56 Hour Work Week Is On The Horizon
The Committee on Optimizing Graduate Medical Trainee Hours and Work Schedules from the Institute of Medicine in Washington, DC is making their final report in nine months and recommend decreasing maximum work hours from 80 to 56 per week. That’s the inside word, anyway.
All I can say is about f’ing time.
It looks like strong support for the care of patients as well as the care of those providing that care is fueling this fire, and I believe the old-schools are probably shaking in their boots right now. This rule change looks to be garnering quite a bit of support.
Additionally, training programs consistently violating the rules as if they’re part of some game probably have a lot to do with the proposed rule changes as well:
Furthermore, we know that despite rules being put in place in 2003 to govern resident work schedules that the culture and traditions remain very strong. What we need are some levers—maybe even some financial levers—to make it easier for people to do the right thing.
Like I said in a post way back — it’s all about the Benjamins. On one hand this could mean yanking funding and even hefty fines (i.e. hundreds of thousands to millions) for training programs that don’t play nice this time around. On the other hand, “levers” could also mean an increase in funding to those programs who are rule-abiding citizens. Either way, it’s about f’ing time.
The primary task of this committee will be to focus on four areas:
- Synthesis of the current evidence base on graduate medical trainees hours and works schedules and their impact on safety.
- Identification and development of strategies, practices, interventions, and tools that can be used to implement reasonable work hours.
- Analysis of both the potential benefits and harms of updating work hours and schedules.
- Short- and long-term recommendations for action by various stakeholders and interim strategies and policies for implementing these recommendations.
According to the thread at SDN, the only problem yet to be tackled is length of training. But, it’s a big one.
I’d say that many people are willing to put up with the extra-long work hours in order to be done with an Internal Medicine residency (for example) in three years. However, there are undoubtedly countless others who would prefer to live a more “normal” state of being and extend training by a year or two.
I guess it really all boils down to how much you really want it, but I see this coming out into the light sooner rather than later. No matter how you slice it, “only” 80 hours per week is the biggest joke I’ve seen in a long damn time.
Extending the residency? Man, I don’t know about that one. Also, 56 hours a week may work out for derm or path, but it sure as hell won’t do for surgery or medicine.
Good grief! 80 hours a week?! That’s 11 hours a day, seven days a week. If you get a weekend, that’s 16 hours a day. If I tried to do that I’d screw up like crazy. Speaking from the perspective of a potential patient, that seems like a nightmare and a prescription for disaster. Not even truck drivers are allowed to work that much without a break.
Finally the States start to the European light! The EU mandates 56 hour work week maximums for all doctors/trainees. This can be extended to 70 hrs/wk with written consent from the physician; not sure about trainees.
It’ll be interesting to see if training programs get extended; my guess is perhaps by a year, but not by two.
As for the idiot who thinks that “80 hours doesn’t fly for surgery or medicine” I really wonder as to how much new information you’re learning/retaining when you’re on hour 26 of a 36 hour shift. Not a whole lot I bet..Oh, and then you get to do it again and again and again. Nothing like q3 call to see all the “interesting cases”. What an education!
Redfox, where do you come off insulting someone you disagree with? I never said 80 hours won’t do for surgery and medicine. I think that six nine-hour shifts per week simply isn’t enough to see all the cases a surgical resident should see. The only method possible is to extend the time of residencies, which would be absolutely horrendous, considering the ever-growing interest and loss of potential income.
As a soon-to-be med student, I have some mixed feelings about this prospect… One the one hand, I’ve never heard anything but horror stories about the grueling schedule of residency training–even from physicians who trained after after they enacted the 80 hour workweek regulations. But at the same time, I agree with those who have said that 56 hours a week just might not be enough time to learn everything you need to learn; the prospect of having to add extra years onto residency training to make up for that shortfall seems like a situation where you’re robbing from Peter to pay Paul.
Hoover, would you be interested in post-graduate medical education if the hours were reduced? Just curious.
TheMemoirist,
Nope, I wouldn’t be interested in it at all. The hours are only the tip of the iceberg for me.
I dislike the medicine “atmosphere” so much I wouldn’t spend an hour a day conversing with attendings or breathing the sterile stench of the hospital air.
Just thinking….
