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October 20th, 2011

Shifting Times

Gopi Astik, MD

hourglassAnyone involved in academic medicine probably is aware of the new ACGME duty-hour restrictions that went into effect  on 7/1/2011. For those of you who aren’t, the new guidelines state that PGY1 residents cannot work for longer than 16 hours straight. If they do work longer, they require strategic uninterrupted naps. The restrictions on PGY2 and PGY3 residents are less stringent, but the total consecutive hours that a PGY2 (and beyond) can work was lowered from 30 to 28. One other change is that residents are mandated to have 8 hours off, and recommended to have 10 hours off, between shifts. As one of the chief residents when this change occurred, I really want to share my thoughts about it.

For our program, these new rules have meant a transition to shift work on all days of the week. We have had night float for the past 5 or 6 years, but we had overnight “long” calls during the weekends. I can see both good and bad things about this new call change. We avoid some resident fatigue, because interns work only 16 hours maximum. The problem is that, in order to accommodate for the shifts, giving interns an entire weekend off is very difficult. The Golden Weekend is becoming somewhat of a myth to our intern class. Transitioning to a shift-based call system also points out major flaws in our handoff process. We have noticed that our “checkouts”/handoffs were not relaying the needed information and, as a program, we’ve been trying various things to improve this process.

resident sleepingOne thing I ask of every resident reading this page is — be nice to your chief resident! We didn’t make this rule, nor did we have any input into the decision, but we have to enforce it. The more restrictions that the ACGME puts on resident work hours, the more complaints I hear from attending physicians about having to pick up the slack. We often do not have the manpower to ensure that every service will have a “full team” of interns and residents to complete daily work, and we have to rely on staff physicians to fill the service gap.

Our job to ensure that residents do not work more hours than they are allowed and, thus, avoid citations against our program. Problems arise mostly when residents who are on weekday call (which ends at 7PM for us) delay leaving because of notes, orders, or patient care issues. If a resident does not leave until 9 or 10PM, they cannot come back into the hospital until 7 or 8AM. This means that those residents probably have not seen all of their patients before rounds begin, and the responsibility falls on other residents or the attending physician. I realize that this issue is a culture shock for some of the older physicians who “used to walk to work in a foot of snow uphill both ways,” but these are the rules, and we all have to live by them. So, please, cut your chief a break!

13 Responses to “Shifting Times”

  1. Glad to see this. Tired medicine is dangerous medicine. We have long known that fatigue increases our personal error tolerance. Good move!

  2. Lee Stetzer, MD says:

    Can you tell me why the tagline for this blog is “chief residents in family and internal medicine” when both of the residents are in internal medicine?

    Lee Stetzer, MD

    • Gopi Astik, MD says:

      The resident writing the blog for last year was family medicine so there are still posts from him listed in the blog. I think that might be reason but i’m not completely sure.

  3. Mark P KLING says:

    Dr Astik, Interestingly , being a prof in EM at Cook County(Stroger) Hospital Residency, sign out and its known pitfalls are well documented in all of the Emergency Medicine literature. As well as other flaws, shift work also provides early closure, premeditated efficiency and speed, etc. An end in sight if u will. All of these “handoffs” you may have noticed by now along with nursing shortage, unions, time off, etc ultimately declines the patient care and experience. A position we will all be in someday ironically. Patients are ultimately d/c’d with less done and more “follow-up”. We went to 3 chiefs for that reason, but more and more hand off is still diversifying the playing field for error which will occur, almost assuredly. We simply accept rules and become more otiose conceding to “rules” rather than common sense. As with most administrative situations, practically they accomplish maybe 20% of what they discuss and mostly in theory is inferior to actual practice. A sorry and pitiful undertone to many careers, jobs, and infrastructure crucifying us in this country. Just always bear in mind that doing the right thing and the “rules” often , even by historical perspective have proven to be diversified situations. Just ask yourself, would u do the same thing if u were in the bed and receiving the care. Intelligence and empathy are forms of art and not the rules. I do respect what u are referring to and we have worked around it successfully in our residency, and our patient population is demanding to say the least in such a place as Chicago with self entitled politicians, furlough days, egos, etc. All of which impact negatively patient care. I respect also your willingness to interact , and interject. But always do the right thing first. “Rules, the right thing, and the ACGME , may be and probably are 3 different entities in most case scenarios. All the best Mark P. Kling, MD, FAAEM, CSCS.

  4. Kim says:

    My concern is that we are not preparing residents for what they will experience when they start practicing. As an attending there are no safety nets of work hours or someone else to pick up the unfinished work. In the long run we are only delaying the inevitable fatigue they are going to experience. I was a chief resident when we had the 80/30 restrictions and we learned to cope with those. I applaud you for trying to enforce such ridiculous restrictions and still provide good patient care. It’s a difficult job.

  5. Sherwyn M. Woods, MD, PhD says:

    I read the blog with great interest! As a retired Professor, and former 12-year Member/Chair of an ACGME Residency Review Committee, I can assure you these issues have been debated more than 20 years! A significant percentage of Residents have long been exploited by hospitals, departments, attending’s, and more senior residents so as to carry the very difficult clinical load that would otherwise be costly and a burden on others. The lower one is in the hierarchy the greater the likelihood of exploitation, as has often been the case with first-year residents . It has been well demonstrated that patient care and welfare declines with exhaustion and sleeplessness. It is ludicrous to resationalize such experiences as “education”. This is not the Marines, and there will be plenty of opportunities in professional life to learn one’s “limits”. Just as “beauty is in the eye of the beholder”, so too is the estimate of a reasonable number of on-duty hours and the appropriate sleep interval. The ACGME has been re-defining and re-adjusting this for years, despite the ensuing screams of pain. I applaud their most recent adjustment based on residency education, not the management of clinical load. While that is not an easy task given the horrendous financial and clinical limitations facing departments and hospitals, inappropriate residency education should not be the preferred solution!

