Duty-hour regulations do not define me as a doctor

I argue with my father a lot. He works as an intensivist at a community hospital in Indianapolis while I am about to graduate from a highly academic internal medicine program in Chicago. Needless to say, we have very different perspectives.

He sometimes expresses views similar to those written in an article, “When I Was a Resident: How Duty Hour Rules Are Creating a Lost Generation of Physicians.” I started residency the first year that the new intern duty-hour regulations were put into effect. After explaining these rules to my father, he asked me: “How do you guys learn? When I was a resident, we did not have limits to how many patients we saw. I would be working until five or six in the evening on my post-call day and then stay to work a moonlighting shift.” I, then, delightfully asked him if that was before or after penicillin was discovered.

The field of medicine has undergone many changes (yet we still carry pagers, but that’s for another rant), some for better and some for worse. There has been much debate over potential benefits and detriments that come with the changes in duty-hour regulations.  I can only speak to the culture at my own institution, but in my experience, there is one thing that has not changed: The pride we take in our work. This is why I take particular issue with the overly dramatized notions brought up in the aforementioned article.

Now to be clear, this should not be taken as praise for the duty-hour regulations: I am not convinced that they are necessarily beneficial. Instead, this is meant to argue, on behalf of the duty-hour generation of doctors, that we are just as capable as the graduates from before these regulations were implemented. This is a look at my own “when I was a resident” short list, once I graduate at the end of June.

When I was a resident, we (also) took pride in caring for our patients. Because we were restricted by shift-work, we learned to become efficient and prioritize our tasks. Yes, many times we had to pass on duties to our colleagues who came in to relieve us at the end of our shift, but usually the most important things were taken care of. We especially took pride knowing that even once we left the hospital, our patients were being looked after by our trusted colleagues.

When I was a resident, we were taught that medicine is a team sport. We felt personally responsible for our patients and felt a personal responsibility towards each other. We frequently assured our colleagues that we would act on any critical labs, perform any critical procedures, and make any remaining assessments on their patients, because they were not just their patients; they were also our patients. We could go home because our colleagues picked us up. Our colleagues could go home because we picked them up.

When I was a resident, our program prioritized our education. With the re-structuring of the program to comply with duty-hour regulations came a re-structuring of conference schedules to allow maximum attendance. We were afforded increased opportunities for meaningful participation, as we were not burdened by excessive service requirements or post-call fatigue when we attended.

Duty-hour regulations have not made us unmotivated. Duty-hour regulations have not instilled bad habits. Duty-hour regulations have not given us poor work ethic. Most importantly, duty-hours have not made us less educated. What duty-hours have done is change our approach to how we handle our responsibilities, and with repetition, we will become good at caring for our patients in this manner.

On a personal note, I will be starting my pulmonary and critical care fellowship in July after I graduate. I am confident that, despite all these concerns regarding the duty-hour rules I trained under, that I am prepared for this role. I am confident that I have seen and cared for an adequate number of critically ill patients. I am confident that I have acquired sufficient procedural experience during my time in residency.

Maybe I am wrong. Maybe I will start fellowship and realize that I am tired. Maybe I won’t function well after answering my pager all night or maybe I will be have a hard time rounding on all the patients the morning after having to emergently come to the hospital in the middle of the night.

I suppose the next question is should I care? While some attendings have home call for a week at a time, other attendings work on a periodic night-block schedule just like I have trained under. Why should I have to work fatigued when I have a team of people to help me?

Now the truth is, I do care, as I am going into a field where making critical decisions while dealing with fatigue is a common occurrence. I feel confident in my ability to handle this as I myself focused on honing this skill during residency (or because I spent all my mandated time off partying instead of resting). That doesn’t mean, however, that it’s a necessary experience for everybody.

For another resident, with career aspirations of a primarily office based specialty such as endocrinology, I see no reason why they need to develop this skill. Similarly, I probably shouldn’t admit this before I graduate, but I am ill-experienced with knee injections. Does this make me unmotivated? Maybe, but to be fair, I probably wouldn’t have bothered learning it even before the duty-hour regulations.

