Guest - 22 July 2007 11:42 AM

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.

LOL i wonder how that patient did..."rocky ICU course”?

Guest - 22 July 2007 06:40 PM

Guest - 22 July 2007 11:42 AM

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.

LOL i wonder how that patient did..."rocky ICU course”?

The patient did great.  The ventric was perfectly placed on the first shot.  My point was that there are guys out there who could do this in their sleep - they were that good.  I’m not going to post here anymore, because I see that this board is dominated by junior residents who love the 80 hour workweek.  You people just don’t get it, and I suspect you never will.  Neurosurgery was never about counting hours for us, but I hope you all enjoy tallying yours.  Good luck.

Guest - 23 July 2007 03:26 AM

The patient did great.  The ventric was perfectly placed on the first shot.  My point was that there are guys out there who could do this in their sleep - they were that good.  I’m not going to post here anymore, because I see that this board is dominated by junior residents who love the 80 hour workweek.  You people just don’t get it, and I suspect you never will.  Neurosurgery was never about counting hours for us, but I hope you all enjoy tallying yours.  Good luck.

Before you sign off, tell us again, did you mean guys could do this literally ”in their sleep” or were you using figurative language?

Work restrictions on physicians in training is here to stay, so just railing against it is pointless.

First thing one should understand though is that the limitations is not merely 80 or 88 hours per week, but also limits the amount of consecutive time you can work.  Thusly, the old days of being on call all night and operating the next day until 10PM are out.  Likewise, staying for conferences and teaching sessions might also be out (At least where I trained it was).  Therefore, there is an impact on your education.  Residents needed to be more self motivated to study outside of the hospital on their own.  It also definitely cut down on the total number of cases a resident could do since operating time is more restricted.

With that being said, what is the learning value of your 100th microdisc or 40th shunt of the year?  I started training without the work hour restrictions, but they were implemented during my senior (2nd to last) year.  From what I have seen people who are coming out now are not necessarily any worse trained than myself.  I have also seen neurosurgeons trained overseas where these limitations have been around longer and they are equally well trained to people graduating from residency here.  Of course I am talking about bread and butter neurosurgery, and no high end skull base, vascular, endovascular, spine, etc.  But then again there are fellowships for that sort of stuff and a limited number of these high end cases to go around anyways.  So from the point of view of training a “competent” neurosurgeon who is capable of handling the cases they are likely to see, I think that we will find that there is little impact.

Another limitation of the work hours is the need for one day off every seven.  Along these lines, those who argue against asking about vacation time need to reconsider whether you should be doing this.  The job is taxing, be it 80 or 120 hours.  It is physically, intellectually, and emotionally demanding.  Having some time to catch your breath makes you a better neurosurgeon in the end.  There are times that I was so tired that it was hard to feel empathy for the patient or family cause every minute I saved in talking to them mean a minute of sleep.  As an attending, I can tell you that what saves you from lawsuits the most is having the patient/family feel that you listened to them and took the time to explain things (as well as good doumentation).  The other lawsuits it helps you avoid is the divorce attorney.  If you don’t understand this, I have seen enough people burn out or hurt patients that you should reconsider.  I sure wouldn’t want you as a partner.

The more difficult issue is that of work ethic.  There indeed may be a greater acceptance of the “shift mentality” in future trainee who are used to the 80 hour limitations.  It is hard to necessarily say if this is a bad thing since again many foreign countries have this system.  Does patient care deteriorate because of this?  For patients that I have seen operated on or who are inpatients I don’t think so, because the surgeons collectively take responsibility.  In contrast, here in the US if the attending is in town, he might be expected to take care of his own patient even if he is not on call (it depends on the partnership arrangement).  Since bad neurosurgeons generally are not kept on staff as colleagues, the “shift” system may be acceptable in terms of outcomes, and may possibly be better since those issues with mistakes and fatigue do not end once you leave residency.  In fact, I can remember times when the attending would make decision after he was on call, and you kinda had to “remind” him of things he forgot to prevent complications. I image the problem has to get worse as you get older. 

There is a down side in terms of elective and outpatient care definitely.  The shift worker does not start that extra elective case or pile extra patients into clinic.  Part of accepting the shift mentality is that you are willing to take a pay cut for a better lifestyle.  It will be interesting to see if more grads in the future take up positions at places like Kaiser that pay a fixed salary but where you work shifts.