  6. Christopher Sitler D.O. says:

    Dr. Astik, I am a current chief resident at an osteopathic residency, and we have implemented a swing shift to help with the staffing issues on the day services. It currently runs form Noon to midnight and is staffed by a first year resident. Currently, they are a “roaming” resident that is available to any service that needs extra help that day (i.e. admission, discharges, etc.), and they also cover the house pager/phone so that code call and rapid respionses don’t pull people away from their teams at the prime rounding times.

  7. MD says:

    While duty hour guidelines are certainly long overdue, I fear that, like many things, they are going too far. Who in real life is given protected nap time beyond preschool?! Guidelines should be just that: guidelines, not gospel. Sometimes you have to work overtime. The trend in medical education to make everything easier and easier is fostering the proliferation of one of the most dangerous entities in modern medicine: the lazy physician who relies on shortcuts just to “get by.”

  8. Lewis Weaver, MD says:

    Unfortunately the ACGME appears to be continue to appease the press with the appearance of safety and has forgotten that the primary purpose of residency is education. I regret not being able to document the original source but the law of 10000 hours is explain extremely well by Malcolm Gladwell in “Outliers.” To prepare physicians of excellence, it is necessary to spend 10000 hours in patient care.

    As one of those who “walked uphill in the snow both way” (and a chief resident 16 years ago), I continue to see the lip service of the ACGME. Shifting sleep wake cycles has been repeatly been shown to be the most disruptive aspect to cognitive preformance but is not addressed by these regulations.

    I would concur with Dr. Kling. The current structure continue to degrade the culture of medicine and care that patient’s ultimately receive by practicing physicians in the name of following the “rules.”

  9. blkellerMD says:

    I have been out of residency for 3 years, so the “80 hour rules” were in effect the year I started, and those were at times difficult enough to comply with. These new restrictions I believe go way too far. Being tired is a part of medical practice, and you better learn to deal with it. I think it is FAR better to do so while in an environment where basically everything you do is supervised at some level and there is a “team”, rather than “learning one’s limits” the first year you are in practice and in the hospital alone with a patient bleeding out and needing to go to the OR. Suddenly being your own go-to is enough of a shock without having to also suddenly figure out how to stay away when you are on call for 3 days straight and still seeing patients in the office. I am not old school and opposed to change, I just think we have to face realities. Being tired is less of a threat to patients when it is a resident than when it is their private (only) physician. And you simply cannot fit the same amount of training into dramatically fewer hours, especially in surgical specialties. Today’s residency graduates are, I fear, less hardy and less well-trained than their “uphill in the snow” predecessors.

  10. Erin Charles, Peds says:

    I agree that functioning while fatigued is a skill needed in specialties with call. I work 24 hour shifts now, 7 years out of residency. I am also concerned about the limited experience residents will now receive, both in number of cases and in being in-house long enough per shift to follow a case through. Also, they will be spending more time signing out and less time doing patient care.
    The way things are going, residents will require an extra year of training to be ready for the real world.

  11. Dacon Scott says:

    I know next to nothing about this topic, but I am interested in going into medicine but also in having a family and maybe even a life at the same time. After hearing all the horror stories from the “uphill-in-the-snow-both-ways-people” I have to admit that I lose almost all hope of doing so, and therefore I lose interest in the career. Doing your job is important, but it isn’t the only important thing, or even the most important thing, whether you all believe that or not. Also, if you are going to be stickler’s about the 10,000 hour rule, then I would like you to know, that for a 5-year surgical residency (or similar specialty) It is possible to get at least 14700 hours of experience while working a mere 60 hours a week, and having 3 weeks off per year. So yes, maybe they won’t have copious amounts of work experience as their predecessors did before them, but they will also be able to dedicate more of themselves, their effort and their passion to the work they do and thereby improve more effectively. This reasoning comes from the book “Talent is Overrated” it cites the 10000 hour statistic with the disclaimer that you actually have to be actively TRYING to improve during those 10000 hours. From my point of view, that is very hard to do if you are barely conscious. I have personally seen examples of this when I meet people at my job who have been working there for anywhere between 11-35 years and still don’t do the job any better than after their first year there. Time isn’t everything. Secondly, even if it was, if you are still getting enough education to do your job effectively than why does it matter if you get less experience than those who came before you? There is such a thing as excess, and it’s opposite is efficiency. If you spend 30,000 hours to get the needed amount as experience that you could still achieve with 14000 hours then isn’t that just a waste? I don’t know about you but I wouldn’t pay $30,000 for a corvette to get me to work when I could just as easily get there with a $10,000 Honda Civic. I would finish by saying that yes, change is inconvenient and people will have to adapt, but I am willing to bet that those adaptations will lead to an even better system of medicine. Is was in the middle of a war that we made our best technological advancements, and whenever we run out of oil we will most certainly make our most creative and effective substitutes. It is in the fire of difficulty that newly formed tools are forged.

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