The common perception is less hours = less tired doctors = less medical errors. However, what also is happening is that we are getting lesser-trained physicians:
The 405 regulations mean residents spend at least 25 percent less time in the hospital. As one doctor who just completed his training put it to me, a five-year surgical residency has suddenly become the equivalent of a three-year one.
PointofLaw.com observes:
The problem is one of scarcity; we could certainly have more medical safety, getting the best of both reduced hours and extensive supervision, by devoting more social resources to health care, but in a world without free lunches, we as a society might rationally prefer to spend our money elsewhere: we can’t devote 100% of GDP to rooting out the last medical error. There are cheap ways to improve medical safety, and there are expensive ways to improve medical safety, and increasing staffing levels falls in the latter category. It’s too soon to tell whether the new hour rules will be a net gain or a net loss.
Related posts:
- Poll: Are the Institute of Medicine’s recommended restrictions on residents’ work hours good for medicine?
- Restricting resident work hours forces doctors to lie, and other unintended consequences of the 80-hour work week
- Shortening work hours, lengthening residency
- Restricting resident work hours leads to a shortage of surgeons
- Resident work hours: An alternative view
- The consequences of limiting resident work-hours
- Surgeons don’t receive enough training when resident work-hours are capped
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{ 24 comments }
One local medical group I know is having difficulty finding another surgical partner to join the practice. The two general surgeons do it all — vascular, colorectal, etc…. They have found that those coming out of residency can’t do these things so they continue their 3 year long search for a compatable partner.
Want to share the numbers that suggest that increased staffing levels is an expensive way to go? Running the numbers show that increased nursing staffing levels in units where research shows better outcomes yields a net cost reduction.
Elliott, I’d be very interested in seeing the study that says increasing nursing staffing levels reduces costs. Please email to me.
Residency means just that, you reside in the hospital. The caliber of surgical residents in todays graduating classes are very weak. On the flip side I am sure they will know how to type and work with an EHR!
Reducing work hours in a pediatric intensive care unit didn’t net any substantial effect. http://pediatrics.jwatch.org/cgi/content/full/2004/1129/1
The residents had 20 fewer hours of duty during the week, requiring an extra resident to cover the staffing needs (this resident of course no gaining experience elsewhere in the hospital that he otherwise would have). Their sleep logs showed that they only gained not quite one extra hour of sleep during each week. Their rate of impending errors did improve for those on the lighter schedule, but this did not translate into effect for the patient, because all errors, whether by the tired, or less tired residents were appropriately caught by the system of supervising senior residents and attending physicians.
It cost a bundle to institute, cost the residents training time and experience, and did not appear to alter outcome. It did offer them 19 hours extra time during the week of personal time. I wonder how wisely that was spent, since sleep was not one of the beneficiaries of that found time.
“Hospitals that increase their nurse staffing ratios either across all units or within individual units have reason to be concerned about the impact of such steps on their finances. However, a new study finds that increased staffing of RNs does not significantly decrease a hospital’s profit, even though it boosts the hospital’s operating costs. A 1-percent increase in RN full-time equivalents increased operating expenses by about 0.25 percent but resulted in no statistically significant effect on profit margins. In contrast, higher levels of non-nurse staffing caused higher operating expenses as well as lower profits.21″
http://www.ahrq.gov/research/nursestaffing/nursestaff.htm
The above quote only refers to hospital costs and not the costs to society and the patient. The numbers for post-surgical pneumonia are a slam dunk. For every 10-20 hours of additional nurse staffing time (depending on the study), one post-surgical pneumonia case does not occur. That case costs 20-30k to treat sot for a 1k-2k investement you get at least a 10-fold payback. That’s not even counting the plusses from preventing UTI’s, less post-surgical mortality, and fewer heart attacks to name a few.
Common misperception is that more hours spent in hospital = more training, more learning, etc.
I can promise you that when you are on the end of a 36 hour shift, you aint learnin jack shit. Your brain is shut down by that time.
So all this crap about staying in the hospital longer to “learn more” is pure bullshit. Besides, the vast majority of resident’s time is devoted to BS scutwork that has zero educational value.
“Besides, the vast majority of resident’s time is devoted to BS scutwork that has zero educational value”
I’ve got news for you. That “scutwork” is also what you will be doing in private practice (unless you are a university attending…then the resident does it). I’ve trained under both systems and from what I can tell today’s residents are by and large a bunch of clock-watchers. The sad fact is most of these guys don’t understand how this compares with real world medicine after residency/fellowship. It will be a real wake up call after training.
