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:

Surgical residents have lots of problems, need more time off

A recent survey of surgical residents regarding their personal and professional well-being revealed that while most of them enjoyed going to work, they had many serious issues.

All 19 surgical residency programs in the New England region were invited to participate, and 10 did so. Of 363 trainees contacted, 166 (44.9%) responded to the survey with 54% of respondents saying they lacked time for basic health maintenance. For example, 56% did not have a primary care physician and were "not up to date with routine age-appropriate health maintenance such as a general physical examination, laboratory work, or a gynecologic examination."

I am not surprised that young men and women averaging 30 years of age or less have no primary care physician? I wonder what percentage of young people who are not surgical residents have one.

Should asymptomatic people in this age group or anyone in any age group have a general physical examination and lab work?

Surgical training is different in Japan

Quite different than what we are used to in the United States as a paper published online in the American Journal of Surgery explains.

In the US, all residency programs are vetted by the Accreditation Council for Graduate Medical Education (ACGME). Japan has no central accrediting organization. Each hospital establishes its own training program without any national standardization.

Medical school graduates in Japan take a national practitioner examination and then complete a two-year rotating internship. Specialization in general surgery residency takes three more years after which the residents may obtain board certification.

The authors surveyed 76 teaching hospitals in Hokkaido, a prefecture in the north of Japan, and 49 (64.5%) responded.

Program directors were in place in 81% of the residency programs. Of that number, 79.3% devoted less than 5 hours per week to education [compared to an ACGME mandate that 30% of a program director’s time must be devoted to education], and 72.4% had dialogues with residents only when necessary.

Of those responding to the question, 31/36 (86%) "had teaching activities outside of clinical settings," but no program had protected time dedicated to teaching.

Fewer than half of the programs had skills or simulation laboratories, with 12.5% having formal simulation training as part of their educational agenda.

Only 55.6% of the programs evaluated the competency of their trainees in knowledge, skills, or scholarly activities.

Not surprisingly, only 8.6% of program directors were satisfied with the way their programs functioned.

To become board-certified in Japan, residency graduates must take a written exam for which the pass rate is 82.1% and an oral examination which has a pass rate of 100%. The pass rate for the oral exam has been an issue. A medical specialty board was established in 2014 and is preparing to oversee the quality of resident education and certification.

Lead author Dr. Yo Kurashima, Director of Surgical Education Research at Hokkaido University Graduate School of Medicine, answered a few questions via email. He said some of the hospitals limit resident work hours and allow residents to go home after call. However, "most do not define work hour limitations, so residents usually work from early in the morning to midnight every day."

No universal surgical residency curriculum exists in Japan, but a national surgical society recently listed criteria that must be achieved prior to board certification.

Dr. Kurashima did some training in Canada where he became familiar with North American residency methods.

For his next project, he said, "We are just starting a national survey which will investigate resident satisfaction regarding their residency.”

I suspect the residents might raise some concerns. I wonder if they will have time to respond.

Work hours limits in Sweden: It's complicated

A physician in training from Sweden emailed me some questions, and the topic of work hours came up. To protect his identity, I have slightly altered a some of his responses, but I have not altered his message.

It´s quite interesting as physician work hours, or rather productivity, are debated a lot in Sweden right now.

The work hour restriction [50 hours/week in Sweden] is not enforced at all. This summer I was working as a junior house officer in a surgical specialty at a county hospital, and I can´t say I noticed anyone trying to cap my work hours, on my first day I was encouraged to work as much as I could.

On the other hand I was not put on the on call schedule, as that involved covering the ED (outside of academia EM-physicians are scarce) and all surgical services. It is hard to get to work 50 hours a week covering only a 12-bed service, when the nurses do all the blood tests (except blood gases), urinary catheters, do all patient transporting, and such. I did get some OR time though.

I think there is no enforcement of the 50 hours/week restriction because doctors here don´t get paid as fee-for-service. There is zero difference if you do 5 or 10 cases during your shift. There is no incentive to work more than 50 hours/week, and doctors don´t.

A problem that is more particular for surgery is the limited capacity of operating theaters, in many hospitals productivity is low, case turnover time is long, and you can only do elective cases between 8:30-16:00 (and God forbid you operate past 16:00). In the hospital I worked, we were not allowed to start elective cases after 14:30, and we only had 2.5 days/week when we could operate.

If you want to make money, you take a leave, go to Norway, work 80-100 hours/week in some rural hospital there for a few months, and earn three times as much. [I was also told about this by some Swedish surgical residents I met while attending a conference there last year.]

