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Cyclops_is_Right t1_j1zr1bt wrote

Reply to comment by WookieeSteakIsChewie in How do shifts work on really long medical operations? by TerjiD

Unfortunately, we’ve learned that continuity of care is better for patient outcomes in practically all scenarios compared to physician rest. Handovers may occasionally result in loss of information leading to poor outcomes which is just the nature of switching hands.

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thegypsyqueen t1_j20dllp wrote

There is no true comparison study of these strategies and for every study looking and finding handoff errors there is another showing long shift lengths also increase errors. We very much do not know which one is “better” but physicians would argue that it’s not humane to accept a system that forces them to work 24, 36, or more hours in a row. We are already working an incredible amount of hours in a week. My point is, this is not a forgone conclusion and the biggest study looking at your argument of increased hours being superior for reduction of errors was a biased study conducted by a group of resident directors.

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LonelyGnomes t1_j21i7uh wrote

Pretty sure a study was recently published that physicians on average thought fewer handoffs were better for patient care, but would not want to be seen by a doc at the end of a 24 hour shift. So basically we’re hypocrites.

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TheRomanRuler t1_j20mkgd wrote

But why can't you do them in such a way that you got 2 surgeons working at the same time, each with 8 hour shifts but which start 4 hours apart. So you got 4 hours working at the same time, but after 4 hours one of them is changed. After another for hours one who has not yet changed is changed. Every time one who has been working longer is the primary surgeon at the moment, other assists.

That way you got 4 hours of time to get in touch with current state of the operation.

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Kael_Doreibo t1_j216kom wrote

Your biggest problem with this, particularly in the emergency departments, is the sudden onset of emergencies, their scale, and the time needed for certain surgeries/procedures. There are times when you, as a medical practitioner, need to be on for the entire period that it takes to resolve the onset of cases before you because any switch-over will result in loss of information and potentially death. With so many emergencies happening all the time in a larger population/operational radius of the hospital it become untenable to keep to that kind of schedule consistently and any inconsistencies results in a cascade effect across rosters/schedules.

It's good to at least attempt to keep to that kind of schedule and it makes sense to try it at least but ultimately it is impossible to just say "this is the solution" for every scenario.

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ninecat t1_j21qd73 wrote

There is already an international shortage in all of the medical professions. Emergencies don’t work to rosters and medical culture trains doctors and especially surgeons that they are super human and can carry on robotically despite fatigue.

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Boring_Vanilla4024 t1_j203ty7 wrote

Yep, and as much as residents love to complain about how much they work, there really is no other way to pack all of the training a physician needs in a few years. There is still a ton to learn and master as an attending.

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El-Diable t1_j207eo8 wrote

Then why not pack it in a few more years?

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Boring_Vanilla4024 t1_j208dob wrote

That would be one option. But physicians already aren't making real money and starting their lives until early to mid 30s as it is. I think most residents today wouldn't want that option though. They essentially want more money for less work hours/less training. They have high confidence and really don't understand what it is like to be out on your own, making most of the decisions on your own without being able to ask your attending what to do.

I personally was happy to get done in a shorter time even if that meant several years of 80-100hr work weeks.

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Purecasher t1_j20ib8n wrote

Do you really believe this, or have you gotten used to hearing and/or making up these excuses. If you looked at how other countries train their physicians, you would know this is not true. I mean, just by reading this, I know what country you work in, doesn't that mean something to you?

Residents are needed to keep continuity of care, and they are cheap and profitable. There's also no good reason they can't be paid more... You act as if wanting more money and less work/hours is in any way a bad thing. But clearly, because of people and a mindset like you, this is neigh unchangeable.

Just stop pretending it's a good thing that people are getting used like this.

More rest and free time add to better learning.

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Boring_Vanilla4024 t1_j20k581 wrote

Less work hours means less exposure to learning cases. End of story.

Also, residents certainly do a lot of work. But every decision they make needs to be supervised by an attending. A private practice attending often can do the work a team of residents does at a training facility. I really don't think they're grossly underpaid. Maybe somewhat, but it isn't like they're working in sweatshops. And, at the end of the day, they are being paid to be trained. It costs serious money to train a resident.

I'm all for more rest and free time if the number of years of training is increased to compensate the loss of experience.

