MGH - Resident Rule Violations

[TulipsAndSunscreen]

http://www.boston.com/news/health/ar...eons_workload/

So a couple of comments:
1) I thought it was pretty much unspoken that no one followed the 80 hour rule
2) These residents quoted as complaining about the hours (as in, they'd prefer to work more)- are they the exceptions or the rule?

I mean I just wonder if they're only interviewing a small minority who actually wants to work more or if most residents legit want to work more. That would surprise me given the general fatigue most residents seem to feel.

[MrsK]

DrK's hospital has been following the 80 hour rule pretty strictly including giving him at least two 24-hour periods off every 14 days. He generally works just under 80 hours weekly.

[Flynn]

So a couple of comments:
1) I thought it was pretty much unspoken that no one followed the 80 hour rule
2) These residents quoted as complaining about the hours (as in, they'd prefer to work more)- are they the exceptions or the rule?

DH's general surgery program followed the 80 hour work week a year before it was "law" to practice for the following year. It mostly worked out.

The year it was "law" it worked for DH 99 percent of the time. The PD wrote several memos that said explicitly that any fudging on hours would result in an IMMEDIATE termination for the resident.

I have no idea if "most programs" follow the rule but DH's did. If they don't follow it and get caught EVERYONE looks bad IMO.

[Flynn]

2) These residents quoted as complaining about the hours (as in, they'd prefer to work more)- are they the exceptions or the rule?

Oh and to coment on #2 -- DH would have prefered NOT to have the 80 hour rule. He felt it short changed his training. His mentor commented that he's not seeing the same "quality" he's used to seeing and wonders if it's due to the applicants (everyone is under the 80 hour rule so the pool is larger for surgery than it has been) or if putting the cap on hours is in effect producing LESS qualified docs.

Who knows.

[DCJenn]

The 80 hours rule was implemented during fellowship. Walter Reed stuck to it pretty closely.

I know that it complicated things during training because they were made to leave when they were in the middle of things.

Residency was so crazy though that it was funny how 'easy' 80 hours a week seemed. How stupid is that?

I'm not surprised that some residents think that they're being short-changed. My husband has said that he doesn't think that the peds residents are as well-trained as they were during his residency years- they just don't see the same numbers of kids.

Jenn

ETA: He thinks they need to add time to the residency to make up for it but he'd never admit it in public.

[ladymoreta]

DH'S hospital also does a pretty good job of following the 80 hour rule. Once or twice he's had more than 80 hours, but the average is less.

I'm not so sure about the argument that it will make them "soft" or less prepared if they don't work 100+ hours a week. Study after study shows that people's long-term memories just don't form properly without adequate sleep. The residents aren't learning as much as they think they are, and they are putting themselves at risk for lawsuits and a poor performance record because of sleep deprivation. This attitude is primarily beneficial to the hospitals' stakeholders, who get much more cheap labor with minimum risk to their bottom line. And they have convinced doctors that this kind of training is better than training that conforms with all sorts of research and evidence on learning, and doctors take pride in the fact that they've survived the ordeal. It'll be a difficult mentality to break out of, but I wouldn't be at all surprised to find that following the 80 hour rule makes more efficient (faster) treatment that leads to fewer errors (cheaper).

It kind of reminds me of what happens with software projects (because I come from the I.T. world). Developers can usually hit any deadline you give them. You have to be careful not to give them too little time (or the software will be buggy), but if you leave it open to all the time they need, they'll never finish. A set deadline helps them prepare to work within the given timeframe, and if it's a reasonable amount of time, you'll end up with a good product. Anyway, I'm not a doctor, so what do I know about their timeframes, but it seems to make sense...

[GrayMatterWife]

Good for the residents that stood up and told the truth: the rules requirements screws up patient care continuity, results in less operating time, and generally makes for a poorer overall breadth of experience. Patients don't die nearly as often because residents are tired; they die because doctors make stupid mistakes from ignorance.

And what Ivy Leaguer at MGH can't figure out how to use basic arithemetic to lie about his hours anyway? As if the chairman was really shocked at the violations. Please.

But I realize that I am in the minority on this. I am of the "Stop whining; start working" school of thought. My husband is in agreement with Flynn's: the hours rule is a shortchange. He thinks it does more harm, both to patients and to residents, than it helps. And it ends up eating tons of their time, tracking their hours and making the math work...and trying to "pass off" patients effectively, so no one gets lost in the off-duty/on-duty shuffle.

[TulipsAndSunscreen]

Yes, I too was wondering if it doesn't mean that more time is now needed in some specialties. They said somewhere in the article that you needed to see x number of surgeries to be able to have the volume to be a surgeon. It seems to me that with fewer hours, they see less stuff. Although I don't necessarily think putting a number out there will help because then you'll be getting psychos trying to fit 400 surgeries into a year.

From a sleep literature perspective, the cap makes perfect sense but I wonder if it's really producing high quality doctors. The problem is of course that for the spouse "only 80 hours a week" still blows so no one really wants a longer residency. DF isn't even there yet and I don't want it to be longer!!

