Wednesday, March 30, 2011

The Doc Will Not See You Right Now

First of all, if any well versed social media docs read this, please advise me on how to protect myself from scrutiny from my own institution (not so social media friendly) and the rules that I mention.

Secondly, I apologize to any readers that don't care about medicine/surgery/residency. This is a long rant on how my world is changing. Feel free to read on, I provide a lot of background information for you to attempt to empathize, if you dare to try.

This morning, during M and M conference, I tweeted about my frustrations with the new intern hours and promised a later blog. I have cooled off for now, but that won't last long.

Some background information:

I am a second year in general surgery residency in a community-based program. I work anywhere from 60-80 hours a week depending on how many days off fall in that week. The current rules state:

  • Maximum 80 hours worked per week (averaged over 4 weeks)
  • In house call shall not exceed an average of every 3rd night (averaged over 4 weeks)
  • Must have one day off per week, a full 24 hours without duty (averaged over 4 weeks)
  • Can only see new patients for a maximum of 24 hours
  • Maximum of 6 hours "post-call" to wrap up and get out of there basically
    • That means our maximum shift is 30 hours long which must be followed by a 10 hour break of absolutely no duty...not including driving time.

I will admit that there are a few occasions where I have worked well beyond the 80 hour limit, but averaged over 4 weeks I think the worst it's ever been is 79 hours. (And I, unlike many residents around the country, don't lie about my hours because I'm sort of interested in what they actually are.) I typically arrive between 5:30 and 7am depending on the rotation. Some days I leave at 3pm, some days 5 or 6pm, and other days later. Post call I usually plan on being there until noon, period. It's not THAT bad. Granted, our social lives still suffer (not to the extent that they did prior to the work hour restrictions). That's right, there used to be absolutely no work hour restrictions for resident physicians. It was common practice for one to work for 24 hours, be off for anywhere from 5-24 hours and be back on for 24 hours with no true days off. Believe me, MOST post call days don't feel like a day off--certainly not when you've been up all night.

Yes, I have fallen ill of the victim mentality on more than one occasion. I get sad that I can't enjoy Sunday brunch EVERY weekend, or that I can't just join the girls for lunch on any given day, or that I can't stay up late tonight because I am on call tomorrow, or that I can't enjoy happy hour on more than the very rare occasion. However, those are small sacrifices for the education I am receiving to be able to adequately and competently take care of my patients on my own when I'm done after five years--and with good technical skills to boot.

In our program, we average around 1000-1100 cases when we are finished with five years. That's a great number! Only 750 are required to qualify for the board examination. So in other words, we operate A LOT. This was a huge part of my placing this program at the top of my list. I wanted to know that I would be comfortable in an OR alone after five years without the NEED for a fellowship. I didn't want a program stuck in the old hierarchial system that prevents most lower level residents from seeing the OR. I wanted a full five years of surgical training, not four and certainly not three.

More background info: in our program, we take in house trauma/acute surgical call every fourth night for about 8 months a year (all the way through)! Chiefs occasionally have the opportunity for home call IF no one on their team is taking vacation. The only times we don't take q4 TRAUMA call (doesn't mean we aren't taking q4 in house call for something else) are:

  • As an intern:
    • Burns
    • ICU
    • Private hospital (without trauma) for two months
    • Possibly an anesthesia month. 
  • As a 2nd year: 
    • ICU
    • Private hospital (without trauma) for one or two months
    • Pediatrics
  • As a 3rd year
    • Colorectal (home call)
    • Cardiothoracic
    • Pediatrics
    • "Pre-call" at our county hospital. 
  • As a 4th year
    • Colorectal for two months
    • Cardiothoracic 
  • As a 5th year
    • One or two months at the private hospital. 
Otherwise, we cover a regular service, usually comprised of either bread-and-butter general surgery, surgical oncology, or vascular surgery. We rotate at private hospital, TWO Level 1 trauma centers (top of the chain trauma centers), and a pediatrics hospital during our five years. Each rotation is one month long.

