The 80-hour work week at UVA Surgery

Ho folks,
My residency program came up with a plan to get our hours under 80 to comply with the new RRC regulations that will take effect July 2003. We will start out new schedule beginning January 2003. It works like this for the interns:
Each service will have a lone intern. For example, Vascular Surgery, which now carries two interns will be reduced to one. That intern will come in at 0600h and leave at 1800h. After 1800h, a night float intern will cover their patients for emergencies only. This float will be covering Thoracic, Cardiac and Vascular patients. This float will be responsible for approximately 45-50 patients at night. It will be the responsibility of the primary team to manage the patient and take care of their routine needs during the 12-hour day. The primary intern will work 12-hour shifts M-Sat and 4 hours on Sunday. They must sign out by 12 noon on Sunday. As an intern on a primary team, you will have to be at the hospital seven days a week.
If you are the night float, you will cover all of your assigned services for six nights 12-hour shifts per week with the overlap. There will be a weekend float person to cover the one night that you are supposed to be off. You do this schedule for an entire month.
At present, I am coving Vascular Surgery. Since I have a fellow intern on this service, if I am not scheduled on a weekend, I get the entire day off. Under the new schedule, I will not get a day off but I am supposed to be home by 1800h each day and back at the hospital by 0600h.
We are testing this system to see if it works. There are super consult residents and super chiefs too. If this works, it will be put into permanent action starting with July 2003. If it doesn’t work, the bugs will be swatted and a modifed system will be put in action.
My biggest problem is that as an intern, under the new system, you do not have the option of staying over and operating. I got most of my surgeries by scrubbing in after hours. You can also get the best teaching too. By getting those extra surgeries, I have been able to increase my OR time but I end up staying in the hospital for 120-140 hours per week. Not a great trade-off for me. sad.gif
I would rather have more hours and more OR time. The only reason I do the intern scut work is to get into the OR.
Nat

Hi Nat! I imagine this has been covered ad nauseum somewhere but 120-140 hours a week at the hospital? My calculations, when I use all my fingers and toes, tell me that there are only 168 total hours in a week. How does it really work? You get some sleep at the hospital, right? Even truckers are required by law to not drive more than a certain amount of hours a day. You must really love it…what about the rest of your life? I remember a while ago you mentioned that you were single and that was unlikely to change and lately I've read that you're engaged. Congrats! Your fiance's a doc, I imagine? I understand that surgeons are extra driven but how did this evolve? Is it ego? Is it safe? Would you be just as happy if you worked a standard 40 hours?
Happy Holidays!
Best,
Greg

QUOTE (gschimma @ Dec 23 2002, 09:49 PM)
Hi Nat! I imagine this has been covered ad nauseum somewhere but 120-140 hours a week at the hospital? My calculations, when I use all my fingers and toes, tell me that there are only 168 total hours in a week. How does it really work? You get some sleep at the hospital, right? Even truckers are required by law to not drive more than a certain amount of hours a day. You must really love it...what about the rest of your life? I remember a while ago you mentioned that you were single and that was unlikely to change and lately I've read that you're engaged. Congrats! Your fiance's a doc, I imagine? I understand that surgeons are extra driven but how did this evolve? Is it ego? Is it safe? Would you be just as happy if you worked a standard 40 hours?
Happy Holidays!
Best,
Greg

