Wednesday, July 23, 2008

Are you guys ready for this?

Another July has arrived, bringing with it another fresh batch of young, impressionable, enthusiastic general surgery residents. According to statistics, most will end up doing fellowships and pursuing jobs with minimal call coverage such as "breast surgeons" or "minimally invasive surgeons". Whatever that means. But some die-hards will stick it out and take a job as a true general surgeon in a community hospital setting. Those that do are going to have weekends like my recent Fourth of July weekend; a weekend straight from hell.

Looking at the call schedule on the preceding Wednesday, I noticed that I was on trauma call at one hospital and ER call at another that weekend. I was also covering another busy general surgeon who was out of town on vacation. It was a confluence of circumstances conspiring simultaneously to create a perfect storm.

I went to sleep Thursday night at around 11. I woke at 5am and worked all day. At around 4pm the pager started and wouldn't stop, smoking from my hip. Level I trauma. Appendicitis. Diverticular bleed. I never went home Friday; operated all through the night, and then went straight from the OR to the floor so I could get rounds started. We had fifty (yes, five-oh) patients in both hospitals combined. I rounded for 7 hours on Saturday morning. New consults, new admits, pages of names on my list. I got home around 2:30pm, ate a Pizza pocket and mowed the front lawn. Your pager's going off again, my wife called out to me. Back to the hospital at 5pm. Free air, another level I trauma, a sick patient in the ICU, an incarcerated hernia. Again, I operated all through the night. At 5am on Sunday morning, I crashed out on the floor of my office for 45 minutes, not really sleeping, but not really conscious either. The pager went off again. I started rounds, struggling to concentrate, but getting through it. I started having paranoid thoughts that the Starbucks guy had given me decaf instead of the Americano I had ordered. I got home around 1pm. The backyard needed mowed. I can't stand asymmetry when it comes to back and front yard grass length. I mowed the back yard. What the hell are you doing?, my wife yelled out at me. I ate like a wild boar Sunday evening. I stuffed myself and ate and kept eating. I hadn't had a regular meal in almost 48 hours. Then, for some reason, I couldn't just go to sleep. I was wired and anxious and kept telling rambling incoherent stories. Finally, I dozed off at around 10pm. But the pager went off like clockwork every hour on the hour until my alarm went off at 5am on Monday. I showered and shaved for the first time in three days and went into the hospital to make some rounds. My partner took one look at me and told me to beat it after lunch. I got home around 3pm and crashed out for the night shortly thereafter.

Now this wasn't by any means a typical call weekend. It was an exceptional weekend; nonetheless it happens two or three times a year. You just have to suck it up. I made it through just fine. I took care of a lot of patients. I did some good work. No one was compromised by my lack of sleep. I couldn't do it every weekend, but every once in a while duty calls.

So you're a general surgery intern. You'll be working 80 hour weeks (and possibly less than 60 hrs if further reforms are implemented). Post call, you'll be eating a nutritious breakfast and reading the newspaper in the comforts of your own home by 8am, irrespective of any work that remains to be done on the patients you cared for over the night. The next day, you'll show up bright eyed and bushy tailed and completely clueless about what happened to the bowel obstruction you admitted while on call or the results of the CT scan that you ordered on the ER patient who had some vague LLQ abdominal pain. But hey, you'll be rested. You probably got a chance to read three chapters of Sabiston. You'll ace the inservice exam.... but will you be ready for the sort of weekend I just described when you're an attending surgeon?


Rural Doctoring said...

I agree absolutely. Some of the longest days/weekends I have ever worked have occurred AFTER residency. I've pulled more 36-hour shifts and no-sleep-for-three night weekends in the past three years than all three years of FP residency combined. If resident work-hours are further restricted, we run the risk of having board-certified physicians who can't rise to the demands of a real job. Especially in areas of physician shortages.

Get some rest. You'll be feeling that weekend for a few weeks more.

MedZag said...

