To all the folks out doing their residencies (and anyone else with an opinion),
I've recently talked with one of the trauma and burn attendings here at Vanderbilt regarding the upcoming mandate to shorten resident workweeks (80 hr cap I think). VUMC has implemented it this year to try and work out the bugs before it becomes required. His is an unfavorable view on the policy believing that it is adversely affecting the education that his residents are getting and that they will be worse surgeons as a result. Specifically, there is no continuity of care. The resident gets a patient ans starts Tx but then leaves at the end of his/her shift. The next resident picks up on that Pt. and may or may not pick up where the previous one left off and may or may not be present for the conclusion of that patients Tx. The first resident comes to work and gets a new pt etc… Eventually, he thought that the residencies may be extended by a year or two or three. Also, he pointed out that there is no such restriction on attendings' workweeks and questioned if their workweek will not be extended much more because of the increased need of supervision said less skilled residents. I would love to hear peoples opinions on the topic. Are there any residents who have experienced a year or two of unlimited hour workweeks who are now working 80. Is your training better,worse, the same as a result? Is life outside of medicine better,worse, the same? Are there attendings out there who have opinions? What about you med students and med student wanna be's(fyi I'm a wanna be); what do you guys think? I look forward to hearing what everyone has to say.
To all the folks out doing their residencies (and anyone else with an opinion),
There's no question that the mandates are necessary. The data are pretty incontrovertable that physicians in training are regularly functioning while sleep impaired, and that outcomes are worse as a consequence.
The mandates were clearly written by internists; even the language that they use gives it away (eg talking about an extension of time for transfer of patient care…). For surgery residents, the structure is problematic. If I have to be relieved of duty after 30 hours, and then cannot return to duty for at least another 10 hours, then everytime I am post-call I will have to leave in the early part of the day. Since the vast majority of our training takes place in the OR, and to a lesser extent the clinics, we will be missing the bulk of our training exposure on a regular basis.
For us, a more reasonable alternative would be to have protected sleep time during the night - four hours for instance - during which you are required to hand off your pager to one of your colleagues.
Our program is quite livable, so once you're out of intern year, you end up working around 80 - 90 hours a week anyway. So that part is not a problem. Our interns bust ass though; I worked 128 hours (awake, on my feet) one week as an intern. Average is about 110 hours/week.
I am going to come down on the side of shorter hours as currently mandated will adversely affect my training as a surgeon. The alternatives in motion here are to lengthen the training period. We are already at seven years including the two years of mandatory research.
There are fundamental differences between the care of a surgical patient and the care of a medical patient. While protected sleep time would be great (four hours per night is my average), there are times when you just don't want to leave. (After 40 hours plus, I didn't want to leave my dying patient who was s/p lung transplant). With one case, I would have wiped out half of my week! How much learning would I get sitting at home or going home before I can get good cases.
I can tell you now that cases such as lap Nissen fundoplications and esophagectomies take several hours to do. Factor in that I want to participate in the immediate post-op care of my patient and I have quickly burned up plenty of hours. I am one resident who is dreading the mandated hours not because I want to prove that I am made of iron but because it is difficult for me to tear myself away when I have invested 6 to 8 hours in a difficult surgical case.
why dont you work 140 hours a week instead of the 120 you work now? that way you could do even more cases, heck you would almost never miss a surgery.
I just honestly dont believe surgeons when they tell me that they can stay awake for 40 hours straight and yet there is no dropoff in patient care.
pretty arrogant to be making a statement like that imho
Call me arrogant and call me a liar but call me when you want a good surgeon. It is one thing to stand on the outside and look in and totally another to be getting it done. Cheers!
I don't want to offend anyone. (so I edited this)
It just seems like there must be a better way to do this - other than having people work when they are over-fatigued - and people need to think more creatively about how to manage it.