We all have mentors and role models that we look up to and strive to become. Here is the dirty little secret: We are not done learning once we exit residency. These mentors did not learn the skills we admire over the 3-6 years of residency, rather, they have developed via their experience over 15-25 year careers. We all have access to the same journals and resources. We all see the same pathologies when we encounter patients. We will all work with senior doctors to help guide our path as we develop over the course of our careers.

Lifelong learning is a competency championed, not only by the medical school I attended, but also by medical schools all over the country. Short of being brilliant, it’s impossible to survive medical school without having the appropriate motivation and work ethic. The graduates of medical school, in general, are passionate people with a sense of duty and responsibility. It seems unlikely to me that a single year of duty-hour regulations will ruin that foundation.

Rohit Devnani is an internal medicine resident, and can be reached on Twitter @RoRo_Nani.  This article originally appeared on CaduceusBlog.

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  • Dr. Drake Ramoray

    If it isn’t the duty hour restriction that is causing a decrease in quality of graduating residents then I am curious as your explanation of the Fallon pass rates for the internal medicine boards?


    Regardless, I find the current generation of graduating physicians willingness to work for big hospitals and corp med (a majority for the first time ever) as far more detrimental to the practice of medicine than work hour restrictions.

    • EmilyAnon

      What happens if a resident doesn’t pass the test? Do they have to wait another year to try again? If so, what do they do in the meantime?

      • Dr. Drake Ramoray

        Passing the boards is not mandatory to practice medicine although many hospitals require it for privileges. Generally speaking they are offered yearly so a full year is required to take the exam.

        • Arby

          That’s interesting. Maybe because I worked in a hospital, I never thought about this.

          What do doctors from other countries have to pass? My former GP went to med school in Mexico.

          • Dr. Drake Ramoray

            The British and the Canadians have a similar board type exam. I cannot speak to the credentialing in Mexico. Australia and New Zealand are also somewhat similar to British and Canada.

          • PrimaryCareDoc

            They need to pass the USMLE to practice in this country.

        • EmilyAnon

          I see. All this time I thought passing the boards was necessary for licensure. Guess in addition to hospital privleges it’s more like a feather in your cap.

          • Patient Kit

            I’ve always heard that we should only be treated by board-certified doctors, so I have always checked to make sure any doc I was considering going to is board-certified before making an appointment. Residents at teaching hospitals aren’t board-certified but they are supervised by board-certified attending docs. Other than residents, I don’t think I’ve ever been treated by a doc who wasn’t board-certified. Do some docs work their whole career not board-certified? If so, why? I always thought it meant something more than “a feather in their cap”.

          • EmilyAnon

            When I need a new doctor, I get a list of names to choose from my ins. company. If the doctors are unknown to me, the BC in their resume is the deciding factor. Some doctors on other threads have complained it’s just another organization out to gouge them. If certification has real meaning, I’ll let the docs speak to that. What does a patient know, we keep our fingers crossed and trust.

          • Dr. Drake Ramoray

            It would appear that there are some 20-60% of physicians who practice without certification. I think this number is high but I couldn’t find other sources


            As to why, it’s expensive, time consuming, perhaps some people can’t, and I suppose some people think that if they don’t have to then well…….

          • Patient Kit

            Thanks for the link to Dr Gunter’s interesting post about board certification and the equally interesting thread of comments. As a patient, I’m not sure what to think about this.

          • PrimaryCareDoc

            Emily- There are different boards. The USMLE is the licensing board exams. There are three exams that need to be passed for licensure. You can take the third test after completing an internship. Technically you can be licensed to practice at that time.

            In reality, there are almost no doctors who practice as a “GP”, who is someone who completed an internship but not a residency.

            Once you complete a residency and you are licensed, you’re considered “board eligible”, meaning you can take the specialty boards. Once you pass the specialty boards, then you’re board certified.

            For example- I took Step 1 and 2 of the USMLE in med school. I took and passed Step 3 of the USMLE at the end of my intern year. I then applied for and got my medical license, but then I still had to complete an additional 2 years of my internal medicine residency. After I finished that, I took and passed my internal medicine boards.

          • EmilyAnon

            Thanks for your explanation. Is there another test to take after completing residency? Or is passing Step 3 all that is needed to get a state license. What happens if you move to another state. More tests? Sorry, so many questions, but it is confusing.