Hey Gregg,
My fiance Steve is so far away from medicine that he gets nauseated if I start to talk about just being in the hospital. I had to beg him to drop off my cosmetic bag (I forgot it one morning that I was on call). He doesn't join me for those little romantic dinners in the hospital cafeteria because he can't stand the "smell" of the hospital. I must be immune because I can't smell anything in the hospital unless it is fresh. As Old Man Dave will tell you, UVa is open and full of glass. There are panoramic prospects of the mountains from most every window. The hospital is very new and very beautiful.
I will say this over and over. I totally LOVE every minute that I spend at the hospital. Now that I am comfortable with the basics of my job, I love every thing that I do from pre-rounding, to writing notes, to working up cases, to posting, to draping, to scrubbing, to operating, to closing. I love that the attending physicians have a wonderful one-on-one relationship with all of the residents and value our contributions to their practice.
The other downside of limiting work hours is that as an attending physician, my hours will not be limited. While the RRC can mandate things for residents, there are no mandates for attending physicians. It is far better to come from working under this system of potentially unlimited hours that coming from 80-hours and going to 120-140 hours per week. Once you have achieved residency, you want to cut back as opposed to working more. This will not be the case. Still, I love what I do and I will make the adjustment. I can ratchet up quite easily.
There are some fundamental differences between driving a truck and repairing a ruptured abdominal aneurysm such as the one that I worked on early this morning. Driving a truck is dull and monotonous. When an incision is open, the atmosphere is anything but dull. There is a challenge to get the work done efficiently with every move having a purpose. Every suture and every tie has a role. The time passes so fast that I hardly know that I have been operating eight or ten or even sixteen hours. Surgery demands 100% every time whether you have been sleeping or not. I am one of those people who cannot sleep more than four hours per night on any day much less on call days. I just don't sleep that much. (This is an innate quality that has been with me since childhood. My Mum was crazy with my wanting to read most of the night). I like to think that this makes me fairly suited for surgery. (I do have colleagues who are suffering everytime they walk into the hospital. They are the first to leave every day. This is not me and will never be me.)
Medicine and Surgery is my life. My fiance knows and accepts this. He is very self-sufficient and has his life too. We chose not to have children because of my demanding schedule. How long will I love this and do this? I can say that nothing has gripped me like surgery and performing surgery. I can come out of a case that has lasted six hours with the adrenaline pumping and head in for the next case. It is just that much fun. I don't think that I would love Internal Medicine nearly as much.
Natalie

Hey Natalie! Thanks so much for your reply. I'm glad that you found your dream job. I'm still searching…
I spent Christmas eve at our local Trauma I hospital…I'm always fascinated by how badly the surgical residents look. Every doc I meet I always ask if they'd do it again if they had a chance and most say yes. One guy absolutely depressed me when he responded yes and then had a distant look in his eyes as he remarked about the sacrifices that he's made.
Do you know why things have evolved this way? Is it a lot of ego? Is it a right of passage? (I'm speaking mainly of the hours that residents put in) What's the difference between being a surgeon at a teaching hospital vs. a private hospital?
Best wishes in the New Year!

QUOTE (gschimma @ Dec 26 2002, 02:04 PM)
Hey Natalie! Thanks so much for your reply. I'm glad that you found your dream job. I'm still searching...
I spent Christmas eve at our local Trauma I hospital...I'm always fascinated by how badly the surgical residents look. Every doc I meet I always ask if they'd do it again if they had a chance and most say yes. One guy absolutely depressed me when he responded yes and then had a distant look in his eyes as he remarked about the sacrifices that he's made.
Do you know why things have evolved this way? Is it a lot of ego? Is it a right of passage? (I'm speaking mainly of the hours that residents put in) What's the difference between being a surgeon at a teaching hospital vs. a private hospital?
Best wishes in the New Year!

