Resident work hour violations

ROL_2010:

No worries, you're not piling on on me. There is no way in hell that I'm posting information regarding my concerns about work hour violations on my own account. Doing so could be career suicide, and I thereby wish to maintain anonymity. To that end, I'm using the account of one of the 4th year med students who posted this (sibling of a co-resident, no longer pursuing ortho after a change of heart, so no conflict of interest using the account.)

Having cleared that, I enjoyed your comment regarding the contract being in breach. And when I become an attending, I'll make sure not to be on primary call for 36 hours continually (among the repeated violations I speak of.) If you want to do that and keep going after call when you are "in the real world", then you're the man! It's not what I seek; but hey, at least there are people who do seek this out, such as orthotrauma3. God bless you all.

orthotaff, to address your questions: This is happening enough so that I already had to discuss it with the PD and GME office, and it still occurs (did you read my initial posts carefully?) The violations are egregious enough and occur so frequently, that one look at my call schedule and the ACGME will be on my program like white on rice.

What do people who want to work 40 hrs/week have anything to do with this? How about more like 36 hours of continuous primary call more than once a week, sticking around 2 more hours on those days to tighten up the service before going home, and working over 30 days continually on such a schedule? Have I got anyone's attention now? How can you generalize when you don't have access to the data on the violations I speak of? We emphasis backing that a*# up with evidence so much on ortho, but when it comes to something like this, even an attending is quick to make generalizations without the facts. Occasional violation? Required dedication and passion-- so you're assuming I lack this? Where's the proof that if someone complains about egregious violations, that this must mean that the resident lacks "dedication and passion"? Do you think that because violations occur only occasionally at your academic institution, that this thereby means that it must not occur more so at other institutions? Very assuming, and without even having the facts to assess before making these assumptions. Interesting.

That sounds pretty horrible to me and definitely in violation of ACGME work hours. I would be pissed too if I were in your shoes. Is this an issue for just you or all of the junior residents? I'm not an attending so I don't know if this is the advice you want but these are my ideas:

1.) I would approach your PD, and the director of GME again and let him know your work hour violations and I might even go as far as to state that you will report these violations if the call schedule is not changed.

2.) Go ahead an report these violations to the ACGME, it may result in a site review, it might put your program on probation, or it might do nothing. However, it will very likely get the attention of your PD and GME office and really make them think about changing the call schedule.

3.) Don't break work hours. When the clock strikes noonish post-call sign-out and leave the hospital. No one can threaten you or punish you for following ACGME guidlines...just don't be negligent or directly compromise patient care.

4.) Don't do anything, roll with the unfairness and the long hours and realize that this too will soon be over and you'll finish residency in a few years. Also realize that long hours=more training and experience (unless it's scut!)

5.) Forget all the above and try to change programs (maybe the best idea)

Also, take comfort that you're not alone. Two fellows I worked with this year (one from TX, one from PA) said that their programs didn't adhere to ACGME work hours at all.

This is a sad state of the current system in that there're lots of folks who would work their backside off just to get into an ortho residency, and then continue to give up a lot to be the best trained surgeon they could be. And you want to whine about the work restrictions. Seriously man, suck it up and get the best training you can, or let us know all know where you're going to practice so we don't have to worry about a loved one being injured and the on-call orthopod refuses to take care of it because they've worked past their hours.

Unfortuately, we all know that the OP has little choice in this matter. Best to put your head down, work your ass off, and get through it. Making waves will only make your life worse... and believe me, the programs that support an enviroment like the one you describe damn well know that they have you by the short hairs.

Just a couple points regarding the post above...

1. It's interesting that people equate # of consecutive hrs worked to getting "the best training you can", as if you're learning the secret to orthopaedic surgery during your 40th+ hour of primary call. I'd like to see the data on that.

2. No doctor worth a damn - resident or attending - is going to "refuse" treatment to a patient, as in the scenario that you provide. That's hyperbole. I don't want to make any assumptions regarding the OP's perspective/situation... but, I don't think anybody is really complaining about putting in >80hrs in scenarios where they're actually needed... it's the pervasive mentality of "hey, stay in the hospital and work on X, Y, and Z for the hell of it because when *I* was a resident yada, yada... and if you leave before Xpm, even if your responsibilities are taken care of, you're less of a man".