While we as physicians can debate this forever, in the end the big question is what will the patients accept.  The work hour restrictions were implemented by the ACGME to avoid legislation being imposed upon physicians.  There is already legal restrictions on truck drivers and airline pilots after all.  Whether you kill 200 people at once (and generally pilots only get one screw up in their career) or over 20 years, you still kill by mistakes in each case.  It was issues with patient safety and resident fatigue that started work hour restrictions.  The contradictory point though is that patients expect their attending to personally see to their issues at all time, turning a blind eye to the question of whether the guy may have been on call the night before (though generally they will ask you if you feel well rested right before you operate on them) since patients feel that the attending is the only one that “knows” their problem.  Whether in the future patients are willing to accept waiting lists for clinics and ORs, as well as whether they accept the concept of the staff physician will determine whether a shift worker system can occur in US neurosurgery.

agl531 - 15 July 2007 07:21 PM

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.

OHSU has a nice vacation policy. You get 3 full weeks with both weekends per year. On your vacation week you will usually be post-call Friday (and hence leaving early to comply with the 30-hour rule) and not expected back at work until the following Monday for rounds which is basically 9-1/2 days off per vacation week...hence the 3 weeks is really 28-1/2 days or 4 weeks.

what if you take 3 weeks off consecutively? then you are really only getting 23-1/2 days off.

Nobody takes off 3 weeks in a row.  You screw the rest of your team every time you go on vacation with your call, floor, OR responsibilities, etc.  One week at a time is all you’ll get pretty much anywhere you go, at least during your non-research years.

Guest - 25 July 2007 04:30 AM

what if you take 3 weeks off consecutively? then you are really only getting 23-1/2 days off.

I don’t know of any programs that allow junior residents to take off consecutive weeks, unless there’s a compelling reason for it. There may be some, but it really isn’t that common. The workload is a zero-sum game, and whatever you’re not doing, your co-residents are.

Guest - 10 July 2007 02:42 AM

To the original poster: I don’t want to resort to crude language since I don’t think it will help you understand why your post offends people in neurosurgery.  I trained pre-80 hours a week, and like many other people on this board, prided myself and our service on its ability to handle things.  I remember starting mid-June and getting my first “day off” (it was a Sunday) in November.  We worked 120 to 140 hours a week in my intern and PGY-2 years, and we learned so much that it was staggering.  By the end of my PGY-2 year, I could admit a sub-arachnoid hemorrhage (write an H&P, orders, place a subclavian line, ventriculostomy and a-line) all in less than 30 minutes.  I could take out a subdural (skin to skin) in under an hour, with the chief resident only scrubbing in for due diligence.  I have seen what the 80 hour work week has done to training, and I know that it is not good.  The 80-hour residents can not do basic things fast (a-lines, central lines, ventrics); they don’t get as much “alone exposure” to ICU problems since there is now more staff around to take care of these things for them; they don’t get the operative experience; and most important of all (which is why your post hits such a nerve with us) is that they don’t seem to understand that neurosurgery is not a “shift” job where you count your hours and vacation days - it is a philosophy that you will do everything within your power for the good of the patient.

When the 80 hour workweek first got started, I thought it was a reasonable idea.  Just because I had been tortured, did not mean that it was the only way to teach residents.  Unfortunately I have been very sorely disappointed with the outcome.  I genuinely feel that people who are concerned about social life issues before they even start should not do neurosurgery.  Don’t take it personally, but I really think you should seriously consider other fields where life style is not an issue (radiology, ophtho, anesthesia, derm...).

You old guys are stupid and I will never understand how you function. I will admit it. If it were not for the 80 hour work week, I would not have even considered neurosurgery. I believe in working to live, not living to work. I do not love neurosurgery or anything else so much that I am willing to sacrafice everything else in my life for it. I was a >250 on step 1, AOA at a top 10 school smart applicant and I’m smart enough to know that working too much is just plain dumb. There is a law of diminishing returns when it comes to overnight work and scut. Neurosurgery is a fantastic field and I am grateful that I will be able to get the same training you old guys did, only in a more efficient way, while having time to eat, sleep, work out, and take care of myself. A neurosurgery resident at my medical school once told me that if you can’t learn your medical speciality in 80 hours/week, you probably shouldn’t be in it anyway. I am confindent that I will work hard and learn neurosurgery as best as possible in 80 hours or less and if you old guys don’t believe me, the advances to the field that my peers and I will make will speak for themselves. We will probably also be better leaders because we’re not dumb enough to think that working more equals better training, patient safety or toughness. It just equals stupidity and following, not leading. Just my 2 cents.