Hi Greg,
There is nothing like surgery to push one to achieve the best and more. I have a constant challenge to make every cut and every action count. I have learned to have little tolerance for things that waste my time or are not of learning value. Every patient and every action is a learning experience for me at this point. If you consult my diary, I will update two more profound experiences where I was stretched to the limit and found myself thriving under the adrenalin rush. One situation was opening a chest on the floor and the other was amputating a dead foot in the CCU at bedside. There is nothing like taking the situation head-on and not backing down. Still I find myself shaking at the prospect when a patient goes into a strange arrythmia that I can't pull out instantly. I guess it just has to do with comfort level.
There are many sacrifices that are made. In the end, there is probably a huge amount of soul sacrifice. I spent a little time with one of my attendings who is known for his ultra-volatile outbursts. He feels a very deep connection with his patients that has evolved over time. (He has that "driven" quality but not to the degree as my residency director. My residency director is less volatile but more "driven" to perfection.) I appreciate both these guys in different ways. My attending was sharing some experiences with a patient who had died over the Christmas holiday.
We both knew this patient very well and we knew that he had been a wondeful human being and father. He has been extremely hard-working but diabetes with hypertension followed by renal disease along with peripheral vascular disease had ultimately claimed his life. These pathologies has creeped in and devastated his body before anyone could catch onto what was happening. He died very quickly from a devastating infection that eventually attacked his heart and brain before it could be stopped. My attending was very emotional about losing this patient that had fought so hard to live. Our patient was 52.
The difference between being a surgeon in a teaching hospital (think university hospital) and a private hospital is that everything comes to the university setting. When the private guys want to spend some quality time off, they often ship their sickest patients to us because we provide full coverage over the holidays. Many private physicians are reluctant to perform large surgeries during the holidays because they know that the staffing at the private hospitals are very sparse. While we were on holiday schedule (Q2d with 24-hours on and 24-hours off), we were better staffed. I covered two services during the holiday period. I covered the Vascular Surgery unit and the Burn Unit. I had a full house in the burn unit. A private hospital would not even run a burn unit over the holidays. We had several patients come into our unit over Christmas.
In the university setting, you are expected to maintain a high level of research as well as practice. None of our attendings fails to maintain a lab or publish regularly. If you look at Sabiston's, one of the premier textbooks of Surgery in use today, UVa Surgery Department has more authors than any other institution. Our department chairman, Irving Kron, M. D. has written and edits his own textbook. Our former chairman R. Scott Jones is the former chairman of the American College of Surgeons. Most of the instructors as this year's meeting of the College were from UVa. My residency director is the chairman of SAGES and a world-renowned laparoscopic surgeon. These guys never rest and relentlessly pursue excellence. This rubs off on the resident staff. When I come out of here in six and a half more years, I will be well-qualified to operate with the best in the country. I should also have a textbook chapter or two written. (The Recall series books are all written by UVa authors) Travis Crabtree is the author of the BRS Surgery review book. Jeff Claridge, one of our chief residents is about to publish a book chapter and about to embark on a Trauma surgery fellowship only to return to Charlottesville.
This residency is demanding both emotionally and physically. I have been fortunate to be able to keep up. I was counting my operative cases done as an intern and I have well over 90 six months into my intern year. That is almost off the scale for every residency program. I have managed to do cases on almost every rotation that I have gone through. Like I stated before, cutting my hours means cutting my case-loads. I am not about doing that. I have gotten the good cases because I have earned them by being willing to stand by and scrub long after other folks have gone home. I have a driven quality but I also have the experience now that I would not have had without putting in the time. It isn't ego, it is love of learning and squeezing the maximum amount of experience and knowledge out of every situation.
Happy New Year!
Nat

Hi folks,
We started our 80-hour work week yesterday with loads of bugs. The biggest bug came when we were inundated with traumas. The super chief is the “go-to” person on traumas these days. At least one day of the month, the trauma chief is home with their beeper off. When this happens and the super chief is in the OR doing a case, there was no back-up coverage if a major trauma comes through. We are working on a solution for this situation.
Last night, as I covered SICU, I had a Trauma resident in the unit with me who happened to be a surgery resident. She was able to take some of the major trauma duties along with the Super chief. Since there has to be at least one resident in the SICU, I was the person for a short period of time. There is a Trauma/Admissions intern who covered the floors too.
The other bug came when it was report-time in the morning. The third-year that is on call for the day takes all of the consults with some help from the chiefs of each division. It took a pretty fair amount of time for the outgoing consult resident to report off to all the chiefs. I see a staggered system coming into play here. The nice thing was that the Super chief and the consult resident got to go home this morning instead of spending the day in the OR under the new system.
Our system is going to work. We are constantly debugging but I applaude the chiefs for getting something worked out that has most everything covered. The major scheduling chief had tons of calls yesterday but we got through the first 24-hours. The learning curve is steep. The other major advantage is that we are all getting to be veterans at patient care. When the new interns come on board in July, it is going to be interesting. We just have to be sure that they are protected so that they can make the adjustments. The other great thing is that we pitched in and worked as a team. This was the best part of the new system.
Natalie biggrin.gif

QUOTE (njbmd @ Jan 3 2003, 08:40 PM)
[snipped] The other great thing is that we pitched in and worked as a team. This was the best part of the new system.

