80 Hour Work Week/work Restrictions?

[TheEmeraldTablet]

In the States  programs have to comply by guidelines that do not allow residents to work more than 80 hours/week. Does anything similar exist in Canada/are there efforts to lobby for anything similar?

 

Thanks!

[JohnGrisham]

In the States  programs have to comply by guidelines that do not allow residents to work more than 80 hours/week. Does anything similar exist in Canada/are there efforts to lobby for anything similar?

 

Thanks!

Hahaha. Having talked to residents/current attendings in the US, good luck with people actually complying in the cases where you are burdened. In a lot of cases its the unwritten rule of simply not recording the correct hours, or you get the snub/cold shoulder. Definitely very program dependent and specialty dependent. With so much variability in the US, there's lots of opportunities to find a program in a primary care field that treats its residents well, if you don't care as much about being in a big city etc. And then there are the "IMG-mills" that stay standing by ensuring that they overwork their visa-carrying staff and staff that feel grateful to just have matched etc.

 

In Canada, i think its province specific. I recall reading up on PAR-BC some lobbied restrictions (like no more than 24 hour shifts) etc.

[rmorelan]

Not in Ontario - and I go over 80 quite routinely (plus study time on top of that). Days are 7:30 to somewhere between 5:30-6:00 and all it takes is two call shifts in one week at 25 hours each to push you to the mid 80s.

[rmorelan]

Hahaha. Having talked to residents/current attendings in the US, good luck with people actually complying in the cases where you are burdened. In a lot of cases its the unwritten rule of simply not recording the correct hours, or you get the snub/cold shoulder. Definitely very program dependent and specialty dependent. With so much variability in the US, there's lots of opportunities to find a program in a primary care field that treats its residents well, if you don't care as much about being in a big city etc. And then there are the "IMG-mills" that stay standing by ensuring that they overwork their visa-carrying staff and staff that feel grateful to just have matched etc.

 

In Canada, i think its province specific. I recall reading up on PAR-BC some lobbied restrictions (like no more than 24 hour shifts) etc.

 

it is a hot button topic for sure in residency - the problem is it just takes X hours to get good at a field and you only have Y years. It is no surprise the surgeons are desperate to get max OR time but they aren't the only ones. You can add max shift length but you just get more shifts. Zero sum game.

 

No matter how you slice it I need to see so many cases to get skilled in radiology as well. Cut the hours, push the graduation time and I can assure you at 5 years already there are not a lot of people hoping it gets longer ha. Still too many hours and you a lot of bad years. Hard question to answer.

[JohnGrisham]

it is a hot button topic for sure in residency - the problem is it just takes X hours to get good at a field and you only have Y years. It is no surprise the surgeons are desperate to get max OR time but they aren't the only ones. You can add max shift length but you just get more shifts. Zero sum game.

 

No matter how you slice it I need to see so many cases to get skilled in radiology as well. Cut the hours, push the graduation time and I can assure you at 5 years already there are not a lot of people hoping it gets longer ha. Still too many hours and you a lot of bad years. Hard question to answer.

Definitely, its a hard situation. You want to learn and be the best you can be, but at the same time you don't want to overwork them to death. It's a circular reference hah.

[Renin]

I definitely go over 80 hours on most weeks, if not all, not including study time.

 

*chuckles* 80 hour work week?

[Lactic Folly]

Residency hours, definitely a hot button topic. Just remember, there are no such restrictions on hours for staff. Sometimes it's easier to subtract the hours not worked, than to try to add up the hours worked.

[ploughboy]

My official hours worked in the last week are well over 100, and this is on a PAIRO-compliant schedule.   The unofficial number is, of course, higher.

 

And I don't think I have it too bad.  The neurosurgeons, the thoracic fellows, and the transplant folks basically never leave the hospital.

[JohnGrisham]

My official hours worked in the last week are well over 100, and this is on a PAIRO-compliant schedule.   The unofficial number is, of course, higher.