If max hours were cut to 56, would there really have to be an extension in training time? Or could you just cut 24 hours per week of useless scut work? This question applies to both med school and residency.
I’m pretty sure fetching coffee, making copies, holding retractors, disimpacting the 9,457th old person, acting as phlebotomist for the billionth time, standing around for hours waiting for attendings to show up for rounds, etc etc etc etc and etc do very little educationally for student or resident.
Not to mention the fact that most people I know do not retain anything when they’ve been up for 24 hours straight much less 36. (Remember how you were always told that getting a good night sleep would yield you better results than last minute all night cramming?) So you can pretty much bet that 6-12 hours of any call night are practically worthless as far as training goes. Heck, if you’re taking Q3 call that’s 24 hours a week right there where you are probably not learning anything but just going bleary-eyed through the motions.
Isn’t it possible that the 56 hour work week would simply force medical schools and hospitals to utilize student/resident time better, and use people like secretaries, phlebotomists, techs, and food service workers to do the jobs for which they are paid?
To finalize with an example: If you made a major league staring pitcher throw 150 pitches per day in the name of “training”, would he become a better pitcher? Of course not! He’d ruin his arm and actually get worse. So at some point a max value is reached beyond which further work is pointless and actually counterproductive. I’m not so sure medical training isn’t operating in just that mode.
It amazes me that an act of Congress was necessary to get the work week changed for residents to only 80 hours. I realized over the past week that no other profession gladly puts in so many hours, is constantly insulted, and uses a backwards ass paper-based records system like medicine does.
This is a natural outgrowth of the governmentally imposed licensing restrictions. Every time the state intervenes to try to correct what it casts as a problem, it creates more disruptions for which it will claim responsibility and seek to amend with more intervention. The government has no place dictating the minimum or maximum number of hours a person can work, but once it has set a floor, it is virtually inevitable that will set a cap, and vice versa. Only a competitive marketplace free of state restrictions on voluntary contracts will produce solutions that satisfy the needs of employers, employees and customers. This will not be an unqualified boon to future doctors.
if the government shouldnt set hours for your residency it shouldnt pay for your residency either.
S.s, if only market forces were at work for the salaries of residents, they sure as hell wouldn’t be $40k.
Something I’ve been wondering lately is, what exactly happens if you just don’t do a residency and practice after your internship? If you’re spending so much time as mostly an underpaid scut-monkey and learn everything by seeing patients, is there an enormous downside with striking out on your own in urgent care or something? If PA’s and NP’s get away with it all the time with much less training, what’s stopping us? Are there really enormous legal and financial barriers stopping doctors, or is it just one more instance of most trainees being beat over the head enough times that they never question the status quo?
56 hrs may be ok for medicine, but I feel like my training is already endangered in surgery with 80 hrs. 56 hrs would mean we’d be forced to work in three shifts per day, instead of two as we do now. Surgeries happen usually in the first eight hours of the day; thus the two-thirds of the residents obliged to work the other sixteen hours of the day for the sake of no one spending too long in the hospital would indeed be doing purely scut work. As it is, I don’t transport patients except in an emergency; I don’t draw blood except when a femoral stick is needed; case managers arrange nursin home placement. The only scut I do is writing discharge orders, and that is legitimate work for a physician rather than a social worker.
If they do this, I would be a strong proponent of surgery opting out of the ACGME entirely.
You folks who don’t want to practice medicine can go and spend a year or two longer and work as litte as you like. I want to practice in the real world, where I need as much experience as possible, and where attending surgeons routinely work 60-80hrs/week.
Thanks for sharing, Alice.
To UBCRedfox: as you can see, a surgical resident agrees that the 80-hour limit (let alone 56 hours) would pose challenges to the training of a competent surgeon. In the future, please refrain from using insults, especially about subjects you obviously have no expertise.
Speaking as a resident it’s about time. 56 hours sounds about right and there is no need to extend residency training by any number of years.
All you need to do is the following.
Most learning takes place on the weekdays. Weekends are usually a skeleton crew and your lucky if your attending even shows up to round instead of just calling you on the phone and asking for lab results from the comfort of his or her bed every Saturday and Sunday morning. Solution is to have the hospatilist service cover the patients over the weekend.
