Friday, November 17, 2017

Residents, duty hours, and respect

The following is an email I received.

I, a surgical resident, would like to ask for help navigating conversations about resident duty hours. You had a very strongly worded post on the subject. My intent is not to contradict your perspective, but perhaps get and give some insight on this question. First, I wish to show you the conversation with a surgeon "fossil" as I experience it:

Fossil: "In my day we worked __ many hours and operated all night and never slept or ate and were glad of it. It made me the surgeon I am today. You will never have this privilege."

Me: "Wow, I agree. You had it much harder." Meanwhile, I am thinking:

▪Working 120 hours a week made you good surgeon. Just because it worked, doesn't make it right. No human being should have to suffer for their job like that. And no patient deserves a surgeon that tired.
▪I wish I could operate with you more. I wish those notes and discharge summaries and case manager hadn't kept me away from most of this case. And the one yesterday. And the one tomorrow.
▪Operating is a privilege and an honor. I would gladly work those hours if it meant I could operate.
▪Please stop implying that I am lazy and entitled for being dissatisfied with some aspects of my training.
▪Please help me learn to be a good surgeon despite all the issues listed above - but particularly with more to know, and less time in the operating room

The conversation above touches on issues of respect and understanding, as well as very real frustration with residency training as it is today. For me, it touches on three major points:

First, respecting the "fossils." Since the development of residency, surgeons have been forged through long work hours, incredible dedication, and no small amount of suffering. This formed ingrained knowledge that cannot be taught, that comes from repetition and practice. A surgeon coming out of this training will know the right thing to do at 9 am or at 3 am. There is no debate that this sort of training makes good surgeons.

Second, problems with historic residency training. The lack of duty hour restrictions took (and still takes) an incredible toll on a surgeon's life, both physically, mentally, and emotionally. Long work hours have been at the cost of sleep, personal relationships, and personal well-being. The errors made while sleep deprived are also undeniable. While muscle memory helps, you are still impaired after 24, 48, or 72 hr call, and the toll of this on our patients cannot be known. To say "you knew this when you signed up for it" is dismissive. No, I didn't know, nor could I have. And once I signed up for it, for me to switch careers would be financially disastrous.

Third, problems with current residency training. Many believe we need to know more and do more in less time than the generations before us.

▪Going from 120 hrs to 80 hrs occurred with no increase in staffing. Those 40 hrs did not disappear, they pulled residents out of the operating room to do paperwork.
▪There are more operations to know, and we must now know them open, laparoscopically, and even robotically.
▪Patients are older and sicker.
▪Medical knowledge is expanding exponentially. There are more diagnosis and treatments to remember every day
▪There is more paperwork, charting, and phone calls per patient, and an increasing team to coordinate around this patient (PT, OT, nurses, case managers, wound care, social work).
▪Increased "floor" demands without staffing leads to more "scut" work for the residents. Scut has its value, but only to a certain extent.
▪Residents who have done fewer operations get less autonomy. Which leads to less autonomy. Which leads to less operating.

I often go days or weeks without operating because there is floor work to do. Minor cases go without resident coverage. I rarely do "teaching" cases with senior residents, and I have never had time to "just drop in" to another case to help or learn when I’m on the clock. Rarely can two residents operate with an attending, or a senior resident take a junior through a case, there is just too much to do elsewhere. This is in a program considered non-malignant, with higher than average cases per resident, and with a program director who does support us and enforces duty hours.

We each think our own training was harder for myriad reasons, but to hear that I will never be as tough or good as those before me shows a lack of respect for the work I have put in and the priorities I have made in my life, including that of surgery. I as a resident can promise to respect the experience and knowledge of those who went before me, and appreciate the incredible work that they have done to get where they are. I also will probably never work those hours, and am stuck in a broken system with diminishing returns.

So, what do I say to this? Do I just agree with the fossil—yes, they did have it harder? Or is there a way to respectfully ask how do I get as good as you are in this completely different training setting?


Skeptical Scalpel said...

I appreciate your thoughtful email which raises many interesting issues. You have articulated much of what is wrong with medical and surgical education these days.

I guess I qualify as a “fossil” myself.

You sound depressed. It’s sad to hear that you can go weeks without operating. I wonder if residents in other programs have similar experiences.

