80 hour work week

My question is: who the heck is gonna police it?

I haven't been under 80 hours any week since I've started. I only had one day off last month (when technically you're supposed to get 1/week). And I have yet to go home by noon on a post call day. I'm not complaining, and I don't mind what I'm doing. But no one in his/her right mind is going to go whining to the program chair because they worked 95 hours last week. I'm certainly not monitoring my hours, and no one else seems to be doing so. They spoke about it during orientation, but I'm not sure if I see any real changes yet.

I believe the 80 hour work week will become reality, but it will take several years to be fully implemented and well enforced. I have heard that Yale G-surg lost accreditation this year because of violating this policy of the RRC. The policy is now a prerequisite for accreditation and the RRC is asking for documentation of compliance. Whether or not an individual program complies will vary widely and I think we'll see more programs "made examples of" . There is a bill in congress that would basically make the New york state law a federal one so that it would have real teeth (big fines for noncompliance). If that passes you will see programs tighten up immediately because when it only takes one person testifying to hit your hospital/department with a 50k fine, then it changes things.

My question is how will it affect training and delivery of care. We work >80 hours per week to get work done that needs doing. If they cap how long we can stay then undoubtedly residents will do fewer cases, many cases that need to be done will be put in line (like canadians waiting for MRIs) and programs that cover multiple hospitals will probably have to pull back to their home base to have enough coverage.

Any thoughts?

I can tell you honestly "Bone_Jock" that if your program doesn't police the 80 hour work week, it will come back to haunt them and you. As many of you know, this will become a federal law soon and in New York we are already being audited (the state investigators showed up on Monday unannounced and will be interviewing every resident in every program!) as well as the program directors. "Pod2be" is correct in that Yale did get "a death sentence" of sorts for non-compliance. This is real stuff and it's going to be very expensive to hospitals that do not comply. Our program, like many others, has instituted a night float system so that we can ensure that residents' rotations will not be disrupted when they are not on the night float rotation. Many programs will have to change dramatically to stay in compliance while others (especially many in NY) have already been dealing with these issues. This is a very important issue that you all need to be aware of because it will most certainly affect your training. If anyone has any specific questions, I'd be happy to speak to you personally if you'd like. My email is [url=mailto][email protected][/url]
William N. Levine, MD
Program Director, Columbia-Presbyterian Medical Center

Wanted to bring this up again because it could affect my application tremendously. I have never thought of some of the more malignant high powered university programs out of fear of never seeing family or having much of a life outside the hospital. However, if most or even all programs have to abide by 80 hours a week than that would open up a plethora of doors for me. I recently spoke with a program director in Michigan who said his program WILL be abiding by the rule next year. He did not know exactly how yet (night float, post-call privelage) but said he would find a way out of fear of losing accredidation. He also mentioned independent evaluators coming into the program to investigate and ensure the 80 hours were being kept. This is a great guy with a great reputation and I trust what he was saying. Anybody else hearing the same where they are at? Has this possibility opened up others minds to more programs? ERAS is one huge monkey on my back and I can't wait to shake him off.

"Papa Homer tell me about the constellations." "Well, uh, see that big dipper looking one? That's aquarius."

I for one will report their sorry @#$%& if I'm working 81 hours/week next July.

No...I have no shame.
My chairman can take that to the bank.

:roll smile:

Micky, you are one lame sack. I like my time off as much (or more) than anybody, but working only 80 hrs/week and being sent home post call is not only going to seriously affect patient care and continuity but also greatly impact your training as a surgeon. If I'm gonna stay up all night admitting people from the ED, I sure as h$%& wanna operate on them the next day and follow em post-op. How do you think youre gonna learn anything by working in shifts "sorry 24 hours is up, gotta go..." and not seeing what happens to your pateints not only in the OR, but afterwards. This is a terrible blow to residency training, and while I agree were all overworked and tired, I'd argue its not only worth it but necessary if you wanna be a pod worth your salt. I'm sure as @$%& not gonna tell big brother whats going on in my program, I feel bad for whatever program you get into with an attitude like that.

Shaving 20 comatose hours off my 100 + hour work week is not a "terrible blow" to my training. Instead of following up on my ED admissions when I'm half-asleep without energy or concentration, I'd rather have a couple hours to read up on the next day's cases, be somewhat well rested so I could approach them with more vigor and energy. Quantity does not always determine quality...Sure if there's an interesting case going when I'm post call I wouldn't mind sticking around, but to stay there for my 540th I & D or tibial nail, which often is the case, would not make me a better orthopod, just one that's more exhausted. Your learning curve tapers after a while...don't think you're a better orthopod than the next guy because you've done 80 tibial nails to his 60. Are you telling me that those extra "postcall cases", when you're exhausted without focus are so important to your training that without them you'd be subpar? Give it a rest pal. Your argument would make more sense if I'd wanted to work 5 hours a day. To cut the comatose hours off my work week when I'm essentially a useless zombie would only benefit my learning.