Badass PGY 2 sigining out, post call and got home around 1:30 this afternoon.

Guest - 25 July 2007 03:07 PM

Guest - 10 July 2007 02:42 AM

Badass PGY 2 sigining out, post call and got home around 1:30 this afternoon.

Hey, Mr Badass who has accomplished nothing, what are you going to do when you wake up as an Attending and realize that you in order to commit yourself to your patient’s best possible outcome, it will require a bit more sacrifice than you appear willing to give.

Neurosurgery is a calling, not a specialty.

Guest - 25 July 2007 03:07 PM

You old guys are stupid and I will never understand how you function. I will admit it. If it were not for the 80 hour work week, I would not have even considered neurosurgery. I believe in working to live, not living to work. I do not love neurosurgery or anything else so much that I am willing to sacrafice everything else in my life for it. I was a >250 on step 1, AOA at a top 10 school smart applicant and I’m smart enough to know that working too much is just plain dumb. There is a law of diminishing returns when it comes to overnight work and scut. Neurosurgery is a fantastic field and I am grateful that I will be able to get the same training you old guys did, only in a more efficient way, while having time to eat, sleep, work out, and take care of myself. A neurosurgery resident at my medical school once told me that if you can’t learn your medical speciality in 80 hours/week, you probably shouldn’t be in it anyway. I am confindent that I will work hard and learn neurosurgery as best as possible in 80 hours or less and if you old guys don’t believe me, the advances to the field that my peers and I will make will speak for themselves. We will probably also be better leaders because we’re not dumb enough to think that working more equals better training, patient safety or toughness. It just equals stupidity and following, not leading. Just my 2 cents.

Badass PGY 2 sigining out, post call and got home around 1:30 this afternoon.

I too am >250 AOA Top 10 (probably 5) PGY 3.  I’m therefore also a pretty smart guy because we have very similar stats, according to your logic.  And I’m smart enough to know practice makes perfect, and 130 hours of practice vs. 80 hrs of practice is much better.  It’s why the seasoned elites have lower mortalities than fresh newbie PGY-2’s.  If you’re doing 130 hrs of scut, I agree.  You’re just a glorified nurse, without the free bj’s.

But the best leaders do work only 32 hours a week.  They operate, research, teach conferences, and train new residents.  They sleep a full 8 hours a day.  Spetzler, Carson, Grady all sleep 9 and a half.

Pure fucking brilliance.  You will never be a leader with that attitude.  100 bucks says youre going to be a private practice sellout doing fusions, converting your hundred dollar bills to dollar coins so you can sit on it and think you’re the smart one.  Maybe you are, but you are in no way a leader, don’t kid yourself.

Badass PGY3 post call hour 38 not signing out until my paper is submitted (t minus 30 minutes).

omg you guys beat 250 on step 1 and went to top 10 medical schools??????????????? thats amazing

Guest - 25 July 2007 03:58 PM

Guest - 25 July 2007 03:07 PM

I was a >250 on step 1, AOA at a top 10 school smart applicant and I’m smart

I too am >250 AOA Top 10 (probably 5) PGY 3.  I’m therefore also a pretty smart guy because we have very similar stats, according to your logic.  And I’m smart

Smart enough to get the numbers but too dumb to know how meaningless they are.

I hope you both grow up a bit during your training.

says the guy who doesn’t have a 250?

come on people. everyone is smart enough to know numbers alone doesn’t mean everything. But it is an indicator of how hard a student has worked.

If it is true that 120 hr work weeks is 50% more ‘training’ than 80 hr work weeks, like some old-school guys on this forum would like to imply, then I’m sure in the future, residency training would be lengthened (say from 7 years to 10.5 years) if the RRC noticed that 80hrs/wk for 7 years is simply not enough training, right?