          • Patient Kit

            I sometimes hear older people refer to their doctor as their GP. I usually assume that their use of the term GP is a throwback to an earlier time when medicine wasn’t as complicated as it is today and that their current doc is not really a GP who didn’t do a residency.

    • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

      I’ve wondered about this- while it may be that duty hour restrictions have reduced exposure, it may also be that the amount of knowledge that graduating internal medicine residents are expected to know has expanded at an astounding rate- and that too over just three years, whereas doctors now in practice have had decades to build up their knowledge.

      • Dr. Drake Ramoray

        Perhaps, and certainly in the area of therapeutics I would tend to agree. Certainly you can’t compare your knowledge base to a physician in practice for ten years (although I could make the case that you have more knowledge than specialists who have to re-cert in general internal medicine, although that is a topic for a whole other thread.) but we are discussing first time pass rates so the 10 years of experience is a relative moot point.

        One could make the case that if you are spending less time on the wards secondary to work hour restrictions that should give you more time to study the expanded body of knowledge. That line of thinking would also suggest that the length of medical school training should be lengthened, which is not a particularly popular, and I hope unnecessary step in medical education.

        • http://intellectualfollies.blogspot.com/ Vamsi Aribindi

          I actually would be okay with extending medical training (I say this as a rising MS3 with a looong way to go).

          I’d like to practice as a generalist or as a specialist who still has a generalist practice- but healthcare being what it is I fear that Family Practice/Internal medicine and even General Surgery are being consumed by specialists- because residency isn’t long enough anymore to train doctors to do a wide range of things. Back in the day, a General Surgeon could set a fracture and put in a shunt for hydrocephalus. A general internist (and really even a good FP) could handle all acute ailments- it was only long term management/diagnosis of complicated issues that was referred out. Now, we’re lucky if a surgeon finishes 5 years of Gen Surg and a 1 year Minimally Invasive fellowship being able to do both an appendectomy and a hernia, and some hypertensives are being taken away from FPs by cardiologists.

          Part of this trend is certainly due to malpractice- what internist can defend themselves against a lawyer who asks why they didn’t refer out their patient? But that is reinforced by the lack of expertise due to how many new procedures, tests, and diagnoses have been discovered with little change in the MINIMUM training length- and that minimum drags down the entire profession.

          I actually blogged about this problem a while back:

          • Dr. Drake Ramoray

            Good post, and blog post. As I suspected there is quite a bit of truth to your original response (I know my surgical colleagues definately agree with you). I do think however that extending the duration to training to meet your vision of primary care, while at the same time continuing the current bureacracy and reimbursement levels will never fly.

            I see your vision, and I totally get what your are saying, but it would require a wholesale cultural shift in healthcare, patient perception of primary physicians at this point, the role of litigation in the US healthcare system. and a complete overhaul of our payment system. I actually make the case we are moving in the opposite direction with the obsession of alogorithms and treatment guidelines. Don’t get the wrong idea I see what you are saying. I see the dream. I just don’t think its gonna happen. (Where is Buzz when you need him?)

          • guest

            You know, the real Drake Romoray was a “brain surgeon,” don’t you? I think you might be a fraud.


          • Dr. Drake Ramoray

            I’m not exactly shy about my alter ego, and it is well known to many posters on these boards are well aware of avatar.


          • guest

            It was a terrible attempt at a joke! Seemed funny at the time…probably just to me :)

    • ErnieG

      I think Dr. Ramoray has hit a point- ABIM pass rates are falling, and correlate with the decrease in work hours. Either the test is getting harder,
      the residents quality is worse, or the residents aren’t getting trained well enough (or all three). Perhaps the decrease in work hours has nothing to do
      with it. But the argument that I don’t know and don’t care may be true for Dr. Devnani, but it certainly don’t help support the idea that residents are no
      worse than the previous generations.