Having recently had a breast biopsy, I can tell you from the experience as a patient that I scheduled my surgery first thing in the morning (with no call for my surgeon the night before) because I wanted her “fresh” when she operated on me. This also meant I had to delay it a few weeks. Could she have done as good a job after being up the previous 30 hours? Maybe and perhaps even probably. In an emergency you may not have a choice of surgeon, but for a semi-elective surgery, give me the most well rested Doc!
However, I have to admit to being a little hypocrital in this situation. I think that because of my excitement in the prospect of practicing medicine that I could function well after 30 continuous hours. BUT, I would NEVER want a doctor that had been up that long to do surgery on either myself or any one I cared about if I had a choice.
Just my opinion…
sorry nat i really dont want to sound like i’m picking on you, my thoughts are directed more to nobody in particular, just surgeons in general.
I understand that its different from the outside looking in, but my point is that its irrelevant. We dont know what its like to fly a plane, yet we still regulate the number of hours pilots fly. Yes, I know flying a plane is different than a surgeon. I’m just saying that you cant automatically dismiss any outside regulation SOLELY because they are not surgeons and thus "dont get it"
I guess we’ll find out in a few years whether there is an outcome difference between the setup now and with hour limits. If, in 5 years, it turns out that there is statistical evidence showing that mortality/morbidity rates rise as a result of subpar training, then I will concede your point that capable surgeons MUST spend 120 hours a week in training. But I think we should at least TRY something different and see how it works out.
Edited by DoctorGeo2008
I changed my mind.
|QUOTE (DoctorGeo2008 @ Oct 11 2002, 02:26 PM)|
Edited by DoctorGeo2008|
I changed my mind.
Changed your mind from what?
|QUOTE (dmaes @ Oct 11 2002, 06:03 PM)|
Changed your mind from what?
I posted a reply and reconsidered so I deleted it.
|QUOTE (njbmd @ Oct 10 2002, 05:42 PM)|
|I can tell you now that cases such as lap Nissen fundoplications and esophagectomies take several hours to do.|
Just a lil' plug for my program....
We do tons of laparoscopy. We also have a Da Vinci robot (one of the few programs in the nation which does) and robotic surgery is now a part of our training.
A lap Nissen is a junior case at our program - you do portions of the operation as an intern and second year, and your first completely skin to skin lap Nissen as a third year.
Our average time is 2 hours, and that's when the resident is doing the case. Takes less time when the staff does it.
Are Da Vinci surgeries more or less expensive than regular surgeries?
do you think its significantly better than regular surgery and are there any statistics available that prove its better than regular surgery? just curiuos
I don't know a lot about the financials of robotic surgery. The system costs over 1 million to purchase, then the disposable components (staplers, graspers, etc) are hundreds of bucks apiece. I suspect the developers are looking to recoup a lot of their investment up front, the way drug companies often do when they market a hot new drug.
In robotic surgery, the robot is put into position over the anesthetized patient. Port access is obtained, much like with endoscopic surgery. The surgeon then sits at a terminal on the other side of the room, and is not scrubbed in (i.e. is not sterile). The surgeon places her forehead against the view monitor, activating the system. You have no peripheral vision at this point, but can only see into the system - much like a high tech video game. You place your thumb and index fingers into control pads, then the natural and real time movement of your fingers, including the 180 degree orientation provided by wrist movement, is transmitted to the endoscopic graspers. There is a filtering of gross movement - so that large movements on your part are reduced to small movements by the instruments, providing a very fine degree of control.
The advantages include the finer control, making robotic surgery a plus for coronary artery bypass grafting, which is typically done under magnification using suture the size of a fine hair. The transmission of your exact movements to the instrument is highly intuitive, and there is a shorter learning curve. You are capable of a much wider range of movement, due to the 180 degree control, differeing significantly from laparoscopy in which you have an instrument on a single, straight axis with only one degree of motion. For the surgeons in the audience, the graspers are similar to a 'right angle' which can be flipped into any angle or degree of orientation.