Natalie,
This is probably a "which came first? The chicken or the egg." kinda question, but I'm asking it anyway smile.gif
I am curious to know if the 80 hour work week lends itself to team work. Do you think working as a team is a direct result of this particular type of work schedule? Or is the team work simply a reaction to any change in the schedule? Meaning - do you think the plus of working as a team will stay after y'all get "comfortable" working the new schedule.
Thanks!
-- Rachel
QUOTE (Duck @ Jan 12 2003, 12:39 AM)
QUOTE (njbmd @ Jan 3 2003, 08:40 PM)
[snipped] The other great thing is that we pitched in and worked as a team. This was the best part of the new system.

Natalie,
This is probably a "which came first? The chicken or the egg." kinda question, but I'm asking it anyway smile.gif
I am curious to know if the 80 hour work week lends itself to team work. Do you think working as a team is a direct result of this particular type of work schedule? Or is the team work simply a reaction to any change in the schedule? Meaning - do you think the plus of working as a team will stay after y'all get "comfortable" working the new schedule.
Thanks!
-- Rachel

Hey Rachel,
There was a tendancy for us to think only of the patients on our particular service under the old system. For example, when I was on the Vascular Surgery Service, I would cross-cover the Cardiac patients but I knew that the primary team would be hitting the floor at 0600h so I could pass off any problems and likely not have to deal with them again. Under the new system, if I were the on the primary vascular surgery team, I would report off to a night TCV resident who would cross-cover all of the patients on cardiac, thoracic and vascular surgery service. In the morning, this TCV resident would report to all of us on all of the problems overnight. We would all be involved in the problems of the whole service. As a primary vascular person, I could interact and offer suggestions on thoracic, cardiac or my patients.
Under this new system, as the STICU resident, I do not participate in morning report but remain in the ICU as the various chiefs come to me. It has been great working with all of the chiefs at the same time. I even get to take care of the Urology patients. This sent me running for my Mont Reid handbook to refresh quickly on urological problems.
When I go to a service where I am the lone PGY-1, my OR time is swatted under this new system but on services where I am part of a team of residents such as the Trauma-Gold or Bronze service that I will cover next month, I will get plenty more OR time. Time in the OR is the goal of every surgical resident. The only reason to cover patients on the floor is because you get time to operate. Even if I am "knee deep in butt pus", I am still getting a chance to operate.
We are still working out the "bugs" of this new mandate but we are taking it for a spin and seeing where we land. I pity the programs that have done nothing. Medical students are playing less of a role in patient care. Some like my wonderful medical student, Suzanne, took the opportunity to stay overnight and shadow several residents who were putting out fires on the floors at night. She loves the learning experiences. You have to be very pro-active about your education because none of the PGY-1s are going to spend precious patient care time trying to hunt down medical students who are tucked away reading somewhere.
I still hate leaving the hospital when I could be scrubbing in on some great cases. When I go to the VA Hospital in April, I am going to get plenty of cases because we are not bound by these rules. I can't wait!!! biggrin.gif
Natalie

Natalie,
Thanks for responding to my question. It sounds like y’all are making this workable with some positive additions to the system to make it more palatable.

QUOTE (njbmd @ Jan 13 2003, 06:21 PM)

We are still working out the “bugs” of this new mandate but we are taking it for a spin and seeing where we land. I pity the programs that have done nothing.

A few months ago I asked a friend of mine, an ob/gyn resident in Knoxville, how his program is dealing with the changes in the work schedules. I ASSUME he is at Baptist Hospital, but whatever. His response: "[They] think it’s a crap deal. A toothless scare tactic. I guess they’ll deal with it if it becomes a real issue."
Having followed a few of the conversations here and some of the press over the new work regulations, I was shocked by his response. I would expect programs to at least make an effort to address these. Hopefully, his program has started to come up with workable solutions. And as you said, I pity the programs that have done nothing.
– Rachel
QUOTE (Duck @ Jan 16 2003, 09:03 PM)
Natalie,
Thanks for responding to my question. It sounds like y'all are making this workable with some positive additions to the system to make it more palatable.