EMRs. No more bloated patient charts. Everything should be on a computer where we can copy and edit yesterdays note. The program should also fill in the lab values for us. About 80% of my time rounding is spent looking up lab values or writing the same information from the previous note. Of course I’m sure someone is going to tell me that having to wade through paper lab values and writing everything out by hand is of some educational value to me. Good thing the govt is mandating that you have an EMR program if you want to get paid by medicare. Next I hope they force all hospitals to go paperless.
Eliminate overnight call. There is no reason why any residency program should be making you work 30 hours in a row. There should be a night float system or some alternative (if you are on call Monday night then you get Monday morning and afternoon off).
If you simply do these three things your hours drop down to around 56.
I looked into this and it doesn’t look like 56 hours is coming anytime soon. Instead, they may institute mandatory naps.
http://www.cleveland.com/medical/index.ssf/2008/05/residents_expecting_to_work_fe.html
Nice research Chris. Naps lol…wow. It wouldn’t surprise me, though.
“Everything should be on a computer where we can copy and edit yesterdays note.”
Where I did my internship, this was not allowed by the attendings. After finishing my work at the hospital, I would spend at least 3-4 hours writing up “fresh” SOAP notes and “convincing, powerful, thorough” assessment and plan. I hated it so much that I left Int Med and am now doing Pathology.
Hi. I felt I had to weigh in on this discussion. First, I finished my neurosurgery residency 1 year ago June, 2007. So, I was a resident before the 2003 work hour restriction, after the restriction when hours were reduced to 80/88 per week.
I think I can offer some perspective from the surgical side. My opinions have a lot of merit because I’ve gone through that transition from college student (and knowing no medical knowledge) to being a fully trained surgeon. I’ve been a junior resident doing “scut work” pre-work hour restrictions, and I’ve worked as a mid level and senior/chief resident post-work hour restriction.
For the most part, Neurosurgical training is 7 years long beyond residency. This new 56 hour work week recommendation would necessitate extending a neurosurgical residency by at least a year… maybe two. Unfortunately, it just takes longer to make a good surgeon than a good ward physician (internal medicine doc etc).
I worked an average of 120-140 hours per week for my PGY2 year as a neurosurgical resident. It was grueling. I did a lot of scut work and there was definitely wasted time. These were the bad things of the old ways. The good thing about the old ways was this… if you had a patient who was going to decompensate at 2am while you were on-call you were the one who had to take care of them. That care… (a decompensating patient) is always difficult and involved. You started to learn subtle signs that patients “might” deteriorate in a few hours, and you would learn to make manuevers to prevent that deterioration earlier in the day or evening. That work you did to “prevent” the deterioration was always less “involved” than the work you’d have to do when the patient was actually decompensating… not to mention it was safer and better for the patient to prevent the episode. You felt ownership for that patient… not only because it is the right philosophy, but because YOU will be the one dealing with the consequences of all of your actions from the daytime. As a result, I used to make sure my patients were in “tip-top” shape during the day/early evening to prevent problems at 2am (on the hope that I could sleep for 2 hours that night while on call).
Now, let me fast forward to the post-work hours restriction. Now, the junior resident who works during the day does not have to be there at night taking care of this decompensating patient. He doesn’t get to see the consequences of his actions directly (yes, he hears about them the next day… but it is not the same). Naturally, he is not as detail oriented in making sure his patients are in “tip top” shape because someone else is coming in a night who will take care of any problems that develop. This is the classic “shift worker” mentality that people use as an argument against work hour restrictions. There is a lack of continuity of care.
With all that being said… unfortunately 120-140 hours per week is insane… I know… I did it. So, while I think the 80 hour work week causes some problems like I mentioned above in resident education… I think it makes work hours “humane” compared to what they were when I was working 120-140 hours per week (only 168 hours in a week btw). And it is clearly here to stay.