We do a lot of administration. A study published in a Swedish medical journal, in Swedish sadly, found that Swedish surgical residents spend 40% of their time on administration and 40% of their time taking care of patients. Their British counterparts did 15% admin and 66% patient care. An average work day was 8.2 hours in Sweden and 12.2 hours in England.

Because of this, few physician hours are "productive" and Swedish doctors see very few patients compared to most Organization for Economic Co-operation and Development (OECD) countries. Queues build up and the hospitals don´t want that. So I guess they want us to work.

There was however a government crackdown on a rural hospital in northern Sweden where the county (which is the governmental body running hospitals in Sweden) was fined for imposing too long work hours. So there may be change, but rural northern hospitals are not in an ideal position to recruit more doctors.

Right now work hours are restricted formally but in practice it is hard to get that amount of meaningful work done. It has some perks however, as residents can pick up their children from day care. [Emphasis added]

Is this where we are heading in the United States?

UK doctors' work hours limits are a fraud

The other day someone tweeted a link to a story that was headlined "NHS junior doctors have little time to eat or sleep." The article—from the Herald in Edinburgh, Scotland—told of a manual from the NHS (National Health Service) that advised trainees to keep water and a food bar handy because they would rarely have a chance to eat.

The manual, which also told the junior docs to "be prepared for dehydration and hunger," is no longer posted on the Internet.

A man whose daughter, a junior doctor, was killed in an auto accident on her way home from the hospital blamed it on the fact that she had worked a long shift. For the record, she had worked a 12-hour shift overnight.

Of junior doctors, he said, "They are under intense pressure, they are working excessive hours, they are getting no respite."

I retweeted the link to the story with a question wondering how it could be that conditions are so bad in the UK. After all, I thought the European Working Time Directive (EWTD) stated that trainees in the European Union could only work 48 hours per week.

A flood of tweets in response soon explained the true situation to me. I was amazed, and you will be too.

It seems that the so-called 48-hour work week is a sham. Trainees can work only 48 hours per week, but it's averaged over 6 months—6 months!

What hospitals apparently do is work the junior docs like dogs and then give them a week off so that the average is 48 hours.

Here are quotes from some of the UK physicians:

That's the key; as long as they give you a week off and the average is ok, all bets off

What the working rules are & what occurs (& are paid for) are 2 very different things.

In my case, was asked to do the 36 hr shift by hospital manager and consultant.

Upcoming survey results from Association of Surgeons in Training show majority [of trainees] come in on their time off.

Shorter shifts with no more doctors means more shifts. Gaps in rotations mean longer shifts

It's not much different to how it was before, just lower pay now!

The Herald piece also said that a survey of 4913 junior doctors in Scotland … "found almost 20% were short of sleep because of their shift patterns and more than half worked beyond their rostered hours daily or weekly [emphasis mine]. Some 40% described the intensity of work as heavy or very heavy." In an editorial, the Herald said, "In practice, the [EWTD] directive is being broken every day in hospitals across the country."

The understatement of the millennium was made by the chairman of the Scottish Junior Doctors Committee, who said, "Although all the rotas [rotations] are compliant with the European Working Time Directive they are not necessarily in the spirit of what the law intended." No kidding?

He also said that junior doctors could be scheduled to work up to 12 days in a row without breaks and confirmed that they sometimes "struggle" to find time to eat.

Some of those who responded to my tweet said they would much rather work a scheduled 24 hours in a row than the life-disrupting shift work that the "48-hour" week has resulted in.

What is my point?

We have all been led to believe that all is well with the 48-hour work week in Europe—clearly not so.

And let's just keep ratcheting down the hours here in the US so we can achieve the same nirvana enjoyed by the trainees over there.

As always, I welcome your comments.

Are millennials cut out to be surgical residents?

When you hear this story, you may wonder.

Recently in a surgical residency program somewhere in the United States, the residents requested a meeting with their program director and surgical department chairman to discuss a concern they had.

A few of them were upset because during a 31-day month, one resident on a three-person rotation ended up working an extra night of call.

6/28/13 ADDENDUM#1: The residents who complained included some non-designated PGY-1s who were hoping to be converted into categorical residents if any such positions became available. This would not be perceived as favorable by those in charge.

I know that old guys like me aren't supposed to say things like this, but if residents had approached my chairman with a complaint like this, he would have thrown them all out of his office immediately.

Residents were summarily fired for lesser offenses than that too.

Despite my previous post about a Harvard Symposium that suggested we should train residents like Navy SEALs, I know we can't turn back the clock.

But people, there is something really wrong when residents start haggling about the number of days worked.

What's next? Requesting an extra hour off because you worked the Saturday to Sunday overnight when Daylight Savings Time ended?