Your residency program has apparently not considered hiring PAs or APRNs to help you with all the paperwork and care coordination. I have been told that some of the burden can be mitigated by these folks.

It’s true that everyone thinks their training was much more rigorous than that of subsequent residents. Not too long before I trained, the word “resident” meant a doctor in training who lived at the hospital.

I don’t think there is any proof that patients today are sicker than patients from 20 or 30 years ago.

I wish I had some better answers for you. I don’t. Maybe our readers can help.

Emily Thompson said...

I don't think anyone who has gone more than 48 hours without sleep is someone I want operating on me. I wouldn't let my hairdresser cut my hair if I knew she was that tired, because we now know that tiredness can result in a level of impaired judgment similar to being drunk enough for a DUI conviction.

I concur with Skeptical Scalpel that I really would like to see PAs and NPs do more of the charting/paperwork, so that you can train more specifically with doing what only you can do: operating!

Anonymous said...

There are thousands of unmatched doctors who are ready to share the workloads if it wasn't for the broken system.

Anonymous said...

Reading you I thought I heard someone speaking about my own residency in Paris France which ended 4 years ago. I completely agree with all you said including the fact that patient we treat are more and more sicker... due to the progress of other specialties and anesthesia and surgery....

Anonymous said...

I'm a recent graduate from residency (2015).

Here are my thoughts...

1. EMR. Where I trained it was a policy for a nurse to call you with any abnormal lab value, vital sign, etc. Sodium 134 (low normal 135)...paged. A typical night from 6 pm to 6 am would yield approximately 100-200 pages as a CHIEF resident. Which brings about my favorite line of nursing documentation,"Dr. notified of sodium of 134 - NO ACTION TAKEN." In addition, for every patient with an abnormal lab you get queries from the coders to go back and - for instance - document anemia (if even 0.1 below normal). Fourth year as trauma chief I spent 3-4 hours per day updating the problem lists for all of the ICU trauma patients.

2. Autonomy. When you ask the "fossils" what their residency was like they all say how great it was because they ran the service. Chiefs operated with interns and there was some autonomy in that the attending didn't have to be present. Residents actually ran the service instead of simply being a computer interface for the attending.

3. 120 hours you say? I think not. You may have been in the hospital that many hours, but you weren't likely working for a decent amount of them. Even at a busy level 1 trauma center, the OR's aren't busy all night every night. You slept, relaxed, etc. You weren't getting paged all night about sodiums of 134, nor were you spending all night catching up on an inbox full of deficiencies, and if a nurse did call she would actually take a verbal order for something.

4. The bane of technology. House wireless phone, pager, and cellphone - blowing up all night. Attendings at home on their computers at night - slightly low potassium needs to be replaced STAT (or your documentation isn't done and I'm getting emails about it). Unacceptable to do anything (including operating) else than whatever they called/texted you about. At least in the good old days you could actually take care of things without being caught up in electronic communication of some form or another (most of it worthless) for the majority of your time. Where I trained there was a link on the homepage to "report unprofessional behavior." Reporting was anonymous and went directly to the Dean's office. Look at a nurse wrong and it landed you a meeting with the program director and the complaint put in your permanent file.

6. At my program I never worked more than "80 hours". If you did it was because you were inefficient and hauled into the program directors office to answer for it and the service attendings would also place documentation in your file lamenting your very existence. I typically worked around 100 hours a week, but I also put in another 2-3 every night sitting in front of my computer at home finishing documentation. And I worked way longer than 36 hours at a time - many times.

An excellent example of the differences in training. My intern year the program director asked the attendings to transfer all pages from the resident pagers to their pagers during the ABSITE (which is ~4 hours if I remember correctly). This plan failed within the first hour, all of the attendings couldn't handle it and transferred the pages back over. Each subsequent year the program director asked and they all flatly refused.

My "80 hours" versus the hallowed 120 hours of the good old days...I would challenge any attending from that era of training to do one month of training now as resident. I for one would much rather have trained in that era. I may have been at the hospital longer, but I could have slept when I wasn't busy, operated independently, and the patient's would have been MY patients (if you know what I mean). In residency you are constantly bombarded with charting/documentation, micromanaged by attendings, etc. You don't really own your patient's and this makes it very hard to maintain your passion for surgery, and without that - burnout rapidly ensues.

patandemma said...

the only solution I can think of is for a resident to go spend a year or two in fellowship in some country like S.Africa at a teaching hospital where the availability of surgeons is orders of magnitude less than needed.especially trauma care. This will be a contribution to that countries health needs.
Cuba does this
The paperwork and compliance requirements are pared to the bone in these countries b/c there are so many patients who will be grateful for even less than perfect care as opposed to no care at all.