"So you're a general surgery intern. You'll be working 80 hour weeks (and possibly less than 60 hrs if further reforms are implemented). Post call, you'll be eating breakfast and reading the newspaper in the comforts of your own home by 8am, irrespective of any work that remains to be done on the patients you cared for over the night. The next day, you'll show up bright eyed and bushy tailed and completely clueless about what happened to the bowel obstruction you admitted while on call or the results of the CT scan that you ordered on the ER patient who had some vague LLQ abdominal pain. But hey, you'll be rested. You probably got a chance to read three chapters of Sabiston. You'll ace the inservice exam.... but will you be ready for the sort of weekend I just described when you're an attending surgeon?"

I'm a medical student so by nature of course I should want the shorter hours and to finish Sabiston during residency, but these are the exact reasons I don't think we should go below 80.

Anonymous said...

As one who has spent more time with a general surgeon than I care to remember, thanks for the good work you do. Your weekend must have something we patients will never understand.

Normally the doc gives the advice, but this time, "Hire a lawn care guy--patient's orders."

Anonymous said...

I agree about hiring a lawn care guy. We have a guy who comes every week, does our mowing and all the trim. he is good too and he charges us 25.00 per week.

Anonymous said...

Jeez Buckeye, I kept waiting for the part where the Gimp came out from his Hole in the basement. 50 surgical patients! Jeez I barely had 50 people on my first paper route and thought it sucked. Never understood why the 80 hr thing only applies to residents, oh Yeah, that Bill of Rights thing. Keep up the good work.

Unknown said...

Thanks for making the time to write this blog and so well too. I've lurked for a while and just wanted to say how much I've enjoyed your anecdotes and insights.

Josh said...

Not to disagree with the end of you post, but current resident/intern post-call mornings do not end around 8AM. More often I and everyone else get home around 1-2PM.

Anonymous said...

I am duly impressed by your wild weekend (and mowing the lawn, too!).

But what you and other current attendings don't understand is that we didn't ask for these rules. I don't think at any point residents were asking for them, except perhaps a few activists. Those of us who entered the system after the rules were made certainly have no choice in the matter. I'm just as concerned as you are about my ability to handle this kind of call without previous experience under shelter of an attending. I know the chiefs who graduated this year had more than a little trepidation about entering the real world as the first class to train entirely under the 80hr week. Ragging on us doesn't fix the real problem.

Maybe the attending surgeons in private practice should organize/sign a counterpetition against this much-rumored 56hr week.

Unknown said...

I have to respectfully disagree about work hour restrictions. Speaking as a 2nd year resident, I don't know if I can believe that patients aren't compromised by our lack of sleep. The question is - how much is the care compromised? Is it enough that it should it be part of informed consent - alerting the patient to the fact that you are on your 30th hour without sleep?

One may argue that since the patient has no choice in the matter (you're the only surgeon - so it's you or nothing), that it makes no sense to let the patient your sleep status - similar to how we don't regularly divulge where we went to school or did our training.

However, as physicians, we DO have some choice in to whether we want to put ourselves into such a situation where 2-3x a year we do 36-40 hour stretches are expected. We shouldn't put ourselves or our patients into that type of situation. And I understand the financial concerns and the shortage of general surgeons (and FP's AND primary care internal medicine docs), but the situation isn't going to get better anytime soon. So we're okay with these stretches for 2x/year. How about 4x/yr? How about 6? How bout every other month? Sounds really fun. We need more of us - pure and simple. And that's not going to happen until they start paying these specialties better. And that's not going to happen until there's some political call for action. And that won't happen until some senator's daughter's appendix ruptures and there's no general surgeon around to fix it. Honestly, a part of me would want that type of change to come sooner rather than later.

And I don't believe that by having these 36 hour stretches regularly during residency, we're somehow "training" ourselves to be good attendings later on. It's the same as the frat guy who drinks during the week to "get ready" for the big party on the weekend. Um... no. You're a dickhead for the whole week instead of just on Sunday morning.

