You talk about how you old school guys were so much tougher because you worked 120 hours a week, but you guys also got the rewards of working that long. Today, residents are not allowed to do operations by themselves, and at some programs residents are little more than surgical assistants and PA’s for 7 years. There would be no more learning for us by working 120 hours a week anymore… it would just be a waste of time. Let us start taking charge of operating again, and I would be glad to work 120 hours a week to refine my skills… unfortunately that is now called medicare fraud.

I just finished residency this year.  Here is my observations on this issue.

When I used to work 120-140 hours per week… that was insane.  Nobody who hasn’t done this… can really appreciate how grueling this is.  You have to really think about it in order to have a chance of understanding what it was like.  I feel like I sometimes forget, and I lived through it.

Imagine you go to work 5am Monday morning.  You are on call q2 because someone is on vacation.  (there is always someone on vacation at least 50% of the time… though it won’t always effect your call schedule).  You take call Monday night… so that makes your call for the week… Monday, Wed, Fri…

At work Monday 5am
Work all day monday.  Work all night monday
Work all day tuesday.  Home at 9pm-5am. (8 hours)
Work all day Wednesday.  Work all night weds night
Work all day thursday.  Home at 9pm.

From the moment you went to work Monday morning.... until you get home Thursday night.... you have slept ONE TIME probably only 6 hours.  (time to go home, eat, shower, etc)

That is 4 days of work and 2 nights of work… on only one nights rest.

The old system was insane.  So, I do not feel bad about requiring restricted hours for residents.  Simply, residents were abused.

Btw, q2 puts you at 140 hours per week.  q3 puts you at a much more humane 120 hours per week.

I do agree with the others though, the shift worker mentality is awful.  We would be better off with hours restricted to 100 or 110 per week.  These are more feasible, but still allowing people to get the training they need.  You might only need 80 hours per week to be a pediatrician, but I think we can all agree that neurosurgery is much more challenging to learn well.

thanks

Let me preface my reply by saying that I am an intern, so I certainly do not have the experience of many of the guys on this site. I definitely have the utmost respect of everyone who trained in the pre-restriction era. However, despite the question of which system is better, we are stuck with this one. And the people who have not yet entered training have little idea about how these things actually work. Moreover, it certainly was not a referendum of wannabe neurosurgeons that resulted in a work week restriction.

To answer the OP’s question, I do not think there is a single program that does not offer vacation time. However, for those of you not yet in training, keep in mind that one week of vacation usually means literally seven days and you will most likely be on call immediately before and after your vacation days.

I am in an 88 hour program with four people in the primary call schedule (the two PGY2s, and the the two interns on the service be they neurosurgery or off service rotators). When someone goes on vacation, it means that everyone else has a much more difficult call schedule. There are many ways to be within an 88 hour work week averaged over 1 month and still be difficult; as someone alluded to earlier, neurosurgery is not pediatrics or internal medicine.

I guess my point is that, in today’s neurosurgery residency paradigm, you should ask about differences between programs in an anonymous online forum. Even if you are not a neurosurgery attending or senoir residency, you are probably an intelligent individual who should have some idea of what you want to sign on to. That being said, even in a post work week restriction world, neurosurgery residencies are still difficult relatively speaking. It’s ok to ask about vacation anonymously, but don’t see, top concerned about this in person or pick this field if you want a lot of flexibility in your schedule. I am lucky enough to have a wife that is a surgical resident; at least I can see her at the hospital once in awhile . . .

Guest - 14 July 2007 08:34 AM

You talk about how you old school guys were so much tougher because you worked 120 hours a week, but you guys also got the rewards of working that long. Today, residents are not allowed to do operations by themselves, and at some programs residents are little more than surgical assistants and PA’s for 7 years. There would be no more learning for us by working 120 hours a week anymore… it would just be a waste of time. Let us start taking charge of operating again, and I would be glad to work 120 hours a week to refine my skills… unfortunately that is now called medicare fraud.

As someone who trained under the ‘old system’ I definitely agree that less operative independence is a casualty of the 80 hour work week and malpractice.  I feel sorry for residents these days because I think the trend is worsening.  It is a pity that neurosurgery can not afford to withdraw from the ACGME and make its own rules.

I think it’s easy to lose sight of the reasoning behind work hour restrictions.  It has little to do with resident abuse, and much more so with patient safety.  Being awake for 36 hours slows reaction time and impairs decision making ability similarly to alcohol.  Many more mistakes are made my residents (in any field) who are post-call than those who are somewhat caught up on sleep.  So maybe it is that neurosurgeons are super-human and can overcome these physiologic consequences of sleep deprivation.  But considering that you’d be sent home and considered irresponsible if you showed up to work drunk, how is it that showing up to work severely sleep deprived is any more responsible or safe for the patient?

i definitely get yelled at more in the OR when i am post-call vs. not . . .

My training has also straddled the work hour restrictions.  Perhaps I didn’t suffer under the old system long enough to see its benefits.  I think I learn better and remember more when I am not chronically sleep deprived.  Most educational research supports this impression. 