The "thousands of unmatched doctors who are ready to share the workload"...does that mean the resident gets to spend more time in the OR while a new subset of doctors w/o medical career paths get exploited ?

Just a thought said...

Anonymous 620. Well said. I think the fossils have no idea what it is like today. I was lucky that my program which is closing was a hybrid of the old and new. The paper work is nothing like it is now. A old family doc showed me one of his charts from his first ten years. It was on a 3x5 index card. It said bronchitis, abx given. That was an actual visit. I could only imagine how many more OR cases and sleep I could have done with that kind of documentation. Maybe even spent time with pathologist and learned what tumors looked like under a scope. Hell I would have had time for activities. Medicine moves about 20 times faster than it used to. It would be interesting if a “fossil” could keep up.

artiger said...

Anonymous at 6:20pm, a lot of your points are valid, and I sympathize, but I have to take issue with weren't there at that time. You have no idea about 120 hour work weeks, and how much we (didn't) sleep during those nights. So, stick to what you know.

Skeptical Scalpel said...

Thanks for all the comments.

Emily, even in the days when we fossils took call every other night (and no going home early the next day), I never saw a resident work 48 hours without any sleep. See comment #3 from anonymous at 6:20 PM and my third paragraph in this comment.

Anonymous at 4:23 PM, as I mentioned in my comment above, I know of no proof that patients are sicker today than they were 20 or 30 years ago. How would you even know that?

Anonymous at 6:20 PM, the idea of coding for every little thing that is wrong with lab results is not new. That has been going on for years. I agree that residents used to run the services in the old days. I also agree that when we worked more hours we weren’t as busy when we were on call because we weren’t cross covering five services. It is true that even minor transgressions are reported to the program director or surgical chair. That is not a good way to do things. Except for the insinuation that we couldn't handle all the work you do, your last paragraph is well stated.

Pat, I don’t think South Africa or any other country wants all of our residents to practice on their citizens either. We need to clear this up here at home. I agree with your comment about the thousands of unmatched doctors who are ready to share the workload.

Just, interesting thoughts. It’s true that we did not have so much paperwork back in the day. I am one fossil who knows what it’s like. I’ve been writing about the negative features of the electronic medical record for years. Don’t underestimate the older docs. I bet we could still handle it if we had to.

Artiger, your comment goes along with mine above which is that today’s residents have no idea exactly what we did or what types of patients we treated.

Just a thought said...

Great comments scalpel!

I think that every generation thinks they had it harder then the next. But most often the people don’t really change, just the situations they are placed in. Most surgeons have grit which you have talked about in the past. I think just like you said the fossils could have made it through our training, but they would be complaining just as much as we are/did. We would have made it through your training just the same. To think any generation could not would be nieve on all our parts.

I am sure you all complained about how terrible it was and the guys before you said the same thing being said about us. The only difference is now you hear about it more with blogs, tweeter, Facebook and such.

Last point is on the sicker patient. Life expectancy has grown a lot and the obesity epidemic has occurred. We have better meds and more resources so you could say it was a wash. However I am sure many in each generation will make the aguement that they have it harder.

As always continue to enjoy the blog.

RobertL39 said...

It's interesting to me that Anonymous at 6:20 writes so incisively (sorry!) about such a mess. But doesn't anyone realize that he's just describing being trained to be a 'modern' surgeon, doing all that paperwork, patient shuffling, and box-checking instead of actually operating? Absent some major change from somewhere (anybody have any ideas where the diminution in data collection is going to come from?) the current data collection binge will continue and people who are supposed to be doctors will continue to spend at least 1/3 of their time collecting data. Progress? I think not.

Unknown said...

As a training registrar in Australia, which is similar to a resident in the US, I can tell you the situation is very similar to what Anonymous 620 describes here. The truth is we still work long hours, we just don't get paid for it. Instead of being up all night operating for our bosses, our bosses do all the operating and we are up all night doing their research projects (and not getting paid for it).