Guy said...

I don't mind people with the residency restrictions but when they get out, people are sadly dissappointed when they make less than pharmacists and CRNAs. This is what managed care has done to surgeons.

Also the fps are going to keep arguing and saying you got 500 for an appy and it only took an hour and I work with a new medicare pt for an hour and only got 150, but that doesn't include preop, postop, and all of the days of rounding, including the 7 days of ileus that the patient had.

Sometimes strictly getting paid for a visit sounds better.

Gary M. Levin said...

Dear Buckeye;
Perhaps we should calll you Blearyeye.

The other comments were interesting, from 'good going' to 'what's the matter with you?'

On a spectrum of humanity and experience the only other hypomanic individuals in this
class are naval officre captains
who command large ships.

No one can keep going at your rate without developing some serious chronic medical problems....shortened life, emotional breakdowns.

Training for 100 hours will not ensure you can do it in practice.
Do you think you will be able to continue at age 40,50,60 ?

I can give you endless stories about heart surgeons, general surgeons who died in their 40s, prematurely. How many patients more could they have seen in the next 20 years had they lived a balanced, alhough very busy lifestyle.

What do your kids and wife do during all this time away and the time you are collapsed on the floor.

Your issues are a lot more than mowing the lawn.

I love your stories, and because of this I give you this perhaps unwanted opinion, after 40 years as an eye surgeon.....two marriages and five children.

Priorities....God, Family,then work.

Daily exercise, even when on call.
Nutrition....follow your own advice as a doctor (actually consult someone in the health and wellness field)

Learn how to be more of a type B
personality. Your type A served you well to get through college, medical school, residency and the early years of practice. Life is like seasons.....they change....wherever you are now, you shouldn't be doing what you were doing earlier on.

Residency hours were decreased,not to protect the residents, but the general public. Many studies have shown the error rate jumps for sleepless doctors. The decisioins were made by objective people who had nothing to gain or lose regarding residency hour limits.

make mine trauma said...

"I started having paranoid thoughts that the Starbucks guy had given me decaf instead of the Americano I had ordered."

HAH! That's funny! I've been there. After so many hours the coffee just doesn't work anymore and you really do start to wonder if someone's making decaf. Then, when it's all over and you finally have the opportunity to sleep, all that coffee comes back to haunt you and you lay awake spewing gibberish.
Can't believe you decided to mow the lawn....twice!
And the eating can only survive on peanut butter and crackers or dry sandwiches for so long before you become ravenous for real food.
Around here, the trauma docs are required to stay in house. Trauma is one 24 hr shift and never two in a row (post call you become back-up), and they can't cover ER call at the same time.
That was truly a long demanding weekend, but doesn't it kinda make you feel good to have one of those every once in awhile? (Easy for me to say, I only have to do the fun part) Here are some more examples of just how tired one can get.

Bongi said...

you mowed the lawn? twice?

are you mad?

other than that, i'm with you.

Jeffrey Parks MD FACS said...

Alice- AMSA is one of the biggest driving forces behind the new intiatives. So in a way, new surgeons are asking for it. I don't mean to rag on you; I just think there's more pressure on your generation of trainees to milk every last ounce of experience from the time spent in residency. You'll be fine, Im sure. But for some others...

Drack- I always appreciate a well placed Pulp Fiction reference.

Make Mine T- Thanks for the cool links.

I knew you'd be with me on this one, Bongi.

Anonymous said...

AMSA shmamsa. Those guys are presumptuous idiots; like the AMA, they claim to speak for all of us when the majority of us don't belong, could care less about their initiatives, and are often embarassed by their actions. AMSA also supports the single-payer system, and I went out of my way in medical school to vocally set out the contrary point of view. If I'd known in medical school what I know now, I would have either a) not done surgery (intelligent, but unsatisfactory), or b) opposed their efforts in this direction as well. Seriously. AMSA is a student organization; who invited them to push residency policies?

