents is ridiculous.

I hate to pile on, but YES THIS! My kids are seeing pretty much all residents during their peds appointments here, and I can't believe some of the stuff I've seen. Back in PDX, I saw med students wearing COMPLETELY inappropriate clothing to clinic and I also reported a resident once for a picture of a patient she posted on Instagram.

ETA: We've seen plenty of great peds residents, too, including one who saw DS2 in clinic on Wednesday. It's just the bad ones that stick in my mind.

[houseelf]

I've had this conversation on this board a few thousand times and it has caused hard and bitter feelings. I personally don't have an answer so I can't pretend to have an answer for everyone else.

Pre 80 hour work week for a decade wrecked havoc on our lives. I can't understate this enough without going into way personal areas. Six years out and we are still unraveling from the pain. It affected health, finances, mental health, marriage, kids, family, life. Like just bad. Sure, there are WONDERFUL components to it as well, but the cost was everything we had and then some.

Still, one of Malcolm Gladwell's book where he talks about the time requirement to become an "expert" in almost any field. From baseball to surgery to engineering, he believes it is about 10,000 hours until one practices a craft at an instinctual level. DH talks about a case of a teenage boy in a drunk driving car wreck who had blood in his abdomen. He was a surly drunk and his really nice parents were mortified. He told DH to "f** off" His parents apologized profusely and signed consent. DH took him to surgery and saw his bowel was severed in three places. Importantly, they found a major artery was hit while packing the kid down. (It was a stablize and pack down case for future surgery due to potential blood loss...there is a quick 90 minute table requirement). DH was a new attending and had a first year fellow with him when they found this artery and it spurted out to the ceiling. DH immediately put his finger on it and went into what he calls "quiet focus" mode. It's the opposite of panic. Everyone else in the room was freaked out. DH told the fellow that he was going to give him one shot to sew the artery and if he couldn't do it, DH would take over. This is the kind of situation that 17 year old kids who you just spoke with 30 minutes earlier die on the table. The fellow panicked and couldn't stitch it on the first attempt. DH took over, threw a stitch, and saved that kids life. He talks about this case as one of those times where training and instinct kicks in. He only attributes being able to do this because there is nothing he hasn't seen or done. That is the kind of scenario is where the work hour restriction may make a difference.

In a similar story, my friend had a pretty terrible C section with a seasoned ObGyn that would be material for something like ER or Gray's anatomy. She said when the shit hit the fan, the energy in the room was beyond panicked, except for her 15 year experienced, work horse ObGYn who went into that same quiet focus mode. I know this guy. He has worked his ass off and there is nothing he hasn't seen. THAT is the guy you want at that moment, not the guy who managed work life balance in residency.

I'm not going to lie. I wouldn't do another GS residency and fellowship for 5 million dollars. Nope. On the other hand, I appreciate that there are people out there who have done it.

I have no answer. It is a hell of a price to pay. Hopefully someone brighter than me can come up with a plan.

eta: Dh will be the very first person to tell you that while he stayed up nights on end keeping other kids alive, his own children were home without him. It is cool to get notes from former patient families and all the accolades. Nonetheless, he missed out on A LOT of his own life and it has had a big cost. Dealing with life and death every day also has killed a small piece of his soul that he can never get back. The chronic stress became a habit.

Anyhoo, too much? Anyone running to sign up for surgery + PhD + fellowship? Lol.

[memyselfandI]

I think your last bit says it all. There's a reason that the divorce rates are so high.