      I do believe that ABIM certification for graduating internal medicine residents is important. There is a scientific knowledge base and critical thinking necessary to consider oneself a board certified physician that I think is reflected by ABIM testing. It does not reflect the ability to be a good doctor- but rather the ability to pick the right answer for a given scenario which requires both knowledge base and critical thinking. Once you start practicing with your real patients (meaning patients which are yours, which
      look to you for answers, and for whom you are responsible than ever, not the “team” of residents”) you learn a lot more about the art of applying your knowledge to patients you will see on a more regular basis. Residency is what prepares you to
      be a doctor to patients. If it is true that the current batch of residents do not have the fundamentals knowledge base and critical thinking skills as prior
      generations as reflected by ABIM scores, then no amount of wishful thinking that “I care about my patient, and take pride in what I do, and trust others to
      do what I do” is going to convince a lot of people that what you do will be any different than the snake oil salesman.

      My own personal andecdote-
      when I trained in the late 90’s, all residents were expected to have certain skills by the time they graduated- LP’s, thoracentesis, triple caths in
      fems/IJ/SC, knee injections, etc. I went into rheum, and purposely would trade a knee injection on my patient to do another procedure on another—why? Because
      I would do more than enough knees in my lifetime, and it was necessary to do the other procedures, and it would make me a better doc. Yes, perhaps a critical
      care fellow won’t need to tap a knee—there’s an ortho or rheum consult to call. But for a specialty that places lines in arteries, veins, cameras/tubes in bronchi,
      tubes in pleural cavities, then putting a 21g in a knee is pretty darn easy. What if you are in a small community hospital with a septic patient, and (dare you) examine a knee and find an effusion in the middle of the night? Sure call the consult. Everything about your training
      has led you to make that decision. What would the more experience and “strong” 45 y/o intensivist do? His consult would be 24h later, once the gram stain in the knee fluid that s/he collected showed gram positive cocci.

      One other point about Dr. Ramoray’s comment- if his perception that newly graduating residents are willing to work for CorpMed is right, then we are going into the abyss faster than I realize it.

      • Rohit Devnani

        Before I tackle some of this, because I have heard some of these arguments before and I have some questions I want to pose– but first, I would really appreciate it if I could make absolutely clear that I never said “I don’t know and I don’t care.” What I said was “I don’t know but I am not that concerned about it right now.” I know that seems like semantics but the former implies a brazen apathy which is simply not the case. I simply don’t believe the exam is an adequate measure of the things I am arguing about: motivation, work-ethic, and the ability to be a good doctor.

        Ok so on to the points at hand–

        1. Regarding the boards being a measure of knowledge and critical thinking: How many current attendings do you think could pass the boards right now? Going on pure speculation, I wouldn’t imagine very many could pass. Does that mean they are doctoring without an up to date set of knowledge and critical thinking skills to apply to patients today? Obviously if they study, then thats a different story but the point is, they are likely practicing good medicine right now despite not having the critical thinking or knowledge base it takes to specifically pass the board exam. Additionally, I agree with your point about residency being a time to learn how to be a doctor to patients. However, I do not believe this is exclusive. I am of the opinion that your entire career is spent learning how to be a doctor to patients.

        Of course maybe I am wrong, my premise regarding “I have pride in what I do, I care about my patients” means that I am motivated to work, learn and take care of my patients. Its not wishful thinking. Its hard work. So theoretically that is supposed to be reflected by a passing board score, but I just don’t know how well the two correlate.

        2. I have heard this argument before regarding “what if you are in a small community hospital.” I understand the point but I also don’t like the premise. To exaggerate the premise, what if I am on an airplane, what if I am on a desert island, etc. Now I understand the small community hospital thing is more likely than either of the other two so its a point worth addressing: but I think I did address it in the original article. One of the points I tried to make is that every day we are supposed to be learning and adjusting our practice patterns to reflect what is needed. That doesn’t end in residency so if there is a skill I didn’t pick up in these 3 years (nobody picks up everything in 3 years, not even the pre-duty hour generation), then I will learn it by asking the experts to mentor me when said practice becomes necessary.

        Also, does this mean I am only ill-prepared to work in small community hospitals but large academic centers would be ok?

        3. I want to ask you a question about your personal anecdote. Now you are right about the knee tap being a low risk procedure compared to the other things I will be expected to do as an ICU doc (and the comment was meant a little tongue in cheek, simply because I think knee injections are boring…happy you like them though!). Let me flip the scenario and ask you why do you think learning to do central lines, LPs, thoras, etc made you a better doctor as a rheumatologist?