A few months ago I asked a friend of mine, an ob/gyn resident in Knoxville, how his program is dealing with the changes in the work schedules. I ASS*U*ME he is at Baptist Hospital, but whatever. His response: "[They] think it's a crap deal. A toothless scare tactic. I guess they'll deal with it if it becomes a real issue."
Having followed a few of the conversations here and some of the press over the new work regulations, I was shocked by his response. I would expect programs to at least make an effort to address these. Hopefully, his program has started to come up with workable solutions. And as you said, I pity the programs that have done nothing.
-- Rachel

Hi Rachel,
This new reg by the RRC (Residency Review Committee) will become very real on July 1, 2003. My program, being fairly progressive, wanted to make the adjustment now as opposed to trying to shift in July when the new residents come on board. So far, it had been working with minor adjustments. The programs that choose to ignore this reg are going to find themselves on probation. Just ask Yale Department of Surgery that wanted to keep the PGY-1s on a Q2 day call schedule. They found themselves on probation in a heartbeat. Howard peds, radiology and urology was not providing accomodations for teaching residents and found themselves on probation. (We are talking residency programs NOT the medical school which received a 100% accreditation rating in 2002! biggrin.gif ). The University of Maryland Surgery department also found probation in their future because of scheduling. This is real folks. The better departments are taking steps now before the hammer hits.
Natalie

Medicine interns for programs at GWU, Georgetown, and Howard are all being asked to keep track of their hours for the next two weeks at the VA. (presumably this is also going on at other hospitals, but this is what I’m seeing) Our chief has bent over backwards to make sure everyone understands that they are to put down their REAL hours - neither minimized nor embellished. The programs are collecting the data in order to put into place their plans for meeting the requirements before June. So they haven’t actually changed the existing setup yet, but they are thinking ahead. I’ve heard from people in other places where a variety of experiments are ongoing, so that they’re ready come June.
For me, it will give me an opening question in my residency interviews next fall - yay. I was so super-saturated with advance information about the MD programs I applied to that I didn’t have any questions in my interviews, and felt inadequate for it. tongue.gif

Natalie,
Your post is the first I've heard of Maryland being/going on probation. I interviewed there and though I haven't done my rank order list yet, they are in my top 3-4 right now. They seemed to be trying to comply, or so they said. Any insight you have would be greatly appreciated. I plan to cross of my list any program that isn't working on compliance (don't need to deal with having a program put on probation while I'm there)

QUOTE (md03 @ Jan 26 2003, 01:57 PM)
Natalie,
Your post is the first I've heard of Maryland being/going on probation. I interviewed there and though I haven't done my rank order list yet, they are in my top 3-4 right now. They seemed to be trying to comply, or so they said. Any insight you have would be greatly appreciated. I plan to cross of my list any program that isn't working on compliance (don't need to deal with having a program put on probation while I'm there)

Hi there,
It is going to be difficult to cross any programs off your list because coming this July, all programs will be flirting with probation unless they get the resident hours under 80. Maryland was on probation last year because of Q2day scheduling. Dr. Barbara Bass said that they managed to get that situation under control. Go to the ACGME website and check to see which programs are currently on probation. I can tell you that Howard and UVA are not. rolleyes.gif
Nat

Uh Oh, now I’m feeling woefully out of touch. I wasn’t aware that there had been any kind of limitations on work hours or schedule for any program outside fo New York up until this 80 hours thing was passed (and that doesn’t take effect until 1 July). The program as my school also had some q2 rotations (which I did during my surgery clerckship) up until they started trying out new schedules to ensure they will be in compliance come July.
And as far as crossing programs off my list, what I meant was if I encountered any program that declared intent to not even try to comply (such as the program Rachel cited saying that it’s a “crap deal”). I havent encountered any program not working on schedule changes during my interviews (I interviewed only at strong, academic surgery programs). However, one of my classmates interviewing for internal medicine said the Hopkins IM program bascially stated they felt that the rules don’t apply to Hopkins residents. If I had encountered that attitude at any program, I would have elimiated that program from consideration.