This all sounds like whinging, but I should say on the whole we are still privileged to be surgical trainees. We love what we do and it is an honour to do even the little operating we can. However I don't know many people who wouldn't swap systems in a second.

That really is the proof of the pudding for me. No boss I know would have swapped their training for ours, yet most of us would love to go back to the old days. None of us are soft or lazy, we are just stuck in a training system that year after year puts out worse and worse skilled trainees and doesn't seem to care to change. I don't know of another industry where it could be confidently said that graduates 5 years ago were better, and 10 years ago were better than that ad infinitum.

Bob said...

I should also add that in Australia to pass our terms we have to keep a logbook. In this logbook we have to do a certain percentage of operations as "primary operator." The amount of an operation you need to do to be termed the "primary" as opposed to "assistant" is quite well defined by the College of Surgeons, however many of my supervisors encourage us to put ourselves as "primary" even when for 95% of the case we have assisted. I only mention this to say that whilst the official numbers of trainees operating is going down, this may not be the true scale of the issue as even these official numbers are very likely fudged.

This is an open secret. Bosses tell stories of new bosses who graduated having apparently done hundreds of cholecystectomies, but clearly have trouble doing simple cases. As a way of putting the issue aside, bosses say that we aren't really trained when we have our letters now, we really get trained during our fellowship. But this feels like a way of not addressing the problem at all, and in some ways justifying it.

There are many pressures in the health system these days, and cost and waiting lists weigh heavily on the senior consultants. It seems like too often though our training is not respected and pushed aside for more pressing issues. As a trainee, there is no more depressing a feeling than waiting all day to finally do a case, when a nurse manager walks in and tells your boss that the trainee can't do this case because there is no time and the list needs to be finished quickly.

Anonymous said...

I think that we shouldn't lose the big picture. This is a symptom of a larger problem which is the lack of competition among hospitals in training residents. There is no incentive for a hospital to let a resident spend more time in the OR, the GME money is coming from Congress anyway without accountability. The ACGME? It's a creation of the same hospitals. It is true that the residents lost the battle of the anti-trust to the AAMC which got exemption in 2004 but that doesn't mean they should surrender instead, they should change the tactics and find allies in the states which can put political pressure on Congress in order to receive,the states, the medicare funding for the GME themselves and subsequently manage it according to the states' needs not the hospitals'. In addition, the states can coordinate that with their requirements for licensure.

Skeptical Scalpel said...

Just, I don’t know how we could determine whether patients today are sicker than they were in the past. Research on the topic would generate a lot of clicks though.

Robert, thanks for the reality check. My only disagreement with you is some people think doctors spend 50% of their time providing data for others to analyze.

Unknown November 19 and Bob, thanks for the Australian point of view. Residents in the US have to keep logs as well. There is no way to tell whether the numbers and types of case entered are real or not. When a resident takes credit for having done a case, it is unclear what the criteria are for doing so. I have blogged about papers claiming that as many as 30% of US surgical residency graduates are unable to operate independently.

Anonymous November 19, I would trust the states even less than I trust the hospitals to manage the Medicare GME money. In my state, physician licensing fees, which are substantial, go into the state’s general fund instead of being used to help police the profession or in any other way benefit physicians.

Todd J. Scarbrough, M.D. said...

I think population sickness is tied to the economic health of the population. Clearly, there are some pockets of America which have been economically decimated over the past few decades. There, health quality is surely lower. I don't need a study, but there are studies I'm sure ( (Worldwide, as poorer nations get richer, their health quality, life expectancy, etc., have been dramatically increasing...)

I'm a rad onc. I did a surgical internship though. I've hung out with and been friends with many inspiring, thoughtful surgeons. Twenty years ago, I think pretty much all the surgeons and surgical residents I knew were very pro-surgery. Also, most of us in general were pro-medicine back then whether we were surgeons or not. Now it seems many surgeons are burnt out and the surgeons-to-be are kind of trepidatious. As are many of us in medicine in general.

What I think we are saying is that old docs and new docs and docs-to-be see things getting worse and not better, that the overall trend for this is out of our control, that doctors don't run the system and the people who do are going to keep trying to make things better (and it will only continue to make things worse).

Anonymous said...