Anonymous said...

And Keegan is living in a dream world. There is a shortage of surgeons, so some surgeons will continue to work incredible hours. That can't be fixed simply by saying that we don't like it; and I doubt that compensation for surgeons or other physicians is going to increase anytime soon. If anything, I bet the primary docs get a bigger piece of the pie, and we keep losing.

Unknown said...

re: Alice

I agree with you that it's not enough to say simply "we don't like it." There are actions we can take. We can always walk away.

The recent Medicare fight is a good example. I'm sure most of it was a political maneuvering to satisfy the AARP, but we (the docs) made a big stink of it also - and our primary threat was that we would stop taking Medicare patients. Period. We came up with stories, testimonials of how great doctors were closing their doors to new Medicare patients. We said "you think a 6 month wait for a primary care doc is bad... try 2 years." I think it partly worked. Not enough for the Senate to do anything more drastic than to stall the cuts, but at least it was something.

But THAT'S our action... our inaction.

Being an FP, I sympathize with general surgeons. I honestly think they should be paid twice what they get now. Hands down. As an FP, I have the option of opening a concierge practice, charge 50-100/month and take on a panel of only 600. I don't need to take Medicare. Don't need Medicaid. Why would I want to be part of a system that systematically screws us and our patients over each and every year? Why would I choose to prop up an unsustainable system like that? It makes no sense.

Unknown said...

... but thinking about it, (and please correct me if I'm wrong), I don't know if there something comparable to concierge/retainer medicine for surgeons. Is there a way for general surgeons to opt out of the Medicare/Medicaid system? I just honestly don't know. I'd love to some thoughts on the subject...

Family Med Resident said...

I'm glad there are still some surgeons who actually choose to serve the patients they professed to care about when they entered medical school. It would be easy for you to open up a boutique practice and make lots of money for lots less hours, but you keep doing what you do, so thanks.

The one quibble I have is that people who trained in the 36-hour plus shift world think that when we only work 27-30 hours we don't find out what happened to that guy with the abdominal pain or that lady with the surgical abdomen who actually had ovarian torsion etc. We actually *do* know what happened. Why? Because we work as a team and we continue to follow patients at a team. So although I leave the hospital for 10 hours or so, the people I take over from when I get back tell me what the CT showed, that someone crashed, that someone developed a bleed. You don't have to actually be the one who was up for 36 hours, pushed the guy to CT scan, drew an ABG and found out he had a PE to learn from the case. He was on his way to a PE when I left 10 hours ago, and he still has a PE when I came back. I don't think that the scut work of answering pages and getting studies done is necessary. When I come back and see that Mr X is on a vent, I think back on what happened. And I wager I care a bit more about him than I would have if I hadn't slept for 2-3 days.

My point is that I think the continuity you speak of is over-rated. I had the continuity in med school: Q3 overnight and no going home post call. I followed cases for 40 hours or more. All I learned from the experience was to be jealous of those lucky people with pancreatitis who got to lie around in bed all day.

Anonymous said...

FMR, you also learned that you can work all night and work the next day. You didn't know that before med school. It's a valuable lesson to learn, once you are out in practice and have to do it on occasion. It's not fun, but it's life.
And don't even joke about being envious about the guy with pancreatitis. You never want to be the consumer in this business.

Anonymous said...

Sleep deprivation is just a part of our job as clinicians in residency and in practice alike; i hardly think being jealous of patients with pancreatitis is FMR's point. Take it easy, JB.

Anonymous said...

Wait until you start practice. The transition will not be smooth at all with resident work-hours.
Teaching quality is not the same anymore with the new working hours.

Check this intresting article
Effect of ACGME Duty Hours on Attending Physician Teaching and Satisfaction

Vineet Arora, MD, MA; David Meltzer, MD, PhD

Arch Intern Med. 2008;168(11):1226-1228.