I didn't see anyone volunteering to work an extra hour to compensate for the night the DST begins.

OK, tell me I don't understand this generation of residents. Tell me I'm out of touch.

But you won't convince me that there isn't something wrong with complaining about an extra day of call.

6/28/13 ADDENDUM#2 As pointed out to me in comments on Twitter, my post does not pertain to all millennials. I acknowledge that such a generalization was unfair.

ED MD wants residency hours capped at 40 per week

Blogging at his site "Adventures in Emergency Medicine," Dr. Sam Ko says resident work hours should be limited to 40 per week. Via Twitter, I warned him that I would rebut his assertion.

Without any data or references except a tangential one, he bases his opinion on four premises.

1. Residents will be happier and nicer to patients because they will be less stressed. There is no proof that this is so. In fact, a recent paper in JAMA Surgery says about one-third of interns who work a maximum of 16 hours per day "demonstrated weekly symptoms of emotional exhaustion (28%) or depersonalization (28%) or reported that their personal-professional balance was either “very poor” or “not great” (32%)." And "at the end of their intern year, 44% [of interns] said they did not believe that the work hours limits led to reduced fatigue." This is not a very resounding confirmation of the theory that reduced work hours leads to happier or better rested residents.

2. "But we did it so you have to do it to." Under this heading, Dr. Ko says, "We are busier than they were 20-30 years ago. Before they probably got more sleep and had less patients in the hospital."

With the exceptions of more paperwork and the burden of the electronic medical record, I'm not so sure residents are busier today, but if they are, what's making them busier is REDUCED WORK HOURS. This recent paper from JAMA Internal Medicine concluded the following: "Compared with a 2003-compliant model, two 2011 duty hour regulation–compliant models were associated with increased sleep duration during the on-call period and with deteriorations in educational opportunities, continuity of patient care, and perceived quality of care." [Emphasis in bold added]

The supposition that there were fewer patients in the hospital 30 years ago is incorrect. When I was a resident over 30 years ago, cholecystectomy patients stayed in the hospital for 4 to 6 days. Even herniorrhaphies stayed 1 or 2 nights. Day surgery was in its infancy. Patients could be admitted for workups which are now done as outpatients. These people all needed H&Ps, had to be rounded on daily and notes had to be written. We had to draw routine and stat bloodwork and start IVs ourselves, we often transported patients to radiology and the OR. I could go on.

Dr. Ko is right about one thing. We did get more sleep when we were on call because we weren't cross-covering many patients that we didn't know very well. The abomination known as "night float" did not exist.

3. Residents won't get enough training. Dr. Ko dismisses this objection by pointing out that menial tasks should be delegated to others. But who are those others, and how will they be funded? In addition to the bolded portion of the sentence at the end of the paragraph above, here's another paper (of many such papers) documenting that many residents are already being poorly trained. And Dr. Ko wants to cut hours by half.

4. Less depression, anxiety and alcohol/drug abuse. He cites a statistic that 300-400 physicians commit suicide very year. That may be true, but there is no proof that decreasing work hours will alleviate that problem. Most papers on the subject seem to indicate that suicide is a problem of physicians who have completed training and are in practice. Did I mention that there are no work hours limits for doctors who are in practice?

Being a doctor is a stressful job. Sleep, or its lack, is not the only factor causing stress. Limiting resident training to 40 hours per week would be a catastrophe for residents, their education and most of all, their patients.

Anguish. Choosing a medical specialty is difficult, Part II

The following was recently posted by an anonymous woman as a comment on a blog post I wrote about the difficulty one has in choosing a medical specialty. I was so taken with it that I wanted to give it more exposure. [Note: The comment contained a few typos which I have corrected. Otherwise it is unchanged.] My response has been amplified slightly.

Since you are so senior to me, let me ask you for your thoughts. I got into medical school, studied, worked hard, got into residency and learnt, spent hours and hours in hospital, loved critical care and got into fellowship. Along the way met a guy (both were residents at that time), fell in love and we both dreamt and read and learnt and discussed cases. He decided on cardiology and I decided on critical care. Both got into fellowships ....worked hard, spent long hours into fellowship...we were committed. We ARE committed but divided.... We had kids and now every day I feel divided. I have a feeling that all "old timers " like you who worked for longer hours and did frequent night calls, had " spouse" who take care of your kids and you did not have to worry as much. Times were different. Times were not so dangerous and kids’ safety outside of the house was not so concerning.

In my situation, my spouse and I are both physicians in fields that require us to spend lots and lots of hours in hospital. If I were to find a traditional practice and work every 3rd night, who will raise my kids? Who will teach them right from wrong? Everything is on rise–drug abuse, physical abuse, drop-out rates. I WANT to raise my kids and be there to guide them. So yes I want a practice where call frequency is lesser, where I can spend evening with my kids (not because I want to have fun but I want to be there).