  • "Main" hospital (also a Level 1 trauma center) 
    • Five people on a team
      • Chief
      • PGY-4
      • PGY-3 typically covers ICU at night
      • PGY-2 typically covers ER
      • PGY-1 usually a surgical intern covers floor at night
    • Four teams
    • Q4 in house call for trauma/acute surgery/floor calls and ICU for all services
  • County hospital (a Level 1 trauma center)
    • Four people on a team
      • Chief (PGY-4 or PGY-5)
      • Junior (PGY-3 or PGY-2) typically covers ICU at night
      • Interns (one surgical and one medicine/transitional/orthopedics intern) cover ER
    • Four teams
    • Q4 in house call for trauma/acute surgery/floor calls and ICU for all services
  • Private hospital 
    • Four people on a team: Chief, a junior, and two interns
    • Average Q4 call (home call as a junior or senior) rotates between the four, only one resident on call every night for floor/ER 
    • A "closed" ICU for the most part
  • Pediatrics
    • Two residents at the pediatrics hospital
    • Q4 in house call for floor and ER
  • Colorectal service
    • Two residents
    • Home call for floor/ER
  • Cardiothoracic
    • One resident
    • Home call for floor/ER
  • Transplant
    • One resident
    • Home call
  • Burns
    • One resident (from our program), one 2nd year and 4th and one or two more interns from another program
    • Q3-Q4 in house call for floor/ICU/ER, only one resident on call each night
  • County hospital ICU
    • One resident
    • Takes Q4 in house call for the ICU
  • "Main" hospital ICU
    • One or two residents
    • No call
  •  County hospital "pre-call"
    • One resident who covers "specialty" service cases during the day: vascular, breast, CT 
    • No call
  • Anesthesia
    • One intern
    • No call
So even though we have 8-9 residents a year, we get pretty spread out among services. Of note, we currently have no specific trauma/acute care service nor do we have a night float system.

The new rules coming up (and forgive me I don't know ALL of them):

  • Interns (PGY-1) can work a maximum of 16 hours in a shift
  • Interns must have 8 hours off between shifts
  • Cannot exceed more than 80 hours per week
  • Required full day (24 hours) off per week
  • Interns cannot take more than three months a year of "night float" call
  • All residents have a maximum of 4 hours post call (total max of 28 hours per shift)

How has our program decided to address this? (I'd love to know others' new plans too). Well, interns will just be working from 6am to 6pm. That's only 12 hours. I thought they were allowed a full 16??? Interns will not be taking night call, period.

That means:

  • At the main hospital:
    • After 6pm, the 2nd year covering the ER, the 3rd year covering the ICU, and the 4th year who is typically in the OR operating on all those patients the 2nd year has seen in the ER are all now required to make up for one whole person's amount of work. 
    • Our chiefs will not be able to take home call. We will be spread too thin if they aren't there.
    • When someone is on vacation, that means only THREE residents will be available as one will be long out of town and one won't be allowed to work. With ~40-45 residents in our program, you can almost plan that there are at least 3 weeks of every month (at the main hospital where we have the biggest team) where SOMEONE is on vacation. 
    • Patients on the floor will not be responded to in such a timely manner because the other residents will all be busy in the ER, ICU, or OR and unable to leave their position immediately.
    • Less OR time for everyone. Cases go uncovered. 
  • At the county hospital:
    • There is only one resident in the ER after 6pm--being someone that is not a resident actually trained by our program (or one that even cares about general surgery). 
    • No extra intern to place lines, chest tubes, etc. requiring the junior level resident to stay out of the OR. 
    • Consults will not be seen in a timely manner. We will likely be seeing consults well into our "post call" hours.
    • Any elective cases will not go after 6pm. No more "clearing the board" and doing chole's at 1am UNLESS it's absolutely necessary because we simply don't have the man power to keep extra people in the OR and off the floor/out of the ER.
    • The wheels will fall off. Less OR time for everyone. Cases DON'T go. Patient's don't get their operation.
  • At the private hospital:
    • Only two of the residents will be able to take call at night. Currently chief residents typically cover nights that we don't have attending staff on ER call. Therefore, this will become a home call situation and chiefs will not be able to take these 4 calls a month. 
    • Interns will not be seeing patients at night to work them up to operate on them the next day. If they did, they would have to leave before their case went.
    • Less OR time for interns but not more OR time for everyone else because they will already be working. 
    • Also remember, we can't take more than q3 call, so we can't just take more calls as juniors or seniors.
  • Transplant
    • Interns can't take night call. No organ donations for you!
    • Less OR time.
  • Burns
    • Interns can't take night call. Only two residents to cover call otherwise (and we can't be q2). 
    • Possibly a shift work thing between interns here could work, but STILL not appropriate.
  • Anesthesia
    • No interns on anesthesia. We can't afford to lose the manpower.
  • ICUs
    • Interns can't take night call. They usually don't anyway. We have managed with this in the past. But interns on the basic services aren't around, this will be detrimental.
  • "Pre-call"
    • Possibly turns into a night float system to help teams out. However, this means one less resident around to cover cases during the day.
    • Less OR time. Cases go uncovered.