3. I'm all for paying my dues and paying respect to those who came before me. I truly believe that we are "standing on the shoulders of giants" in this profession. The pioneers of this specialty were/are phenomenal people that did amazing things... and none of us would make it far in this field without our mentors. That said, the argument/mentality that "this is how it's always been done" is asinine, and doesn't fly ANYwhere in "the real world" in ANY context. Times, circumstances, and rules change.

4. As has been said already, the work hour restrictions are bound by the contract, handed down and enforced by the ACGME, and to be adhered to by the programs. Current residents didn't ask for the restrictions or create them. It's not the fault of the current ortho residents that they exist. Yet residents are being treated as if it is their fault. The animosity that I've seen it create between attendings and residents at some programs is unfortunate.

This is obviously a very sensitive topic as you can see from the initial post to all of the subsquent posts. Here are my 2 cents on this very important topic:

1) Work hour restrictions are very real (what I mean by this is that for years other parts of the country were not really addressing them even though they have been in place for many years in NYC due to the Libby Zion case; as an aside if you're interested in history that is where the Bell commission rules came from which led to many of the modern work hour restrictions)

2) Your job as a resident in training is to inform your chief residents of work hour violations. The chief resident's responsibility is to then ensure that there are no work hour violations. If that chain of command does not work then you have to go to the Program Director and/or Department Chairman. If that chain of command is not available to you (because of fear of retribution, etc...) you're left with no other outlet than to go to the DIO (Designated Institutional Official) who typically oversees the GMEC (Graduate Medical Education Committee) - the oversight committee for residents, work hours, etc...

3) If you are uncomfortable with that pathway then your other opportunity is on the ACGME Anonymous Resident's Survery which every program's residents must fill out on an annual basis. If you have tried appropriate communication pathways and failed I don't really know of any other pathways for you to choose. Remember that this survey's outcomes are critically evaluated by the RRC during site visits, the GMEC in internal reviews, and ultimately by the department if there are significant "red flags" raised.

I hope this has helped answer some of your questions -

wnl

Dr. Levine already put this one to bed as far as the question from the origional poster.

However, a point to be emphasized in what he said has to do with the origin of the work hour restrictions. A lot of what was said above on both sides is focused on the resident. Unfortunately, I think that misses the point. It is no more about being macho, "passionate", "professional" or having great character than it is about residents having a better lifestyle. On the contrary this all came about, as alluded to by Dr. Levine, from concern about patient safety. Remember those people?

"Sucking it up" may be good for junior residents in the short run, but what about the patients? If it's to be all about the residents, then what about those junior residents who will be abused in the long run when no one has the guts to speak out? I think there are definately ways to address this without destroying a program as mentioned above. I also think there is a duty to do so through the appropriate channels, which in the majority of cases will not hurt the program or the junior residents and should certainly help the patients.

When I take care of a patient in the ER in the middle of the night and then show up the next morning to get them ready for surgery the parents (at the peds hospital) sometimes ask with a bit of concern, "Are you still here?" "Did you get any sleep last night?" They're not feeling sorry for me that I might be getting abused as a resident. They're not asking if I'm dedicated, passionate, macho or showing my elders respect by working long hours. They're asking if I'm going to screw their kid up because I'm tired. I usually try to reassure them that I'm not tired, I feel fine and we do this all the time. That's what the work hours are about. It's not about the residents. There can be problems created by the work hours for patient safety in the form of hand-offs, etc. However, here again, if the patient is put first, the hand-offs are thorough and patients get seamless care by adequately (loose term) rested residents. I've seen it work (and not work). Yes, sleep deprivation affects judgement (I've involuntarily been part of such a study).

I'm fortunate to be at a program where we do conform to the restrictions, and frankly I don't think it's that hard to do. Yes, we occasionally go over hours and have problems, but that's the exception, not the rule. I really think any program that truly wants to comply can find a way to do it. There are non-program-destructive ways to address problems that really should be used rather than "sucking it up". Turning a blind eye may seem tough and dedicated, but it is essentially very selfish.

Personally, I'd rather have a well rested orthopod taking care of my loved ones rather than the guy who is going for days without rest either to fatten the pocket book or just to show he can.

I agree whole-heartedly with jdoc, but the only thing the work hours have shown is a slightly higher mortality rate in stroke patients. Likely due to handing off patients...which is going to increase now that a lot of programs are prob going to go to a moonlighting system due to the new work restrictions.

Macho, passionate, whatever. My problem with the original poster is not reporting the hours violations. Its that he/she is only willing to do it AFTER he/she graduates and screw over his junior residents who have worked just as hard or harder than him/her to get where they are.