Reducing work hours further, for surgical education, would be a disaster. As it is… that resident who is here all night and not here during the day doesn’t get to operate. As a neurosurgical chief resident, y our job is to become competent and efficient in your surgical procedures. That means doing them over and over and over and over. You can intellectually know how to do a procedure. You can learn that very quickly. But to become technically proficient, to be good at it, and efficient… it takes practice practice practice. Something that reducing work hours to 56 hours per week would prevent. When I was a chief resident my job was 1) run the service, make sure all the inpatients were getting adequate care… that meant rounding in the AM before going to the OR and teaching the junior residents what to do for each patient. In order to round on 40-60 patients (yep, that’s how many we’d have on our service at once) we’d have to start around 6am to finish by 7am in order to start my OR cases by 7am. Medicine residents would be amazed at the ability to round on 60 patients in 1 hour but as neurosurgeons we learn how to do this… and without making mistakes. Because mistakes are not acceptable. Usually what that means however is to be efficient on rounds during that 1 hour… the junior residents would have to have all the information about the patients right on the tips of their tongues or at their fingertips. When I rounded it was not acceptable to go look something up on a patient during rounds and not to be prepared for rounds. It wasn’t that I was trying to make my junior work hard… it was I just didn’t have the time to spend looking stuff up on rounds. Otherwise, we’d just have to start rounds even earlier. Rounds are finished, junior residents have their “task lists” for the day, and I go off to the OR.
2) Operate all day long. We’d do 1-4 surgeries per day depending on how long each surgery takes. 7am until whenever we are done. Some days that is 4pm (rarely) most days that means operating until 7pm or later… lets just assume 7pm.
3) Check on post-op patients (have to go see how patients I operated on earlier in the day are doing now, make sure no complications that would necessitate going back to the OR)
4) Discuss all the patients on the service with the junior residents, be aware of the changes updates, squash problems, suggest treatment options, review new head CT’s, MRI’s etc.
5) Go Home (Q2 home call (me and the other chief resident shared this call… thus Q2)
So if you are keeping track… that means AT LEAST 1 hour of work after the OR is finished. Ie… 6am-8pm 5 days per week. That is 70 hours per week. Now remember I’m Q2 weekends… so I have to come in and round, operate on any emergencies or urgencies for the weekend (usually at least 1 surgery or more per weekend) That adds at least 10 hours every 2 weeks. Now we are up to 75 hours per week. All I need is one emergent surgery at 2am at any point during that week while I’m on-call and bam… I’m at 80 hours per week.
So, I’m not sure where I can cut the fat out of that schedule to reduce to 56 hours. I’d have to give up a whole day operating in the OR… which would mean my ability as a surgeon would take a hit. That is not acceptable to us as surgeons.
I’m busy… more to come… maybe.
um… sorry for the error.. neurosurgical training is not 7 years beyond residency… it is 7 years OF residency. Typo.
My last night of general surgical residency (4 years way back then) I basically lost a patient in the ED (trauma multiple, multiple stab wounds) because I was simply not thinking clearly due to lack of sleep. I’ll never forget the feeling when I had to tell his fiance that I had f’ed up. I blamed myself for years for until I realized it was primarily overwhelming fatigue that caused my errors in judgement. So all you gung ho surgical residents out there remember: If you’re as cocky as I was and think you can take it no matter what, think again – last night, last patient, all ORs tied up, no juniors to help, it’s just you and a patient who came in talking and was gone 30 minutes later. Maybe if I had been a little less fatigued…maybe…
Why are people saying that 56 hours will ruin us??? Why would you say such a thing? Lol check out this website about European Residencies….
http://findarticles.com/p/articles/mi_m0999/is_7222_319/ai_58358816
They work 56 hour limit BY LAW, and what’s funnier is they were proposing to set it down to 48 hours. LOL hilarious. If you think 56 hours will ruin the world, then obviously you don’t think very highly of European Medicine. I think they have great doctors.
I have read through these comments and have seen some good points. I also am enjoying medical training and would like to point one thing out to the surgeons and those against decreasing resident work hours.
You say that it will take away from your ability to see a wide variety of cases, from your ability to stay up all day and night to take care of patient problems around the clock, this is true. You acknowledge that fatigue and resident error are problems that exist, as necessary evils it seems. But to add on years is not acceptable and to reduce hours hurts your progression as surgeons.
However, we are missing one important point which stems from the errors and oversights caused by fatigued and overworked residents (which is well documented in the literature). The point that so many seem to gloss over is the care of the patient, which should be ultimate. It should come before all else. If the price to reduce resident error and improve patient outcomes is adding on a year, or two, of residency (at 56 hour weeks) to get that experience that is so necessary, then so be it. The decision to forego patient well-being in an effort to learn everything you need to learn in as few years as possible is unacceptable.
The point is that the hours now are hurting our patients and THAT needs to change.