Jointspace, although I understand your willingness to do whatever it takes to get through residency, I am not sure I would want my fractured acetabulum operated on by a sleepy ortho resident who has not seen a sleeping cot in 36 hours.
I think this whole "rite of passage" typical of surgical residencies ("we had it tough when we were interns, and so you must endure the pain, too") has gotten out of hand, and it was about time they cut the hours. However, I also think that some residencies may need to go to 6 years instead of 5 in order for residents to get an adequate exposure to different surgical cases.

And in response to your nauseating "patient care/continuity" point...If you think you deliver good patient care on your 36th hour in the hospital you're crazy. Your patients would be better off if you're not there. In this profession, residents and attendings should be careful when they discuss ethics and patient care goals...when attendings routinely ignore patients without insurance and leave their care to a second year resident who's done a single tibial nail, or how ortho clinics are jammed with patients but no attendings...you want me to swallow your BS that shaving my postcall hours is so detrimental to patient care? There are problems with the system that need correcting, but my post call hours is not the issue. When an attending who doesn't even so much as look at a patient without insurance...I wish I had a penny for everytime I heard an attending say "Don't schedule any clinic patients"... The same attending will then rant about how he likes to round on his postop patients (only those with insurance of course) to deliver better continuity of care and followup. What a caring doc! And many of these attendings even have the nerve to give us a lecture every once in a while about patient care and continuity. The hypocrisy is just sickening. If you think you're making your contribution to society and patient care by sticking around for a few more hours when you're half-asleep you're nuts. Overworked and tired residents do not deliver good care and are not sharp in the OR...you'd be doing them a favor by going home. You're better off focusing your energy on areas that actually do affect patient care.

hey man, i'm not gonna go point to point with you on this. and justifying one inadequecy with another dosen't make things right either; you can either learn from bad examples or use them to justify your own shortcomings. and i agree being a sleep deprived resident isn't the best thing in the world for patients or yourself. and i think something should be done to reduce hours. but the attitude that this is just another job with set hours and nice little printed out guidelines to follow is completely unrealistic and immature. if you wanna come into your graduate training with a punch out time card and set of rules in hand, your experience may be just that plastic.

Never said I wanted a time card or set hours...but I've gone up to 43 hours without sleep twice last month...it's inhumane and unfair to the patients I have to take care of. I've made mistakes during these times directly affecting patients. And if no one is complying with the new rules, then I'll keep my trap shut and keep plugging away with my 115+ hour schedule. IBut if I see that most programs are changing their ways and complying with the new rules, while mine kind of lingers in the shadows because we're not in NY...guess what... I'm reporting them. And I've talked to a couple other residents in my program and we all talk and joke about it too. No I don't want set hours or a time card to punch out but I do want some fairness and some standardization of work hours across the board. I'm in a very busy academic program and quite honestly attendings don't seem to give a rat's arse about our schedule or how busy we are or how many hours we work. Of course it's the old "we went through it" attitude, but when they went through it I wonder if the core of knowledge to master was anywhere near what it is today. The boys at the top have to flex their muscles for some of these guys to listen...if they don't I'll make sure someone knows. That's all. I like Orthopaedics' idea of making it a 6 year program or possibly adding one more resident to every program to deal with this. And the night float system described by Dr. Levine sounds great and it's nice to see an attending show interest in this. Because I can tell you that at my program, the gen surg team has shown more respect for the new guidelines than the ortho department...it's as if the ortho attendings/chairman are hoping they can get away with it. They have not talked to us about it once and when a resident brought it up at a conference the chairman downplayed it and didn't treat it with the seriousness that it deserves. I for one will make sure that he does IF other programs are making changes.

The nice thing about the new rules is that they interview residents DIRECTLY and I heard they can do so over the internet anonymously. I don't think anyone would go to their chairman and complain so it's good that they ask us.

I agree that it's unfair if most programs comply and a few don't.

Micky, I think you make a good point that general surgery programs in general are more under fire and will be under closer scrutiny than ortho programs, because traditionally their hours are more grueling.

I agree 100% with Micky. There already seems to be a lot of resistance to the new guidelines in the Ortho world, but something has to give. My biggest fear is that my program will think they can fool the system by playing with the hours and then end up getting busted either by a random check or because one of my fellow residents blew the whistle (I probably never would). The last thing I want is to have my program lose its accretidation and have the two years I put in become worthless, or leave me scrambling to find a third year spot somewhere.
Still, this whole problem in part stems from the fact the healthcare system is out of control. I am at a busy academic center which sees a tremendous amount of trauma. These patients aren't going to disappear, and someone needs to take care of them. The work load is heavy, not because the attendings are malignant, but because we are just that busy. Even though it pains me to think of making Ortho a 6 year program, the extra set of residents, reduced hours, and more academic time would definitely make it worth it.