        So for instance, lets imagine you see somebody in your rheum clinic who is immunocompromised and clearly septic and needs a central line quickly. I know this is unrealistic but lets just pretend that you had a central line kit and everything so that there was the opportunity to do it yourself. Would you? Its an urgent line. Do you think its prudent for you to do it right away since the patient needs it, even though its been years since you last placed a central line? Or do you think that even though its needed quickly, its still better for somebody with more and recent experience to do it even though there will be a delay? I would imagine the latter, though maybe you are awesome at central lines and I just don’t know it :)

        The point is, all those things are risk/benefit so to go back to the original question you posed where I am at a small community hospital, yeah the risk is probably minimal but if I am 10 years into my career and I haven’t done a knee tap since the 5 total it did in residency for me to achieve ABIM competence, then I still won’t do it. Simply because I won’t remember what the risks were, and the risks are certainly different in my inexperienced (even though I completed my residency requirements for taps) hands compared to yours.

        I think that covers it, yeah?

        • ErnieG

          While it may be true many attendings can’t pass the boards “right now”, they did once (I hope). The point that they cannot pass the board “right now” is not an excuse for resident who can’t pass the boards at the end of residency. At the end of residency is when you have the greatest
          fund of knowledge, and which is where learning is a priority. If you don’t pass
          the boards, then the knowledge and critical skill may not be there in the first
          place. You become eligible for the
          boards at the end of residency, and the boards are written for that audience.

          Will you be ill prepared to work in a small community hospital? I can’t answer that question, only that there won’t be a night float to cover calls ’cause patient illness does not follow ACGME hour restrictions. .

          About a patient of mine with septic needing a central line in my office…not really a credible scenario. How did they walk in the first place? What would I be placing a line for—norepinephrine for septic shock…Do I even have that? Wouldn’t a 16g in a peripheral vein for fluid run faster? Wait—wouldn’t they be better in a ED, where urgent/emergent things get done anyway? But if they really needed an urgent central line, in whatever concocted
          scenario, How would I confirm placement? Supposing they walked in hypotensive and
          tachycardic—are there even saline fluid bags in my office? Remember…I trained before the work
          restriction, and had no problems putting in a cordis at 2AM in a liver failure patient cause that’s when the FFP and platelets were done going in. And yes, I was very good at putting in SC TLC’s with no assistance. If in whatever credible emergent scenario, I would have no problem with a fem line in an emergent situation.

          Like I predicted, it does not surprise me about the knee tap.

          The procedures made me a better physician because the patients needed it. It made me a better rheumatologist because I know what can be tapped on a lung, what can’t be, and what to expect from the hspitalist (wait, they don’t do that, I mean the pulmonologist); doing LP made me a better rheumatologist because I can explain to the patient what I am expecting the neurologist to do when he or she puts that needle in their back; it made me a better rheumatologist; it made me a better rheumatologist
          because when the lupus patient has to get urgent dialysis, I can tell them a
          little about what the neph is going to be doing to their neck or groin.

          • Rohit Devnani

            So thats all fair. Not excusing boards failure (I sure as heck don’t want to fail mine). Also we do take overnight call, just not as interns (at least in my program) and some hospitals operate with night float physicians. Regarding the clinic scenario, I understand its not realistic, just wanting to try and come up with a parallel for something more dangerous than a knee tap– which I still maintain I am not going to be a lesser doctor for not doing them but thats certainly a matter of opinion. Fair points on the procedure stuff though I could argue that you don’t need to actually have done them and become proficient in them to be able to explain those things to patients (because the knee tap is a convenient example, I have regularly sent patients to our joint injection clinic and I am able to explain to them what to expect even though I have only done 5).

            The bottom line is, I understand all those concerns. I am particularly passionate about arguing the stigma that duty-hour trainees are lesser doctors. I am one of those duty-hour trained docs and I am confident I have had a fantastic training.

  • Dr. Drake Ramoray

    There were similar hour restrictions that were started around 2003. It was the first round of the current trajectory. So the decline is at least temporally correlated to those previous work hour changes, and yes I am aware correlation is not causation.