Every time residents bring this up, we get brushed off. Even though we are the ones that do the work day in and day out, we are told by our administrators that this is how it will be--without lending an ear to concerns. We have often mentioned specific trauma services, a night float system (which I know from experience works very well for at least one other institution, with less residents). We have also mentioned having interns work 6a to 10p or 2p to 6a, or 6p to 12 noon--the full 16 hour shift. No matter what, "post call" no linger exists in an intern's vocabulary. I'm not sure anyone has the right answer, but just taking one or two residents out of play for 12 hours a day--the most terrible idea ever. Eyes glossing over and continued attempts at dismissal of the subject when we mention the so-called "plan" during the most appropriate time, i.e. when a majority of the residents, involved staff, and the department chair are all in the same room and have an hour to spend together, is also terrible.

All in all we fear everything will fall apart. Part of this is due to surgeons' egos and the fact that we all think we know a better way of doing this. Another thing is the culture of residency, especially surgical residency. One expects another to work. And work hard. There already exists a chasm between the physicians that trained without any work hour restrictions and those of us limited to 80 hours. This will provide yet another divide. Poor little interns are going to catch a lot of flack for something that isn't even their fault. A lot of this is fear of change. In my opinion, that is a well warranted fear.

If we don't have manpower, patients don't get seen, studies don't get ordered, drugs don't GED administered, and surgeries don't happen. In the worse case scenario, that means patients die. gloomy, cynical side of me coming out in full force. Concern for patient safety also coming out in full force.

So patients go unseen, and residents don't see them to learn from them. They operate less. They deal with less problems. They see less complications. They work up less patients. They lose out on valuable training time. That means residency has to be lengthened in terms of years. From my understanding, this is how it is done in Europe where many countries have 60 hour or less work week restrictions. Surgical residency is six years or more.

The other bad thing: how will these new docs function when they are faced with 24 hour call alone? I'll let you infer.

All of this in the name of sleep--the other side of the coin. If residents aren't well rested, they make more mistakes. True. Less mistakes to learn from and more opportunity for mistakes when they are faced with a sleepless night later and have never been forced to function under such circumstances.

Other sad fact, each year this will apply to more and more residents at different levels, not just interns. So you are less trained at EVERY level--not just one year.

Any honest 20-something can tell you that more free time away from work does not necessarily equate to sleep or even rest. It often means more dinners out, more happy hours, more brunch-time mimosas, more pick-up kickball games, more nights out with the family, more time visiting friends in other cities, etc. All of those things I miss. Yes, I miss sleep but I do sacrifice some to gain a life. It will be interesting to see if these residents rate their happiness any higher than those of us not subject to the new rules. I fear not. It will also be interesting to see how many of them sleep during those hours off, as opposed to taste the newest brew at the local bar or take the kids to the zoo.

Perhaps we are sacrificing manpower, time for patient care, and education for more time with family or the sandman. On the other hand, perhaps we are sacrificing manpower, time for patient care, and education for more mimosas.


  1. Great post. I wish i had easy answers. Residency work hours cause so many headaches. Keep blogging. Your voice is needed

  2. Christian, thanks for the kudos! Thanks for stopping by and reading!

  3. I'm all for work-life balance, but that seems like taking it to the extreme. It's terrible that the leaders in your program don't seem to be listening to your concerns or appreciating the problems that the new system will create. I'm very lucky in my program in that we have a night float system that allows us to do very little call during the year while still ensuring that we're providing service where it's needed. It seems like a good balance to me (albeit not something that every program can implement, unfortunately).

  4. Great post. I don't know how it's going to work out, but I really wish they'd set up the changes in some sort of randomized way so that we could at least measure whether patients are harmed and if training suffers.


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