I agree, the people coming out now do not have the surgical or clinical skills that I though of as common. I trained at Charity in the 70’s and some of most vivid learning experiences were in the long hours when you decide whether the patients safety and comfort are more important than your own rest. I later was the only ob in a small town and I can assure you that knowing your limitations and capabilities are best learned early. If you cant take the stress of fatigue, take another job. The new people are more selfish and less concerned with the patients welfare. But they are better qualified for the coming of socialized “it is 5 oclock and I’m out of here” style of medicine.
Agreed. Today’s residents are a bunch of whining babies.
Agreed. Today’s residents are a bunch of whining babies.
Who’s whining now?
Wait just a minute…
All the doctors are in cahoots when managed care or government payers conspire to keep their earnings low and below their fair market value.
Yet, when residency programs conspire to keep resident wages low and below what they would be in a free market, the residents are labeled as lazy. How is this not hypocritical? It seems to me that the older generations of physicians do just as much complaining about being overworked and underpaid as residents do.
“Who’s whining now?”
Actually they are not whining, they are simply stating that today’s residency does not adequately reflect the reality of practice. The RRC will not be around after residency to police your hours in the real world. Not a whine, a simple fact. Medicine is not shift work and the RRC has had the (unintended) consequence of turning all residency programs into shiftwork.
You guys are a bunch of fools.
Nobody is advocating a 9 to 5 work week, just some common sense restrictions. 80 hours seems like a good compromise. 9 to 5 is 40 hours a week, not 80 so quit bitchin
Everytime this is discussed, a bunch of idiots chime in with “well i guess we’ll all go back to 9-5 workdays” as if the only alternative to the old 120 hour work week schedules is a paltry 40 hours.
There is room in the middle between 120 and 40 hour work weeks.
Multiple studies have shown that residents up for 24 hours or longer on a shift are LEGALLY DRUNK in their capacity to make decisions. So i guess you guys must have no problem with a drunk surgeon operating or a drunk resident attending to a patient in respiratory distress.
what arrogant fools you are.
“I’ve got news for you. That “scutwork” is also what you will be doing in private practice (unless you are a university attending…”
So let me get this straight.. You think residents should spend up to 120 hours a week in the hospital just so they can learn how to do scutwork and be “prepared” for the outside world?
What kind of garbage is that? You freely admit that there is zero educational training in working those exhausting schedules, so your comeback is to say “yeah its not educational but its the real world scut so they should have to deal with it?” Please tell me you are joking. Thats the most pathetic argument for longer work hours that I’ve ever heard of.
And again you ignore the impact on patients. I guess you do think its OK for a LEGALLY DRUNK resident to attend to a crashing patient in the ICU?
Quit whining and get back to work. Learn to tie a knot before showing up in the OR and maybe read about the case prior. Some of the very basics that todays residents just flat out ignore…
Had a 2-1/2 year course of treatment from a non-profit hospital’s university-affiliated surgical group several years back. Found the residents to be terrific — far better bedside manners than even the nurses. Also saw after the fact that the notes in my record from the residents were very thorough. Since I have fewer complimentary things to say about the attending, I’ll say nothing on that subject. He gave support to a lot of unpleasant stereotypes about surgeons.
It is obvious the naysayers on this thread have never worked in private practice. This is the truth, unless you are an ER doc, hospitalist, or in a “lifestyle” field you will be expected to take overnight call…period. That’s the way it is. The options are for patient’s/ERdocs needing night services or c/s are A: On call doc B: NO DOC….PERIOD. You will be expected at times to work an inordinate number of hours as an attending. There is no RRC to hold your hand in the real world…period. This is not arrogance or garbage thinking, it is the way it is and to start talking about “shiftwork” for all fields of medicine to correct the present hours issue means the writer has no grasp of economics and the fact that medicare/government payers are actively trying to cut spending wherever possible. “Scutwork” as the anon resident (I assume) derides is part of every private attending’s day to day life. Either accept it or go do something else….period. Your future patient’s will thank you.
I wonder what residents are calling scut work these days. Much of what I did for patient care as a student and resident could have fallen under the rubric of ’scut’ no longer exists for these trainees to do.