    While I don’t necessarily relate board pass rates to the quality of current graduates as the end all be all the decrease in pass rates certainly means something, and I don’t think it means that the current or even the previous work hour restrictions are making better doctors.

    I think it is possible that the work hour restrictions are contributing to the decrease in pass rates, another poster has suggested that it is related to the vast expansion of medical knowledge. My original question was indeed if it is NOT the work hour restrictions then what could it be? So far you have only indicated that you don’t think it’s the work hour restrictions but you have not provided a plausible alternative explanation.

    • Rohit Devnani

      I haven’t provided a plausible alternative explanation for 2 reasons: 1. I really have no idea. 2. I am not that concerned about it.

      The purpose of my piece is simple– to argue that work restrictions have not made us lazy, dumb, or any less caring. I don’t believe the ABIM exam is an adequate measure of any of those things and I certainly don’t believe it is an accurate reflection of how good a doctor you are, which frankly is all that really matters. So because of those reasons, while the decline in pass rate may not be nothing, I am not that worried about it yet.

      • DeceasedMD1

        Lucky you. Now you get to fight with us instead of your father. (That was a joke.) But seriously the ABIM exam is likely failing more so they can make a bigger profit next year. Have you seen the salaries those guys make? It is a lucrative business, plain and simple.

      • Dr. Drake Ramoray

        Don’t get me wrong I’m not saying the board exams are an accurate reflection of physician quality. We do however have nothing else objective by which to judge the knowledge base of physicians. Furthermore, many patients, like those who have posted on this thread do take board certification seriously.
        I much liked Deceased and others (as I have posted on other threads) think a large part of the ABIM motivation is a money making scheme (especially Maintenance of Certification). That being said your defense of you generation of physicians is grounded solely in your subjective opinion while discounting the one objective (albeit flawed) piece of information that is contradictory to your argument because well.. reasons.

        • Rohit Devnani

          So you would have me concerned because of a flawed piece of evidence just because its “objective?” The only thing its an “objective” measure of is how well you did on the test itself. The meaning of the results are subjective. You can’t have it both ways. You can’t say that you don’t believe the exam is an accurate measure of physician quality and then say that you are concerned the decline in board pass rates reflect a decline in graduate quality. For the sake of amusing hyperbole, sleeplessness and irritation were once considered “objective” measures of the 4 Humors to be to be imbalanced by an excess of Choleric yellow bile. To be clear, I am not saying that the ABIM is equivalently ridiculous…just making a joke!

          You’re right, this is my subjective opinion. Its an opinion piece. The only thing this piece concerns is the quality of my generation of physicians. Until you can show me that the tests results mean something relevant regarding the quality of physician, you won’t convince me that this is something I should be concerned about. Again, I can only speak regarding my institution, but my peers have had plenty of feedback from pre-duty hour board certified experienced practicing physicians regarding the quality of our work and decision making. I take that a lot more seriously than a certification exam.

          Now I understand my opinion alone won’t have you convinced, but hey, if you were a part of the pre-duty hour generation, already board-certified, then this really isn’t your problem anyways :)

          As far as all the other stuff: patient preference, managerial takeover, NPA/PA rising, all that stuff is way beyond the scope of my post.

          Its a simple question, my friend: Have duty hours made my generation of trainees less motivated, lazier, and dumber than your generation?

          I believe not. You may believe yes.

          Guess what, you all are stuck with us!!

          Oh and next time, please don’t take the liberty to paraphrase for me– “I’m a doctor. I don’t know and I don’t care” is far more conceited that I care to carry myself. I try to be respectful.

          • Dr. Drake Ramoray

            “………….is far more conceited that I care to carry myself. I try to be respectful.”

            “I believe not. You may believe yes. Guess what, you all are stuck with us!!”

            You are definately right that we disagree. I do hope you have a great day.

          • Rohit Devnani

            hahahahahahaha oh COME ON, man, that was a joke. On an internet forum.

            Listen, if you were truly offended by that then I sincerely sincerely apologize. Its not my intent to offend. Simply trying to make light of a disagreement.

            In a show of faith let me answer your initial question, but I can only answer if from my standpoint–

            I don’t know why we are failing the boards now, but if I fail, it will be because its too beautiful in Chicago right now to be spending time indoors studying :) on my vacation time.