We do not think about all this when we get into medical school and I did not think about this when I married my husband and we did not think about this when we chose our subspecialities. Perhaps that was a mistake.

It was easier for us. There were far fewer women in medical school. My class of 180 had only 20 women in it. Our chances of marrying another doctor were much lower, especially since same sex marriage was not in vogue back then. I was fortunate to have married a woman who is both a nurse and a saint. She took 13 years off from work to raise the children.

Have you thought about joining a group and working part-time, maybe with shorter hours and fewer nights on call?

I was touched by your palpable internal turmoil. My heart goes out to you. I hope you can find the balance you seek. Your last paragraph sums it up. Everyone in medical school should read it.

What do interns do when they're on call?

You may be surprised and dismayed when you find out.

A study in the Journal of General Internal Medicine from a VA hospital affiliated with the University of Wisconsin reveals some startling facts.

During a 14-hour call period of 3 pm to 5 am, medical interns spent 40% of their time on computer work and 30% on “non-patient communication,” such as clinical conversations with team members, other physicians and nurses among other things. Direct patient care accounted for a whopping 12% of their time.

What about teaching and learning? Would you believe 2% of the time?

The study was conducted using observers trained in time-motion research. They followed the 25 interns who volunteered for the project, but did not interact with them or influence them in any way. The study was likely much more accurate than most previous research on this topic, which was based on self-reported surveys of house staff.

Other interesting tidbits from the paper were that the on-call intern cross-covered an average of 27 patients per night, which seems like a lot to me. The amount of time spent on “sign out” or “hand offs” was not stated. They averaged 4 admissions per night. Only 93 minutes [11% of the total time on call] were devoted to “downtime,” that is sleeping, eating and recreational computer time.

So it looks like internal medicine interns at the VA in Wisconsin do a lot of “scut work” and don’t have much time for learning or sleeping. With only 4 admissions per night, you would think there might be more opportunity for sleep, but since this was internal medicine, each admission probably took two hours.

The interns in the study worked every fourth night. Ironically, in the good old days when we worked every second or third night, we cross-covered far fewer patients because there were more of us on call each night. Therefore, we got more sleep and were less tired the next day.

When one looks at the small amount of time allotted to patient care and teaching and learning, one is not shocked that many graduates of residency these days are not confident about starting independent practice.

I suspect the results would be similar if surgical residents were observed.

What do you think about this?

A version of this appeared on Sermo yesterday and most agreed that interns are not being properly trained.

Why is the attrition rate of general surgery residents so high?

The cumulative attrition rate of general surgery residents has been holding at about 20%, a figure that has been steady for nearly 20 years. This figure is higher than that of most other medical and surgical specialties.

The institution of the 80 hour work week was heralded as a solution to the problem of attrition. Students who in the past wanted to be surgeons but had shied away from surgery were thought to be more likely to enter the field. The presumption was that in the old days, surgery was considered daunting due to the excessive number of hours worked.

If the attrition problem was just about the hours worked, one would expect the attrition rate to be less now; so far, it is not so.

The latest study of this problem points out that attrition occurs early in the course of training and is not related to the gender of the resident or any other specific factor.

So why do so many surgical residents drop out or wash out?

I believe a major cause is that medical students do not understand what surgical residency training is really like. In some schools, third-year clerkships are as short as 4 to 6 weeks, and part of that time may be devoted to clinic or subspecialty rotations.

Many medical schools limit the amount of night call that a student is required to take to one night per week with the proviso that the student is only to be awakened if something interesting is happening on the service. Some schools define night call as ending at 11:00 p.m.

Limited exposure such as this gives the students an unrealistic picture of what a surgical residency is like. This can result in disillusionment when the prospect of 4 years of real general surgery residency hits home. [I am counting only 4 years because the new Accreditation Council for Graduate Medical rule limiting first-year trainees to a maximum of 16 consecutive hours of work will simply postpone the problem for a year.]

An interesting paper from 2006 noted that a significant number of applicants to general surgery residency programs were “relatively uncommitted” to the field of general surgery compared to applicants to other surgical disciplines.

The combination of unrealistic expectations and lack of commitment leads to residents resigning or performing poorly.

This problem has implications for both the program and the departing resident. When a resident leaves a program, a competent replacement may not be easy to find, and the departing resident often finds he has wasted a year or more of his life because he often ends up in a non-surgical specialty.

True to my style, I am good at pointing out problems but not so good at finding solutions.

What do you think?