After 5 pm (3 at the VA) all phlebotomy was student or resident. Need to get your patient to x-ray, well start pushing the bed. 12 lead EKGs were obtained by getting the machine from the Unit, and putting the electrodes on the patient’s chest. I placed foleys, obtained blood cultures, put needles into just about every place in the body immaginable. Hematocrits were spun on the cetrifuge, urines were spun, stained and examined under the microscope, I could do a Wright stain or H/E in ten minutes for the blood smear or touch prep. Virtually all of this was labeled as scut by many then. Residents now do none of these tasks, and what’s more, they will never be able to do anything for themselves/their patients without continuous handholding from the support staff of their hospital. The only scut that remains is documentation; back in the old days (oh, say 1990) we did all that with ball point pens on paper; same thing they do with their PDAs and rows of terminals at the nursing stations now.
It ain’t scut, it’s patient care. And the peons today are doing a heck of a lot less of it than just a decade ago.
Anon 1:35,
I think the complaints stem more from the issue of compensation than working long hours. I would gladly work 120 hrs/week cleaning hospital bathrooms if you’ll pay me my attending’s salary. It isn’t the amount or menial nature of scut that presents the problem, it’s the fact that residents already earn less than minimum wage, and unlike hourly employees at Burger King who can increase their salary by working more hours, residents venture even further into sub-minimum wage territory with increasing hours.
cdclled:
Let’s get this this straight. If you are a resident than you are in a glorified APPRENTICESHIP. You are not an attending. You are certainly not qualified to take care of patient’s on your own (at least early on). You can call it a conspiracy (which I agree to an extent it is), but the simple fact is without the residency certificate you couldn’t practice in your (sub)specialty and without an internship you can’t practice anything at all. You knew very well beforehand that the hours were lousy and compensation per/hour not great. The idea is to get paid a livable wage while you are learning how to become an independent competent doctor. Certainly it could be more. If you didn’t already know medicare pays the hospitals over 100K per resident per year. If you would have cleaned toilets just because it was an attending wage then very simply you are in the wrong profession. And please cut the comparison to Burger King workers. You residency is a set period of time in which you are making at a minimum of 30-35K per year. After the residency ends you can increase that by a factor of 5-10. The level of “scut” is much less than when I was an intern and frankly the fact is you will be doing “scutwork” as an attending private doctor…get used to it. The fact is you are a resident…. an apprentice in a field with awesome professional responsibility. Not an hourly or shift worker. Trust me your attitude makes me wonder what will happen when I need regular care by doctors.
It is just as irresponsible for residents/interns to perform unnecessary 30-hour shifts of patient care as it would be for them to come to work drunk. Even if studies don’t always show a reduction in medical errors with work hour restrictions, they also don’t show an increase in errors. At least one study shows that objectively, case volume is NOT affected by work hour restriction. Here’s another study. So if there is no real benefit in working longer hours and having burned-out, chronically sleep deprived residents, why put anyone through it? Why not allow them to be good parents, husbands, wives, students, etc while learning to be doctors, or at least allow them to exercise and maintain a healthy lifestyle and positive outlook? Yes, they will have long hours and call nights once they are in the “real world”, but is this good justification for them to abuse their health right now?
Do you think there is a problem with nurses working only 12-hour shifts? There are studies that show that longer nursing shifts have a deleterious effect on patient care.
Should airline pilots “put the passengers first” and fly 36 hours in a row with no sleep? Would that really be “putting the passengers first”?
The older doctors are in the mindset of “I did it, so they should do it too”, as if it is some sort of hazing ritual. Hazing isn’t a good enough reason to make decisions this important.
“I trained at Charity in the 70’s and some of most vivid learning experiences were in the long hours when you decide whether the patients safety and comfort are more important than your own rest.”
You know it would be one thing if that were a rarity, but since it’s not, there is a problem with the system. Most people went to medical school to be doctors not martyrs. Don’t force your desire to purge your percieved sins on the rest of us. And frankily, you aren’t helping patients with the machismo.
“I later was the only ob in a small town and I can assure you that knowing your limitations and capabilities are best learned early. If you cant take the stress of fatigue, take another job.”
You gonna pay my loans off?
Finally, this is getting to be enough. A significant number of older docs on this forum continue to harp on their younger colleagues. In my experience as a chief surgical resident, the "worst" surgeons I've seen are mostly the older docs who operate rarely, and are not up to date on the appropriate medical management of patients. As a chief resident, I have had to constantly "de-privatize" patient in our large academic medical center (with a large number of private attendings who have admitting privilages). These folks keep griping about the resident hours, while their own post-op and medical care is substandard and inappropriate (DVT prophylaxis, post-op pulmonary edema issues, inaapropriate overloading of CHF patients, and overall outdated and innaproprite "clinical judgment"). Overall, when my frineds and family ask me for doc recs, i usually say "just do not get anyone >10yrs out from residency unless you know that they keep up with current evidence and guidelines.
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