I agree with jointspace on ths one. I cant believe you people are in orthopedics. I'm a fourth year at a major well-known academic institution; we work a h$%& of a llot more than 80 hrs a week, yet not one of us are happy about the changes being made. Orthopedics stands a lot to lose much from the new rules, if they are enforced. I may be tired post-call but the absolute last things I or any of the other residents want to do is go home and miss a days worth of cases on our service. Its simply not fair, nor is it good for our training, despite your points of feeling 'refreshed' or having time to read. Sure this is necessary, but what you need as a pod is experience, and that is what we will lose a lot of. You guys should not be looking forward to the new regulations but regretting their existence, for your own sakes. If it were easy, everybody would do it. The other problem is we will be short-handed and most programs cant add other residets, or the cases we do will drop even more, not meeting residency guidelines. This is not something to be happy about, people.

BigK,

Personally, I don't care one way or the other, but the new law is now a fact of life. I, like I'm sure most of us, made the decision to go into Ortho before we heard anything about this new law. I applied to Ortho fully expecting to log long hours and work my arse off for five years. I am willing to do whatever it takes to become an orthopod. However, not everyone feels this way. And if you are at a program that does not follow the new law, and they get busted, you WILL suffer the consequences if they lose their accreditation. That is something I think we should all fear.

Kwire, I disagree that our education experience is going to go down this @$%&ter with new work hours. If programs go to the night float system like Dr. Levine mentioned, we will still get plenty of "pod" experience.

The majority (75%) of your operative experience comes between 7 AM and 6 PM. WIth a night float, you will likely have 11 months of the year that you are working your 12-14 hours days five days a week. You will still have your 24 hour weekend calls as well, so you still get in some call during that time. Those five days a week that you are operating, you will be fresh and able to put in 100%. You will also be able to read as Micky pointed out.

You will miss out on a lot of call and trauma experience when you are off night float, but you will have an entire month when you are doing the call and trauma five days a week. You will miss out on following and managing the trauma cases that come in over night, but there is no law that says you can't follow in the periphery. You can still read the chart and see what is happeneing with the patient you oerated on at 2AM. You can even talk with attendings about the patients. You just can't "work" on the patients. The one other thing you will miss out on during the night float month is the 38th hour when you are struggling to keep you eyes open to do that 500Th I&D, because the attendings before you worked those kind of hours.

bigkwire -- if you're shaking in your boots wondering whether you'd get good training in the OR with the new rules, I suggest you don't stay at your "well-known" program. We get so much trauma here there's more than plenty to go around. It's constant and we have multiple trauma patients coming in through a revolving door...with the new rules, I have absolutely no doubt I will be an experienced chief/attending when I'm done...there are 5 OR's running freaking CONSTANTLY.

I can see how training could be affected at some places that don't see as much trauma...like some cush community programs that don't see as many polytrauma cases. But man, I can tell you I'll get more than I want by the time I'm done here. I cannot wait for the new rules.

Let's face it, none of us are slack-asses or we wouldn't be where we are today. I think that the new resident work hour restrictions only have one problem. They weren't in place during my intern year while gen surg was abusing me like a @#$%^&* step child! My program has so much trauma that I KNOW my training will not be affected by the cut in hours. Think about it, you could probably have nailed a femur after your first month of ortho as a 4th year med student. As a matter of fact, I know plenty of med-students who did! Considering 90% of us will go into private practice where 80% of our cases will be scopes and total joints, the trauma training you miss isn't that big of a deal because you know that you're going to refer your polytraumas to a center.
Last month I worked 120 hours. I almost wrecked my car 5 times driving home from work- what's more important; graduating with 500 IM femurs or graduating at all???
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Who wants cheese with their "whine"
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Hey if my program institutes these new guidelines fine, but if they don't, I'll continue working my 100 hour work weeks without complaints. In our program, life gets better as you move up. we take call from home as a pgy-3, so although I'm falling asleep during cases now, that's not going to be the case in a couple of years. I'll take my knocks as young buck and I'll be better for it in the long run. I don't want to be pampered. And believe you me, if I'm ever too tired to operate and I don't ask for help and I harm a patient, I hope some judge locks me up and tosses away the key. It's like stepping behind the wheel of a car when you're drunk off your behind. There's just no excuse for it.

Amen Bonejock.. T, there are other reaons that you should be locked up you know. )