          • Dr. Drake Ramoray

            My most recent response was meant to convey that we probably disagree on many things, namely work hour reduction and that you are conceited (without coming outright and saying that I think you are conceited). I also used a direct quote to not paraphrase you, just as you requested.

            It was not meant to convey any sort of offense taken on my part at what you have said, and rather than stray into character assassination, I opted to terminate our discussions as it has become evident that further discussion would not be productive with regards to the topic at hand.

            Seeing as my opinion has not changed (and I will assume neither has yours), and I don’t believe I can get you to see outside of your own bubble, I again do hope you have a good day with the nice beautiful weather in Chicago for I have no ill will towards you and wish all that is the best for you in life and your future endeavors as a physician.

          • Dr. Drake Ramoray

            The orginal version of this reply was deleted, rest assured that I am not offended and I believe your posts reveal more about you than you think. I do hope you have a good day as I hold no ill will towards you.

          • Rohit Devnani

            Cool beans. Again, no disrespect intended. Take care!

          • Patient Kit

            Hmmmm. I gotta say that saying that, if you don’t pass your boards, it will be because it was too nice outside to study, doesn’t exactly inspire confidence.

          • Rohit Devnani

            Don’t worry, I was only joking (not about the beautiful day in Chicago part). I am studying a lot. I don’t know any docs who are practicing that aren’t board certified. Those numbers indication the % that are practicing without certification seem high to me, but I only interact with a specific population of docs.

            Don’t worry I will pass the boards :)

          • Patient Kit

            Good to know. There’s a learning curve to picking up on individual posters’ senses of humor. My own dark sense of humor has been misinterpreted a few times here on KMD. Best of luck to you on your boards and with your career.

    • DeceasedMD1

      I don’t pretend to have an answer, but in general, I think it would be hard to learn in a CorpMed environment. That phrase, “See one, do one, teach one” is meaningless if there is no time to “see one”. The average time for a PCP visit in 12 minutes– hardly a learning experience.

      Looking at the EHR’s, many residents may have never seen an actual formal eval or SOAP note. EHR’s may be destroying more than medical records but the learning process as well I would think would be affected as who can read that crap? Maybe they have. I mean no disrespect and am sure Dr. D is very capable, but I would think it is harder to actually learn in an environment of chaos.

  • Patient Kit

    Please clarify for us potentially confused patients: When exactly did the resident work hour rules change? 2003? So, all docs who graduated from 2002 on and did their residencies from 2003 on, did them under the new work hour rules? And docs who finished their residencies by 2002 did them under the old hours rules?

    • Rohit Devnani

      More or less, yes.
      So basically in 2003 work restrictions were implemented such that residents should not work more than 80 hours a week. Then as an addition to the rules in 2011 it was made such that interns (first year residents) could not work more than 80 hours a week AND could not spend more than 16 consecutive hours working in the hospital.

      • Patient Kit

        Thank you for the clarification. One of the primary care residents at the medical clinic at the teaching hospital where I’m currently being treated seems so anxious and overwhelmed that I’ve had to request a three-way meeting with him, his attending and me when I wasn’t comfortable with a treatment he was suggesting.

        I’d hate to see how anxious and overwhelmed he might be if he was working longer hours. I probably should have requested to see a different resident instead but he wasn’t that bad and I didn’t want to unnecessarily hurt him. Plus I guess I thought he would rotate out or something but a year later he is still there, still “my” main resident and no calmer and I find myself avoiding primary care as much as possible. I’m a pretty engaged patient so no real harm done — but this guy is so nervous, he makes me nervous. I’m primarily there for the specialist care anyway (which has been excellent) and hopefully I’ll be done with my little intensive yearlong Medicaid stint before he’s done with his residency in that clinic.

    • EmilyAnon

      Kit, you might already know the impetus behind the current rules for reduced doctors’ hours, but just in case here is the story of a journalist’s crusade to change what he claims was the cause of his daughter’s death in a hospital. He was a fascinating character. It happened in your neck of the woods, Brooklyn. I remember following the saga during that time.


      • Patient Kit

        Now that you mention it, I do remember the Libby Zion case, but that happened quite a while ago — in 1984. Thank you for reminding me. It puts the resident hour rules in perspective for me. It also reminds me of how many hospitals have closed or merged in NYC since 1984.