Anonymous said...

It's not the hours. It's all the stupid things THEY waste your time on as a resident.

No smart resident would have anything against 80-100-hour weeks IF all those hours were truly educational. But 50+% of those hours are wasted on stupidities that sound good only on paper. This is why people prefer reading their textbooks at home to putting in Foleys and pushing beds at the hospital.

The residents are not your bitches. They are future attendings and they should be treated with the same respect as an attending, especially by non-MD's. Hospitals make a lot of money on the backs of their residents, and they should start returning the favor and treating residency as a 100% educational activity, not as slavery.

Anonymous said...

Get used to the “stupid things THEY waste your time on.” I’m in my 3rd decade of practice as a board certified surgeon, and believe me, the “stupid” things never end. 3 weeks ago, I was called out of bed to insert a Foley that the nursing staff could not get in. I was able to get it in because of the hundreds of times that I had done that “stupid” task as a student, intern, resident, and attending. The truly “stupid” thing is preferring reading a textbook at home to hands-on front line patient care exposure. The reason that some prefer reading a textbook is that it is something that some people are already good at. When you are in the hospital, you have to do things as a student or trainee that you may fail at, may be humiliated that a nurse or tech can do better than you can, or that get your precious little hands dirty doing.
To state that hospitals make money from educating residents reveals a fundamental ignorance of health care economics- the opposite is true. It takes a lot longer and costs more money to get any intervention done in a teaching hospital. Even Medicare recognizes this, giving extra funds to hospitals that are involved in graduate medical education.
While “bed-pushing” (I never had to push a bed, even when hours were unlimited) is a waste of time, thinking that you are someone’s “bitch” for having the privilege of receiving a medical education reveals a level of arrogance and ignorance that puts into question your suitability to make good use of the educational opportunity that you are receiving. Step aside and let someone else have your place- someone who will be less resentful. It’s not slavery when you can walk away anytime you want.
BTW, you will have to earn the respect that you crave, even as an attending MD. They may smile to your face because they have to, but they will be mocking you when you are out of earshot when they know how you view “non-MDs.”

Anonymous said...

Kudos to you for sucking it up and doing what's right on a holiday weekend. I'm with Bongi, though--mowing the lawn on top of it all...NUTS.

All I wanted to say, playing a smidge of devil's advocate here, is that it's VASTLY different to pull a weekend like you did and know from the outset you'd return to your baseline schedule, both for overall morale and knowing at the time it has an ending, than having that kind of life be the baseline, as it was before the work-hour implementation. OK, maybe not quite that bad all the time, but the point is that extremes can be dealt with as long as the person is flexible and knows they happen. However, it also has to be a reasonable increase from what they were working before, not a 500% increase. I can't say much about the 80h, but the 60h (first I've heard) is BEYOND RIDICULOUS. I worked that as a computer consultant regularly with no overtime (though avg billed hours were considered at bonus time), and I certainly didn't have human lives in my hands.

The other fallacy is the accross-the-board implementation of the hour limit. 80h/wk will greatly impede a surgical trainee's learning possibilities as the job requires specific vigilance/work beyond clock hours while a path, rads, derm just to name a few, couldn't be further opposite in terms of needs/issues. To lump all these residents in one basket is already mistake #0 before any hour limit is imposed.

Ok, I rambled-sorry. Great post, JP.

Anonymous said...

the hospitals do make money on residents.
in addition to the bump you mention, which are indirect medical education funds, they receive direct education funds that averaged (several years ago), 120k per resident from medicare.

i didn't glean from the post the same things you did. from my internal medicine residency many years ago, the things i considered junk work were arranging disposition at nursing homes, filling out endless forms that anyone could have filled out, drawing bloods, running things to lab, caling around to find patients a primary care doctor in their home town. of course i still have to do most of that (except the blood draws and running things to lab) now.
agree with you on the value of front line education versus book learning. every day during residency is precious, even if you don't realize it at the time.

