Comments on: Restricting resident work hours forces doctors to lie, and other unintended consequences of the 80-hour work week http://www.kevinmd.com/blog/2009/03/restricting-resident-work-hours-forces.html Wed, 15 Feb 2012 00:27:00 +0000 hourly 1 By: Anonymoushttp://www.kevinmd.com/blog/2009/03/restricting-resident-work-hours-forces.html#comment-90209 Anonymous Tue, 10 Mar 2009 23:34:00 +0000 http://clients.emmense.com/kevinmd/2009/03/restricting-resident-work-hours-forces-doctors-to-lie-and-other-unintended-consequences-of-the-80-hour-work-week.html#comment-90209 Anon 9:16<br/><br/>You make me think back and open my eyes to an aspect of this I had not previously considered. It isn't just, or I think even primarily the detailed teaching on rounds that make the internship and residency. It is the detailed teaching by patients. We worked very very long hours as interns, but not all of it running around to attend dozens of patients. I spent more than a few nights spending several hours at the bedside of one unstable patient. I learned a lot about clinical processes as well as the emotional process of dying sitting for hours at the bedside of a single patient titrating morphine and lasix (always in the wee hours).<br/><br/>With a larger service, I would not have that experience which is the core of my clinical instincts today. Anon 9:16

You make me think back and open my eyes to an aspect of this I had not previously considered. It isn’t just, or I think even primarily the detailed teaching on rounds that make the internship and residency. It is the detailed teaching by patients. We worked very very long hours as interns, but not all of it running around to attend dozens of patients. I spent more than a few nights spending several hours at the bedside of one unstable patient. I learned a lot about clinical processes as well as the emotional process of dying sitting for hours at the bedside of a single patient titrating morphine and lasix (always in the wee hours).

With a larger service, I would not have that experience which is the core of my clinical instincts today.

]]> By: Anonymoushttp://www.kevinmd.com/blog/2009/03/restricting-resident-work-hours-forces.html#comment-90183 Anonymous Tue, 10 Mar 2009 02:16:00 +0000 http://clients.emmense.com/kevinmd/2009/03/restricting-resident-work-hours-forces-doctors-to-lie-and-other-unintended-consequences-of-the-80-hour-work-week.html#comment-90183 The restrictions on time are courtesy ACGME, not the government. Hospitals and programs comply with the policy because of studies demonstrating increased mistakes when residents are tired, so if they don't go along they are exposed legally. To that extent, restrictions on student time are absurd, because students have no LEGAL clinical responsibilites ie writing orders. The rule extends to clinical duties; it does not dictate where you are on your own time. If I want to check out my clinical duties and stay with a patient's family that's my business, I just can't perform any clinical functions. The biggest problem with these policies is that they have led to more hand-offs, and I can see from our M&Ms that many sentinel events start there. The other problem everyone has failed to mention is that the policy leads to fewer residents on service at a time, covering far more patients; and that is the other cause of sentinel events I see. Don't get me wrong, I like being out of the hospital and spending time with my family. But when I'm at the hospital I cover way more patients than my attendings did when they were residents, and that is what makes me most uncomfortable. With so many patients it is easy to have 3 or 4 unstable at once, and we don't have the support in house to cover that. The extra work also makes teaching team greatly diminished; we don't talk about the disease process in every patient, we just have to pick 1 or 2 interesting ones and hammer through the others superficially. The older attendings tell us it wasn't always thus; they used to have 6-8 total patients on rounds and would discuss the pathophysiologic process in all of them extensively. We treat many more patients, but the teaching is much more superficial. Example: fewer patients covered in the unit (2-4 as opposed to 6-10) but much more detailed teaching. The restrictions on time are courtesy ACGME, not the government. Hospitals and programs comply with the policy because of studies demonstrating increased mistakes when residents are tired, so if they don't go along they are exposed legally. To that extent, restrictions on student time are absurd, because students have no LEGAL clinical responsibilites ie writing orders. The rule extends to clinical duties; it does not dictate where you are on your own time. If I want to check out my clinical duties and stay with a patient's family that's my business, I just can't perform any clinical functions. The biggest problem with these policies is that they have led to more hand-offs, and I can see from our M&Ms that many sentinel events start there. The other problem everyone has failed to mention is that the policy leads to fewer residents on service at a time, covering far more patients; and that is the other cause of sentinel events I see. Don't get me wrong, I like being out of the hospital and spending time with my family. But when I'm at the hospital I cover way more patients than my attendings did when they were residents, and that is what makes me most uncomfortable. With so many patients it is easy to have 3 or 4 unstable at once, and we don't have the support in house to cover that. The extra work also makes teaching team greatly diminished; we don't talk about the disease process in every patient, we just have to pick 1 or 2 interesting ones and hammer through the others superficially. The older attendings tell us it wasn't always thus; they used to have 6-8 total patients on rounds and would discuss the pathophysiologic process in all of them extensively. We treat many more patients, but the teaching is much more superficial. Example: fewer patients covered in the unit (2-4 as opposed to 6-10) but much more detailed teaching.