The decreased independence in the OR and elsewhere in the hospital started before the work hour restrictions and I believe has more to do with patient safety and liability.  I love hearing the stories from the old guys about doing open appendectomies as 3rd and 4th year medical students.  Imagine that today.

But I do tire of the the older generation who trained in “the days of old when giants walked the earth” who insist that we who train now are all worthless and weak.  Yes, it was uphill both ways to work and you were barefoot and it was snowing.  Great.  You had to whittle your scalpel from a spoon from the cafeteria, there was no CT, no MRI, blah blah blah.  It is a different world now.  There’s no comparison to the size of the services that we run, the acuity of the patients we care for.  You used to be able to get sleep on a night of in house call.  We generally don’t even make it to the call room.  Did you even have 23 patients on your service, because that’s what we’ve admitted on a night on call. 

So taking that call q2 made you the great surgeon you are today, good, I’m glad.  But maybe if you hadn’t worked so hard you wouldn’t be writing that check to your most recent ex-wife.

Oh, and don’t forget that outcomes are better than ever.  Well, except for GBMs, but that’s another story…

I’m glad there are residents out there who have experienced both pre and post restriction rules, and feel that it’s not so ‘bad’ to not be constantly sleep deprived.

If you read Dr. Nolen’s “Making of the Surgeon” book, you realize he spent most of his time doing scut work (drawing blood, walking the tube over to the lab in another building, running some of the lab tests himself, etc.) Sure he was taking q2 call and working 120+ hours a week but a big chunk of that time was not taking care of patients or learning to operate.

Guest - 18 July 2007 03:42 PM

I think it’s easy to lose sight of the reasoning behind work hour restrictions.  It has little to do with resident abuse, and much more so with patient safety.  Being awake for 36 hours slows reaction time and impairs decision making ability similarly to alcohol.  Many more mistakes are made my residents (in any field) who are post-call than those who are somewhat caught up on sleep.  So maybe it is that neurosurgeons are super-human and can overcome these physiologic consequences of sleep deprivation.  But considering that you’d be sent home and considered irresponsible if you showed up to work drunk, how is it that showing up to work severely sleep deprived is any more responsible or safe for the patient?

What you say about the effects of sleep deprication is true. However, that’s not why these rules have come into being. New York was the first state to legislate work-hour restrictions on physicians, and it only happened after a sleep-deprived resident got into a car wrech on the way home. It’s true that these rules do (should anyway) have a positive impact on patient safety, however, they came into being to protect us, believe it or not.

Well, I have trained entirely under the 80-hr work week (I’m a pgy3), and I disagree on a few things posted here.  For one thing- I think we can all understand that just because the 80 work week exists doesn’t mean that one necessary works 80 hour weeks.  This should not be a surprise for anyone who has done a sub-I in a few places.  At my program, we get around the issue by taking “home” call.  So, we stay at the hospital for a full day post call, basically everyday unless things are really slow. Does that mean you are occasionally up for 36-40 hours straight?  I’ll leave that to you to figure out.

The way we balance that sometimes difficult situation is by having a great weekend schedule (we average 6 days off a month as juniors, and 7 as seniors!) Weekend call is painful, but it doesn’t happen that often.  So you get to stock up on sleep and home time.  Plus, we only take call Q6 during the entire program, so it’s pretty reasonable.  The thing that really makes it worthwhile, though, is the fact that we NEVER miss out on cases post-call, and both the pre-80 hour and post-80 residents feel our operative experience is better now that ever.  This is why we have made NO moves to change the call system(we could certainly move to a night float plan if we wanted to, but the residents like it the way it is.)

But come on guys- there is nothing wrong with wanting to have a reasonable life outside of residency.  That doesn’t mean you’re not “hard-core” enough to make it through.  I live for vacation!  If I didn’t have that to look forward to, those “80” hour weeks would be that much more painful.  Nobody in their right mind is going to ask those questions on the interview trail, but it should be fair game on this board.

For the record- we get one week (9 days) free and clear any time of the year, 7 days at either xmas or New Years, and one week (9 days) which can be used for an expense-paid conference or another week of vacation.  Wish we had more, but that’s why it’s not anesthesia.

Basically, my $0.02 is that you can achieve the 80-hr workweek in three ways:
1) you can be forced to work so fast and so hard that you’re like a nuclear-powered gerbil 80hrs/week.
2) you can be forced to miss out on educational opportunities, conferences, OR time, etc., which is what the Old Guard fears.
3) your program can hire ancillary staff to cover all the non-educational parts of your job, i.e., the scut.

In my opinion, #3 is the most appropriate solution, and it does essentially nothing to sacrifice your training.  It makes you a happier, healthier person, it provides safety for your patients in that their doctor is not a zombie half the time, and I think it actually makes your training more effective to be awake when you’re actively trying to learn.