Fossil here, var nonsurgeon.

It's a little strange to be told by today's trainees that we don't understand the systems they work in now while also being "schooled" on what we went through back in the day.

With few exceptions, EHRs have been a burden on anyone who has to deal with them. I pushed the admins to include students and house staff in testing the systems, in good part because they tend not to balk at digital solutions as much as we dinosaurs do. They are often in the best position to offer the most useful feedback.

It's telling when admin is willing to consider this--create electives in order to utilize the tech experience some of our students and trainees had in their pre-medical school lives. And even more telling when they don't. That's when all of us should pull together to push for systems that improve patient care, rather than the bonuses admins receive, on the backs of students, trainees, nurses, attendings, and everyone else attempting to provide actual patient care.

It's worth pointing out that at least for some of us, time not spent at the computer as trainees was spent writing notes by hand, drawing blood cultures, and transporting patients to radiology. Personally, I think all of that was better for patient care. There's an emerging literature that students attending a lecture retain more information taking notes by hand than on a computer. And however annoying drawing sepsis labs and blood cultures myself was, I rarely if ever had false positive cultures and the time spent doing all of that meant I was actually with my patients. That sharpened my sense of who was ok and who was about to crash.

If faculty need scribes, it's hard not to imagine that residents and fellows need them, too. All of us should be at the bedside (or OR or clinic or procedure room) more, not less, and should work together to make that happen.

Chris Porter MD said...

Anonymous 6:20

I agree that today's residency is harder, and unbearable for a surgeon trained in the 90's.

I work nights in two different settings. In job #1 I was hired to replace residents no longer supplied to the VAMC starting in 2011 due to hours restrictions. Residents sign out the services to me at night. At job #2, I'm a locum in a small private non teaching hospital where I can give verbal orders and roll back over to sleep.

Over just six years, the documentation/training module/order entry burden has exploded at job #1 and remained stable at the other. I now find it unbearable to work nights in the teaching setting. While my job description in the two settings is identical, job #2 is far easier - and feels more like my 90's residency, even if I spend the night operating. The other is non-stop non-clinical nonsense. The end of verbal orders is an under-recognized paradigm shift which hugely impacted how one spends time in a hospital.

Skeptical Scalpel said...

Anon from 11/20, I have blogged about some of the studies that show retention of info is better when notes are taken by hand. I wonder how well it is retained when a scribe writes it down. I'm guessing "not very well."

Chris, your comments are spot on.

Anonymous said...

On the topic of patients being "sicker" nowadays...

I don't think that the general public is any sicker today than it was 20, 30 years ago.
However, I think that we've seen a wave of medicalization that has brought disease more to the front of the mind for the general public. People may have had the same problems in the past, but I don't think they were conscious of them to the level that we are today (And especially with all the WebMD self diagnoses...).

Also, as Just a Thought said, the documentation used to be a lot simpler, so we didn't have a record of every exact issue that was talked about in visits, whereas now we would know that the pt had problems A, B, and C, but was treated for bronchitis.

Skeptical Scalpel said...

I know we have a record of every issue. And that record is copied and pasted into every progress note in the chart. If residents are doing that (and I know they are), they are just creating more work for themselves. PS: Except for the assessment and plan, no one reads the notes anyway.

Why should the fact that a patient has a few more positives in her past medical history result in more work for a resident? I'm not buying it.

Jonathon Wooff said...

I am an RN currently working as a senior EHR software analyst. I get a front row seat into the lives of the residents/fellows/attendings within the enterprise where I work and I can tell you that the regulatory and compliance burden is OUT OF CONTROL. As a software analyst I could create a program that would allow you as a physician to complete your documentation in a timely and efficient manner, thus freeing up your time to spend it with patients. In fact, this is what I would love to do...I have a deep sense of respect and solidarity with my physician colleagues. Unfortunately I am prevented from creating streamlined workflows because of the useless bureaucrats working within the regulatory-compliance industries. Instead I spend the majority of my time designing software schemes that allow the organization to capture documentation that will keep the hospital in compliance. THIS is why physicians are spending so much time in front of the computer. The EHR is not the enemy. The compliance and regulatory State is the enemy.

Skeptical Scalpel said...