Probably the most helpful aspect has to do with the visualization. The camera is on a 'snake'. Thus you can visualize through any degree of angle: you can look 180 degrees back on the port site through which the camera is placed; you can 'drive' the camera up into the diaphragmatic hiatus during esophagectomy; and so forth. You are never working 'backwards', because the system always compensates so that movement is oriented to your perspective.
The most significant detractor - which is major in my view - is a complete loss of tactile feedback. You have absolutely no idea the degree of force that you are using in grasping or pulling tissues aside from the visual cues that you see. Clearly, this increases the possibility for occult tissue injury during handling.
Da Vinci is very helpful in some types of surgeries, e.g. CABG (increased control and exposure) and trans-hiatal esophagectomy (increased exposure in a classically difficult case). It is ridiculous overkill for cases which are easily done with endoscopy, like lap chole's and lap Nissens, but many surgeons are doing these robotically in order to increase their experience level, and because patients are requesting them.
There will be a distinct place for robotic surgery in the future practice of surgery, and I suspect it will become preferred first line approach for some types of procedures. I don't think it will replace standard minimally invasive approach for more common procedures - these are done safely and efficiently with current technology.
|QUOTE (spiritdoc2b @ Oct 11 2002, 12:46 PM)|
BUT, I would NEVER want a doctor that had been up that long to do surgery on either myself or any one I cared about if I had a choice.
One of our recovery room nurses developed a small bowel obstruction over the weekend, coming into the ER on a Sunday night (actually, the wee hours of Monday morning...). The general surgeon on call had been killed over the weekend, and had literally been up for two straight days by this point.
The nurse had signs concerning for compromised bowel (high white blood cell count, tachycardia, suggestion of focal peritoneal signs on examination), dictating that she be explored urgently.
When the surgeon was speaking to her at bedside, advising immediate surgery, he was literally swaying back and forth with exhaustion and fatigue. She looked him straight in the eye and said, "Dr. So-and-so, I trust you with my life and would let you operate on me or my family in an instant. But there is NO WAY you are operating on me right now, in this condition. Go lay down, get a couple of hours of sleep, and we'll do the surgery after you've recovered."
And that is exactly what they did.
why was he able to sleep for 2 hours? there werent any more patients to take care of during that period for some reason?
Pretty much. Call turns over at 6am, at which point emergencies are deferred to the next person. Of course, you would still have your normal Monday schedule in place: clinic, elective cases, inpatient rounds, etc. to deal with.
To expound a bit further, that is one of the differences between call as a staff and call as a resident: the staff has some ability to protect him or herself. They can have the resident take care of most of the work-up and post op cares, they can cancel elective cases and clinics when needed, can choose to defer a surgery until after they have eaten or rested, and so forth. As a resident, everything is pretty beyond your control. You are first line for all patient needs; when you are post-call, you are expected to attend surgeries and clinics and to patient care without regard to what you went through the night before.
Consequently, with a few exceptions, most call shifts at staff level involve more sleep and more rest than at a resident level.
Our residency director handed out cards today for us to keep track of our hours spent in the hospital including on-call hours. We are supposed to note the longest period of sleep that we are able to get while on call. So far for me, the longest period of sleep that I have gotten has been about 90-minutes after I asked the nurses to hold the calls until I could get a couple of winks. They were able to oblige because none of the patients were unstable.
While I can turn off the floor calls, I can't stop the trauma admissions. The traumas come when they are going to come. On one night I ended up with six over the course of 12-hours. Couple that with calls from the floor every 30 minutes and I didn't get any sleep at all.
Again, the answer that is going to be posted is that the length of my residency is going to go from seven years to probably nine with the extra sleep thrown in. It doesn't much bother me one way or the other because I live to operate.
If work hours are so important to residency program directors, why cant I volunteer to work a guaranteed 130 hour work week and finish in a half year shorter?
Surely I should have the option to do that since they think sleep doesnt matter and every hour spent outside the hospital is a waste.