]]> By: Bad Medicine, Good Solutionshttp://www.kevinmd.com/blog/2009/03/restricting-resident-work-hours-forces.html#comment-90178 Bad Medicine, Good Solutions Tue, 10 Mar 2009 01:13:00 +0000 http://clients.emmense.com/kevinmd/2009/03/restricting-resident-work-hours-forces-doctors-to-lie-and-other-unintended-consequences-of-the-80-hour-work-week.html#comment-90178 The ineffeciency you speak of stems from government regulation/mandates and cover your a$$ documentation against lawyers. If you can find away to get rid of them, then more will be done. <br/><br/>As for hour documentation, my hospital has badge swipe in systems for the employees, but yet they have a whole seperate other program for the residents which is self reported. People don't want to know the truth. If they did, the residents would swipe in, too. Every one knows that in residency you are supposed to lie. That's why the new idea of dropping down to a 56 hour cap is rediculous. We can't even cap at 80 hours. The ineffeciency you speak of stems from government regulation/mandates and cover your a$$ documentation against lawyers. If you can find away to get rid of them, then more will be done.

As for hour documentation, my hospital has badge swipe in systems for the employees, but yet they have a whole seperate other program for the residents which is self reported. People don’t want to know the truth. If they did, the residents would swipe in, too. Every one knows that in residency you are supposed to lie. That’s why the new idea of dropping down to a 56 hour cap is rediculous. We can’t even cap at 80 hours.

]]> By: Anonymoushttp://www.kevinmd.com/blog/2009/03/restricting-resident-work-hours-forces.html#comment-90173 Anonymous Tue, 10 Mar 2009 00:34:00 +0000 http://clients.emmense.com/kevinmd/2009/03/restricting-resident-work-hours-forces-doctors-to-lie-and-other-unintended-consequences-of-the-80-hour-work-week.html#comment-90173 As a medical student, I was faced with the "lie or cause an awful lot of trouble" quandary in my very first clinical rotation. I went along with the lie choice for a week or so, and then rebelled and went with the "let the chips fall where they may approach" . . . with support from a couple of other students who were in the same pickle. We were threatened with dire consequences that never occurred, patient care was improved, and I don't think that any of us ever regreted it.<br/><br/>Now, more than 20 years later, seeing what ethical depths some have descended to, who just started with the little "necessary" lies, I am more glad than ever that we made the right choice. <br/><br/>A system which "forces" people to lie in order to function is a system which is founded on a lie and should be stressed to the point of bending or breaking by someone with the courage to tell the truth. The "necessary lie" is the process by which systems become and foster evil and the truth the means by which that descent is prevented.<br/><br/>Medicine is supposed to be a profession of gentlemen. Let's keep it that way. As a medical student, I was faced with the “lie or cause an awful lot of trouble” quandary in my very first clinical rotation. I went along with the lie choice for a week or so, and then rebelled and went with the “let the chips fall where they may approach” . . . with support from a couple of other students who were in the same pickle. We were threatened with dire consequences that never occurred, patient care was improved, and I don’t think that any of us ever regreted it.

Now, more than 20 years later, seeing what ethical depths some have descended to, who just started with the little “necessary” lies, I am more glad than ever that we made the right choice.

A system which “forces” people to lie in order to function is a system which is founded on a lie and should be stressed to the point of bending or breaking by someone with the courage to tell the truth. The “necessary lie” is the process by which systems become and foster evil and the truth the means by which that descent is prevented.

Medicine is supposed to be a profession of gentlemen. Let’s keep it that way.

]]> By: Anonymoushttp://www.kevinmd.com/blog/2009/03/restricting-resident-work-hours-forces.html#comment-90168 Anonymous Mon, 09 Mar 2009 19:37:00 +0000 http://clients.emmense.com/kevinmd/2009/03/restricting-resident-work-hours-forces-doctors-to-lie-and-other-unintended-consequences-of-the-80-hour-work-week.html#comment-90168 I think the focus should be on working smarter, not longer. I believe you can get 120/wk training in 80/wk using time wisely and eliminating busy work. This requires rethinking the daily progress note in many institutions, streamlining rounds, VALUABLE education time, a cohesive and easy to access medical record, and for goodness sake just go home if your work is complete and you are being covered. Maybe instead of capping resident hours and hiring more staff to take care of patients, residents could be freed up to take care of those patients with some inspired reorganizing of the system in a shorter amount of time. Accomplish that, take a away the hours cap, and then no one has to feel guilty about taking part in a meaningful patient experience as described above. I think the focus should be on working smarter, not longer. I believe you can get 120/wk training in 80/wk using time wisely and eliminating busy work. This requires rethinking the daily progress note in many institutions, streamlining rounds, VALUABLE education time, a cohesive and easy to access medical record, and for goodness sake just go home if your work is complete and you are being covered. Maybe instead of capping resident hours and hiring more staff to take care of patients, residents could be freed up to take care of those patients with some inspired reorganizing of the system in a shorter amount of time. Accomplish that, take a away the hours cap, and then no one has to feel guilty about taking part in a meaningful patient experience as described above.

]]> By: halfmdhttp://www.kevinmd.com/blog/2009/03/restricting-resident-work-hours-forces.html#comment-90167 halfmd Mon, 09 Mar 2009 19:27:00 +0000 http://clients.emmense.com/kevinmd/2009/03/restricting-resident-work-hours-forces-doctors-to-lie-and-other-unintended-consequences-of-the-80-hour-work-week.html#comment-90167 Residents aren't the only ones who have to lie. At my medical school, students supposedly have work-hour restrictions, too. I pulled 85 hours/week during my first month on surgery and later told the clerkship director that I was within the specified time frame. Residents aren’t the only ones who have to lie. At my medical school, students supposedly have work-hour restrictions, too. I pulled 85 hours/week during my first month on surgery and later told the clerkship director that I was within the specified time frame.

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