        So, the law changed in NY in 1989 to limit resident hours to 80/week and 24 consecutive and those hours rules went nationwide in 2003. I must admit that I would not want to be the patient being treated by a resident who was in his 36th straight hour of working. But 24th wouldn’t be so great either.

        Libby Zion died in Manhattan, not Brooklyn, at New York Hospital (aka Weill Cornell Medical Centerl) which has since merged with Columbia U’s Presbyterian Hospital to form New York-Presbyterian Hospital. It’s a very good hospital system. I’m currently being treated in that system.

  • Arby

    Nope. I used the old school term from HMO days. He was board certified in internal medicine.

  • DeceasedMD1

    This is what is destroying the education. Learning from CorpMed.

  • EmilyAnon

    Both of my cancer doctors are hospital based. (no outside offices) But their bills come from their personal billing companies under their name only. Is that considered working ‘for’ a hospital? Other bills for labs, imaging, facility fees, etc. are billed by and paid to the hospital.

  • EmilyAnon

    I haven’t noticed facility fees on my office visits. The EOB only lists one sum and it’s been consistent for many years for both docs. My ins. pays about 80-85% and the rest is my co-pay to them (isn’t that balance billing?) Not complaining one bit though, my portion is minimal and I am so grateful to both doctors. Of course there are facility fees for labs (on hospital bill) For example the amount charged for CA 125 blood draw is about $350. Broken down:
    phlebotomist fee $62
    CA 125 (blood test) $135
    facility fee (lab) $153

    Even though Insurance knocks this way down, I have no co-pay. I know I have it real sweet with this ins which is employer provided. But ill winds are looming because our plan has been bought out by UCLA and my PCP (one of 15 operating out of 5 clinics) is not happy about the takeover. We don’t know what the changes will be, but I bet patients won’t be happy either.

    • Dr. Drake Ramoray

      I am glad you are happy with insurance. Your oncologists are not hospital employee but appear to have a contractual agreement with the hospital.

      Your example is not quite balanced billing as your co-pay is due at the time of service regardless of charges if you are seen by the physician, although it appears to make up about 15% of your visits.

      Balance billing: I charge $500 for a service. Your insurannce company is contracted with me to pay $250 and your co-pay if $50. I collect your co-pay of $50 at the time of service and then if things go smoothly months later get paid the $250 from your insurance (the contracted rate). Following that total collection of $300 the remaining balance of my charges $200 is written off to balance our books. Balance billing is if I send you a bill for that $200 difference between my charges and the sum of my collections from your insurance and your co-pay. (Some insurances include your co-pay as part of the negotiated rates but including this in my example makes it more complicated than need be to explain balanced billing).

      Every time your doctors see you they right off a percentage of their charges because each insurance company has a different negotiated rate so hospitals and doctors just bill a higher dollar figure for their services than wha they expect to get paid. I am going into this extra detail because this is how patient’s without insurance get screwed by the hospital.

      Let’s say that the hospital charges $1000 (after facility fees etc) for the same service that I provided for $500 (Some tests I do in my office actually cost 3x as much at the hospital I will use double for simplicity). If you don’t have insurance, assuming the hospital doesn’t have an indigent program, then they just send the bill for $1000 (or demand it all prior to the test) and as such lose the negotiated rate that your insurance provides for you.

      We see several patients with no insurance who we have a cash pay system for them to have their blood work drawn here because it is significantly cheaper to have it done here as we do not charge any facility fees. (and have a no insurance discount rate).

      Hope this all makes sense, and is a window into the distorted third party payer system in health care. This also is a primer for how the consolidation of physicians into hospitals probably won’t reduce costs.

      • EmilyAnon

        Wow, medical billing is truly complicated. I’m sure every insurance company has different rules, so I can see why doctors have to employ staff that does nothing but.

        I opened the link you provided. After 10 minutes I had to stop reading because a knot was forming in my stomach imagining I was one of those desperate patients navigating through a sinister hospital billing system with no or substandard insurance. I don’t see how anything will change short of a revolution – in the true sense of the word. I’ll go back to that depressing article after I’ve recovered.

  • JR

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