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Purecasher t1_j20m8md wrote

That's the only reasonable alternative in your mind, which does not surprise me. Except, it is possible to train physicians without significant quality difference, with less exploitative working conditions in the same amount of time. AND there are fewer medical errors.

To me, it is truly laughable that you consider it a privilege that residents are paid to be trained when you calculate how much they bring in as revenue and quality of life for the graduated physicians. Admittedly, I don't know much about the numbers in your country, to that regard.

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Boring_Vanilla4024 t1_j20pn99 wrote

It can cost upwards of $180k per year to train a resident in the US. Stop with the BS about how much revenue they bring in... they don't, and they're a liability.

When I worked at an academic center my residents were often out the door on non-call days hours before I finished. And you spend a ton of time teaching, looking for and catching errors, and explaining to angry family members why what the PGY1 said on pre-rounds was incorrect. Residents don't bring more quality of life to attending, but quite the opposite. Academic attendings are rewarded by being paid less than their private practice colleagues.

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jbeansyboy t1_j21b0ez wrote

I tend to agree with most of what Vanilla says. I’m a relatively new private practice general surgeon and I’ll tell ya, I wish I had more time in residency, or at least more time for what I do.

I trained in the days of the “80 hr work week”. All the older folks say they are much better than us because they worked 120 hrs, etc. I think they may have graduated slightly better at overall surgery because they didn’t have to deal with as much administration as we do and most things were operative back then, AKA trauma solid organ injuries, AAAs, or intraabdominal abscesses are a few quick things that come to mind vs now we nonop most of those things.

Additionally I think they had the confidence to think they were good to go after residency because they had more autonomy back then. Most hospitals require attendings in the room now vs back in the older days, residents could operate alone. The ACGME leaves it up to the attendings to allow residents to operate alone but the hospitals have rules that supercede that if more conservative.

This all being said my 80hr work week was never such. Always in the high 90s and on transplant in the low 100s. But we log it as 80. Because we don’t want to get in trouble or losing credentialing.

I would be in favor of lengthening residency with the last year kind of a…. Pseudo attending year where you can operate alone with someone in the hospital in case you need it. You run your own clinic, take your own call, etc. and then having less hrs per week.

But I don’t think I would be in favor of tacking on more years for that. I’d like to get rid of some of the basic science in medical school. I spent a year relearning basically everything I learned in undergraduate courses. That I never use now. I’d just put those things as prerequisites to medical school.

I’d also like to see more direct pathways to specialities ~5 years if one chooses. I do private practice MIS/gen surg. I spent many many many hours and days helping with liver and pancreas transplants that I do not feel help me on a regular basis, or ever. Maybe see a few but not spent 20 weeks on the service. That time could have been seeing and doing more bread and butter surgical cases. Same with endovascular and etc. vascular and CTS are moving toward this.

For those that aren’t sure what they want to do they would have to finish formal residency and then do fellowship like we currently have.

For things like family medicine, emergency medicine, peds, and derm, it already seems very doable how it’s set up. They didn’t seem to work many hrs at all given how their speciality. Good for them!

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Raddish_ t1_j20noxq wrote

Uh is training a resident really that expensive? At what point are they just getting money back from not having to hire mid levels.

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Boring_Vanilla4024 t1_j20oy5g wrote

It can be upwards of $180k per year. This was in 2014.

The Costs of Training Internal Medicine Residents in the United ... https://www.amjmed.com/article/S0002-9343(14)00596-8/pdf

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passwordisnotaco t1_j20qiok wrote

Good thing that, in 2015, over 25% of hospitals received more than $180k in government funding for each resident they trained. https://www.fiercehealthcare.com/practices/study-suggests-medicare-overpaying-1-28b-annually-to-support-residency-programs

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Boring_Vanilla4024 t1_j20tbs6 wrote

Great. Pay them more, and be sure to pass along some to the attendings that have final say in all decisions and bear all the liability. Don't train them less.

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YoureGrammarWronger t1_j20tadx wrote

Yes withy he exception of breaks. With breaks, even with the handovers, there is an increase in positivity of outcomes.

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SleepyMonkey7 t1_j21qzpg wrote

I've often wondered about this. Are there any studies showing this? I've heard from a few doctors that's it's this way just because 'it's the way it's always been done.' Also wonder if there is truly nothing that can be done about information loss during a handover. We've become pretty good with information these days.

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