Also, another question, has this made attendings hours longer? Someone is picking up the slack right? And med schools still admit too few doctors to cover all the residency spots every year. So how are they pulling this off?

[DCJenn]

As my husband's mentor told him when we got here, "Glad to have you back and remember, there is no 80 hour limit for staff!"

Because child neurology is an elective, they don't always have peds residents rotating through. They occasionally get medical students. He likes to take residents and medical students with him to Ft. Hood because it's got volume that they just don't see down here. (as big a military presence that San Antonio has) Of course the PICU and ward have residents and interns but since they rotate on-call status he really only deals with them when he's on-call.

When he's on-call, he generally works from 7am -7pm and goes in on weekends. It's a rarity that he has to go in during overnights though. I think in three years, he's only had to go in once on an overnight and that was for a very sick child who was dying and he just wanted to be there for the family.

Jenn

[Bittersweet]

There is no shortage of arguments on both sides regarding the prudence of the 80hr rule. As far as I know, there is no conclusive empirical data on either side and my DH is so new to residency that I don’t yet have an opinion. Regardless, I think residents face a truly difficult decision when deciding whether to accurately report their hours. The program’s opinion of the individual resident and the reputation of the program matters – neither of those are helped by a program being placed on probation.

As for the residents in the article, I don’t know whether they are truly representative. First, those interviewed (1) chose surgery; and (2) chose to train at Mass. Gen. Second, I’m guessing there are few residents anywhere that would choose to publically criticize their program’s lack of compliance (to the media no less) for fear of professional repercussions.

[Pollyanna]

Good for the residents that stood up and told the truth: the rules requirements screws up patient care continuity, results in less operating time, and generally makes for a poorer overall breadth of experience. Patients don't die nearly as often because residents are tired; they die because doctors make stupid mistakes from ignorance.

And what Ivy Leaguer at MGH can't figure out how to use basic arithemetic to lie about his hours anyway? As if the chairman was really shocked at the violations. Please.

But I realize that I am in the minority on this. I am of the "Stop whining; start working" school of thought. My husband is in agreement with Flynn's: the hours rule is a shortchange. He thinks it does more harm, both to patients and to residents, than it helps. And it ends up eating tons of their time, tracking their hours and making the math work...and trying to "pass off" patients effectively, so no one gets lost in the off-duty/on-duty shuffle.

I agree with this completely. Dh also feels the 80 hr rule has short changed patients and his experience (especially during onc). He also hates residents who use the 80 hour rule as a way to get out of work. You know, the ones that show up and can't help out in a case because it might put them over an hour or two. Never mind what would be best for the patient.

On the other side, the 80 hour limit (and the fact that our program keeps all the residents within their hours) has been wonderful for our family.

[KCwife]

I agree with this completely. Dh also feels the 80 hr rule has short changed patients and his experience (especially during onc). He also hates residents who use the 80 hour rule as a way to get out of work. You know, the ones that show up and can't help out in a case because it might put them over an hour or two. Never mind what would be best for the patient.

Yep.

[Flynn]

DH and I had an interesting discussion about this topic last night.

From his perspective, the 80 hour rule in large part changed the "type" of person who signs up for surgery.

When you signed on before you knew you would be "WORKED" but honestly for these "Type A kick ass and take names surgeon types" that was part of the draw. THEY could take it. Bring it on. They were the toughest, the best and the brightest. (I sound like a military commercial. )

Now that's not necessarily the case. There is a component of residents who choose surgery with a (gasp) "shift mentality."

DH has looked but to his knowledge there is NO data that says patient care has gone up since the 80 hour work week -- and it's been studied. There is however LOTS of data saying lack of sleep is harmful to docs and anyone else making important decisions. Duh.

The 80 hour work week changed our life for the better (TIMES TEN). It was short lived though because then came fellowship. Dammit.

DH is glad he did 90% of his training PRIOR to the rule.

[MarissaNicole]

This is all interesting to me - I guess I thought that with the new rule the hours didn't really change, it just took a bunch of time for residents to try and make their hours comply.

I am curious if the MGH is a place where residents are encouraged to write their real hours and thats how the violation got reported or if it is unspoken that you adjust your hours and a resident blew the whistle? If they blew the whistle I imagine they are gonna have a rough time the rest of their residency.

Also although DH is only an MS he still thinks that hour restrictions are hurtful - he is concerned with getting the most experience and patient interaction during his residency as possible (I somewhat disagree - I think that 80 hours a week over 6-8 years should seem like enough training but then again this is partially because I would love to have him home - but at the same time I realize that the rediculous hours will be more than worth it in the end.) I'll be curious to see if DH's opinion changes when he IS a resident but I highly doubt it.

[TulipsAndSunscreen]

The problem with the system is that it relies on residents to report compliance. Whether or not you like the rule, that's a flawed reporting system.

If they don't report it, they could be forced to work too many hours. If they do report it, they face possible repercussions including their program being uncertified. If their program loses certification, then their residency at that institution is no longer accredited to teach them. Seems like a circular reference to me.