Jeffrey Parks MD FACS said...

Well put jb. The "scut" I slaved over for hours as an intern now is done by .....ME. Only I do it 700 times as fast and without even thinking about it as an Attending.

Even transporting patients was useful. You'd have to figure out how to work the IV machines, unhooking them, pausing them, etc. And you got to explore the hospital; cardiac stress tests, radiology, going to the lab.

Being an intern/lowly resident isn't all about "medical education". You aren't a student at Yale anymore. You are an employee at the bottom rung of the medical profession, trying to learn as you go along. It's this Gen Y "Age of Entitlement" that we see...

Anonymous said...

So many of you are missing the point. There will not be any days like this when the current generation of residents are attendings because we won't stand for it.

the difference between the current generation and the older generation is that we value our lives outside the hospital, being well-rounding, seeing our families, volunteer work, and so on. We no longer define ourselves by our jobs alone as you do. We appreciate that medicine does not have to be the way you think it does, it can be done differently and it can be done better. The only problem now is that we still have to deal with attendings like you who are so hard headed you can't understand how these changes could possibly work. Like many things in medicine, it will take 40 years for this to come about properly, but it will work in the end and work much better than it does now.

When you die, you will say, I was a surgeon. You will have done has much harm as good in your profession (as any person in medicine does) and your patients will have gone on to abuse their bodies and be ungrateful for what you did for them.

When I die, I will have been an internist. I will have done as much harm as good in my profession and my patients will have gone to abuse their bodies and be ungrateful for what I did for them. I will have worked half as much as you, formed tight bonds with family and friends, volunteered for a charity, traveled the world, and retired to a loving wife, stimulating hobbies, good friends, and a full life.

The change is happening and there is no stopping it now. You can spout your dooms day scenarios all you want, but the new system will work so much better than the current people will wonder why we took so long to change.

Jeffrey Parks MD FACS said...

Anon- Be careful with the generalities. I enjoy my life as is. I love my wife. I work out 4-6 days a week. I write and read what i like. I don't feel I'm "missing out" on some unexperienced "perfect life" that would be available to me if only I didnt work so much.

And if I truly thought I did as much harm as good in my profession, I don't think I'd be able to come in to work tomorrow...

Your comments are probably not representative of your true inclination; more likely you'll find that you WANT to spend more time with your patients. You'll WANT to commit yourself to the optimization of their health care needs. That's medicine. If you truly define yourself as The Doctor, it's inevitable....

Kipper said...

I worked in tech operations through the dot-com boom, and while I would never imply that the body of knowledge I needed to bring to bear in my work was as far-ranging or that the consequences were as grave (my errors could cost a great deal of money, but in the end it was *only* money: no one ever died because a website went down), the time commitment and the need to bring analytical skills, quick thinking, and accuracy to bear in high-pressure low-sleep situations was similar. The need to manage on-call time in a professional and disciplined fashion was also similar. And y'know what? I and my cohort stepped up straight out of undergrad -- in some cases straight out of high school -- with no particular pre-professional training to prepare us meet the pressure and time demands.

So I think your new doctors will be fine (at least the good ones), the same way my colleagues and I were fine.

Linkster said...

I love your blog. But I am a chronic every day pain sufferer who receives no respect from Medical Physicians, besides "seeking meds labeling".
When I see you complain of being tired, I will gladly trade you my situation for yours any day of the week 365.
I know what it feels like to not be able to sleep for 4 days straight, and I cannot function after the first 30 body goes into spasm mode, I feel shaky and my pain is unbearable...but somehow someway I am still here.
I just got back from vacation from Worlds of Fun and Schlitterbahn Water park for three days and I have been in bed or reclining ever since (75 hours ago) I just cannot recover.
I know I have the intellect to be a doctor but I do not have nor ever had the stamina it takes.
Wish you well, don't understand how you guys and gals do it.
Jeff in Nebraska