-- David

What makes you think that option #3 is sufficient to reduce hours from 120 to 80?  As some one who trained under the old system, I think you’d be naive to think option #2 doesn’t happen to some extent.  Option #1 - “the nuclear powered gerbil” is what we were back in the good old days.  We knew what to do, and how to do it when we were so tired we couldn’t even stand, let alone think.  I knew a resident who once placed a ventric while fast asleep.  I am glad I trained then, and further I think the 80 hour workweek is one of the worst things that could ever happen for the future of neurosurgery.  It will be interesting when you people finish residency and have to develop a work ethic to avoid getting sued and being hated by patients and colleagues.  One of my greatest role models when I trained told me he never scheduled anything in the evening of his O.R. days - he thought it was bad luck to be thinking about trying to get out fast.  That’s not a mentality consistent with the current training concept, it’s just the best thing for the patient.

One of the understressed parts of this thread is the point that it is very difficult for the MSIII to understand the difference between 80 hours of neurosurgery and 80 hours of pediatrics in a week.

As such, there are, no doubt, more people who would consider neurosurgery now than “in the old days”.

This means we run the risk of populating the specialty with a higher percentage of people who do not have the passion to make neurosurgery a life calling. Let’s face it, the giants who have moved the field over the years, and who have created opportunities for patients to have better outcomes, have not achieved their impact without extreme dedication to the field.

Sorting out in a one day interview the person who views this as a calling from the person who just thinks this is cool is significantly more difficult in today’s environment. To me, this is the new challenge to the specialty.

Discounting the merits of a PGY2 simply because that individual was born a few years too late to enjoy the wonders of a 120 hour work week is not getting us anywhere. But we need to get much better in hurry at identifying people like the OP, who long before they have ever taken call as a junior resident even once are trying to solidfy their vacations.

At the risk of coming across as a naive 4th year medical student, I’ll offer my two cents:
What’s more important?  Quality patient care, or some tally of “hours worked”?  The problem I see based upon this message board is one of perspective:  some of the posters seem to be more concerned about achieving an arbitrary machismo standard--a scale compared against the straw dog “pediatric resident"--then “working tirelessly for the sake of patients.” Are neurosurgeons in particular, and physicians in general, working hard to provide excellent patient care primarily, or is it more about bragging rights, money, and prestige?  A change in perspective is in order, irregardless of whether one works 80 hours or 148. 

I understand that as we get older our perspectives change and our idealistic notions are tempered.  This is particularly true when one considers a potently high stress field such as neurosurgery, where poor outcomes can seem to be the norm.  But is this “evolution in perspective” the natural course of things, or simply a case of moral and philosophical laziness?  Don’t get me wrong: I appreciate the quandries imposed upon us by “Reality”.  I appreciate the fact that after 36 relentless hours of being “on” the last things from ones mind are the moral implications of dealing with a terminal patient and their family.  I can understand that after the 150th bad outcome that one becomes inured to the implications thereof.  I know that careers can be destroyed, despite best efforts and heroic measures, when a malpractice attorney gets ahold of words said in a moment of empathy-I’m sorry--and twists them to suit his own ends. 

Are these reasons to become cynical, or opportunities to practice mindfulness?
Sometimes the comments on this message board remind me more of kids arguing over the attributes of one comic book hero over another than intelligent human beings at the top of their profession.  And quite frankly, it’s embarassing.  I love neurosurgery, I see neurosurgery as a noble profession, and I don’t want to see it denegrated.

I’m like the next guy:  I’d like to live in a nice house, drive a fast car, and marry a beautiful wife.  But is striving for these ends more important than moral and philosophical integrity?
I ask myself “What do I want to stand for?” Did I go into medicine and choose neurosurgery for bragging rights, or am I studying what I love, and hoping to help others as an end in itself?”

I guess my point is that strength comprises more than endurance.  Does being “tough” mean you are able to push away your feelings, work hard and become numb?  Or does toughness mean you can face your fatigue, doubt, and grief full force and continue to excel? 
To me , true strength means that one can one can face darkness and say"F*%k You!” Strength is wallowing in all of the horrible sh#t we face on a daily basis and maintaining equinimity-not becoming bitter, not becoming jaded, and continuing to strive for the best in patient care.  I’ll be the first to admit it’s tough--I’m by no means the patron saint of equinimity--many people would describe me as a cynical f*%k.  But human beings have the ability to feel empathy, the ability to strive, as well as the ability to reason.  Why not harness all three and shoot for the moon?  Afterall, and at the risk of invoking a cliche, if you miss you’ll still be among the stars.

Purkinje, you are not the only one who is shocked and embarrassed at some of the things that are posted here, mostly behind the veil of anonymity.  Despite your youth you have clearly thought more about what you are doing than many who have been doing it much longer than you.  However, I think you will have to work to keep that idealism.  Thanks for elevating this thead.

This is one of the best threads in a while.

I’m going to have to give props to people like David who are putting their name to the words they are writing. I certainly don’t have the balls to put my name on this post.

I’m also going to side with him in calling out the resident who claims he knows a resident who put in a ventric while “fast asleep.” Let’s say that was the truth, well, use your common sense and ask, “do I see anything wrong with that picture?” Is it “tougher” to drill a hole through someone’s skull and poke a catheter in, or to admit to oneself that you are only human, and you have limitations, and patient safety, rather than this machoistic competition, should be your utmost responsibility.

I don’t blame some of the old-school guys who want to feel they paid the dues to join this good-old boys’ club, and the new generations are having it way too easy. But times are a-changing.