Jonathon, thanks for the comment. I agree the regulations and compliance issues are a huge part of the problem. I just saw a tweet from Harvard cardiologist Michael Gibson. It said ordering and documenting a flu shot takes 32 mouse clicks. And a doctor has to enter all the data. That's part regulation and part poor EHR design. Here's a link to an article about it. Scroll way down to find the mouse click part of the story.

Anonymous said...

Anonymous Europe: You just can’t compare two totally different eras. The old fossils usually can’t even turn a computer on (experience..). They do not even know where to log the operations or how to do the documentation properly, because it is all shuffled onto us... depriving us from gaining experience by performing operations. We are running their wards, running miles every day, while all they do is sit in their rooms and “do academic work” (=nothing). Besides, the world was different back in their days. Their wives did not want to divorce them if they did not nurture their marriage (also experience)., and maybe it was not that important to them to know their children before they turned 30.....
I still recall stories about what they used to do while being on call (and that was definitely NOT surgery, unless you consider bbqing on the roof surgery...).
Sorry, I do NOT mean any disrespect to anyone. There are fossils out there also, who can turn on a computer and help us out, even teach us.Maybe the picture I painted is somewhat tainted and I do not see every aspect of it,maybe it is just the bitterness speaking. Still I completely have to agree with the email.
I gave up science completely, because you just can’t do two things well at a time. Either you are a good surgeon or a good scientist these days, or you live alone.... Besides, I have a Ph.D. and that is the greatest regret of my life. Had I started with the surgical training earlier, I would be a way better surgeon by now. The old fossils fooled me back in the day, that I needed that Ph.D, and I will learn the procedures afterwards. Yeah... count on it. I will never get fooled again.

Skeptical Scalpel said...

Your comment reminded me of something. When someone starts, "With all due respect..." someone else is going to get disrespected.

Isaac G said...

The interesting thing I am noting in the comments is this; we are glossing over the bigger picture. Maybe older docs did have it worse, it doesn't matter. That still doesn't make it right. It wasn't right then, and it isn't now. Docs who work 120 hours a week are not good for pt's, or themselves. How can attending help residents NOW, so things get better? How do we improve our culture form within?

Rugger said...

Sounds like the whole surgical training idea needs to be re-worked. I completely agree that we are no longer training surgical residents to be capable of general surgery on day 1 after graduation. That's a shame.

Skeptical Scalpel said...

I've been saying that for years.

frankbill said...

Looks like this surgeon missed something during his training. the sad part is bad surgeons still get hired.

Skeptical Scalpel said...

Frank, sickening story. Thanks for the link.

artiger said...

That story casts a lot of doubt about the credibility of board certification, doesn't it?

Anonymous said...

Anonymous Europe: Medicine should not be about screwing up our lives to save other's.....

Anonymous said...

Just a layperson here, but interesting reading.
Am shocked the above discussion on extremely long hours could occur without some mention of "chemical support" especially when y'all have such easy access to anything you need.......

Skeptical Scalpel said...

wasn't mentioned because, other than caffeine, it is not possible to obtain stimulants in a hospital. You can't write a prescription for yourself and no one would risk writing such a prescription for others. If you were caught, you could lose your license and career.

Anonymous said...

I read with interest some of the stories regarding surgical internship and residency and unfortunately it doesn't seem that this topic has touched upon the issue of surgical intervention by surgeons when non surgical intervention may be just as viable I practiced medicine in San Francisco for years as an endocrinologist and one day I fell walking my dog down a steep hill. I immediately consulted with the chief of orthopedic surgery at a major teaching hospital regarding an isolated fibular fracture(bimalleolar). Immediately she said she would get me in for screws and a plate the next morning since she recognized me. After looking at the film and the extent of the fracture, I went for a second opinion where we decided to proceed with ultrasound and after 9 weeks of intensive treatment and a boot, the imaging showed correct alignment and proper healing of the bone. Twenty years later and the ankle still remains strong, with no arthritis My point being, hospitals welcome surgical intervention as a revenue stream,especially in cases like mine which are quick same day procedures without batting an eye and little consideration of long term complications from a plate and screws in a 45 year old (at the time). Credentials or not, after that experience, I always encourage patients to get a second opinion on these type of quick surgical interventions.

Skeptical Scalpel said...

I don't have a problem with getting a second opinion, but your anecdote suggests all surgeons are knife happy, which is not true.

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