 

And I don't think I have it too bad.  The neurosurgeons, the thoracic fellows, and the transplant folks basically never leave the hospital.

hooray for 14 hour days, 7 days a week....but really probably 16-17 hour days, 9 days a week? (obvious typo haha).

[NLengr]

I'm coming into my final year in residency now and basically residency has consumed my life. If I'm not working (mostly operating now) at the hospital, I've got my nose in a textbook, a journal or some guideline studying. It's so bad that I now listen to CDs of recorded lectures from my specialty's American review course when I am driving the car, just to get the extra study time in.

[ploughboy]

hooray for 14 hour days, 7 days a week....but really probably 16-17 hour days, 9 days a week? (obvious typo haha).

 

Hurray for being on 1:2 call on a busy service, with various post-call academic obligations.  To be fair, it was 1:2 only in the short-term, and over the month it averaged out to 1:4 (which is pairo-compliant, but the fact that it was pairo-complaint didn't make me any less stupid by 4AM of the final call).

[rmorelan]

bottom line is there are long, long hours here (just finished working technically 27 straight days personally. I need to get some sleep). Cannot sugar coat that - that's medicine.

[JohnGrisham]

bottom line is there are long, long hours here (just finished working technically 27 straight days personally. I need to get some sleep). Cannot sugar coat that - that's medicine.

Yep, i think more people need to realize that on the onset - before they get to that point and are flabergasted. But i assume most adjust, and those who can't find fields that they can survive better/acclimatize too. 

 

I would like to see impartial longitudinal studies though, on the safety of functioning on some of these longer shifts, and situations like yours of long days, continually without break etc.   Though, it would be hard to really get good data out of it, as the human element is always there - some people can handle it better than others etc.

[rmorelan]

Yep, i think more people need to realize that on the onset - before they get to that point and are flabergasted. But i assume most adjust, and those who can't find fields that they can survive better/acclimatize too. 

 

I would like to see impartial longitudinal studies though, on the safety of functioning on some of these longer shifts, and situations like yours of long days, continually without break etc.   Though, it would be hard to really get good data out of it, as the human element is always there - some people can handle it better than others etc.

 

well they have done for many fields the impact on patient care - as you get tired you make more mistakes but if you hand over all the patients to someone else they don't know the patient so there are mistakes from that. We know its impact on resident quality of life but on some level there is a bottom to how much you can care about that because the alternative is to stretch out residency to be even longer for many fields.

 

Part of all this is a bit of "ok, so it is isn't perfect but what is the alternative?" - I mean you have so many residents, and so much to cover. Staff aren't coming in to cover over night shifts etc, and you need staff to be awake the next day so they are fully functional as the buck stops with them". Cannot take on more residents as there are no jobs in the end if you do that.

 

I think in some fields it matters more than others as you really can fly on autopilot for parts of every job in medicine (I am sure some of the surg residents do simple surgeries basically almost in their sleep - I know I was rattling off consults instinctively by the end of pgy1 on simple stuff (oh look it is another COPD exacerbation - what ever will we do? Ha)). I find I am able to do less of that in radiology than I could in first year in other rotations even now that I am 9 months into pure call on Rads. No muscle memory as it were for reading CTs. I am tired most of the time if that makes sense - never really rested at any point. Kind of drifting from day to day, and usually preparing for call, on call or post call mathematically speaking. 

 

Our first year of call is the worst - we don't know much yet so are slower reading scans, and we do the most call in our first 12 months (62% of it actually - of the total call we do over the 3 years we do call - 7 call shifts every 28 days for 13-14 straight blocks. We start a bit later doing call than other services as a new pgy 2 rad knows nothing initially and thus cannot do call until we learn, and we stop call about month 5 in year 5 so you can spend every single moment of your life preparing for the exam (and I mean every. single. moment.). Total on service call time is about 3 years). Rad call is pretty bad to be honest - quite often there is absolutely no time to rest for the full shift. You only stop if literally ever other service in the hospital is also doing nothing. Otherwise someone, somewhere wants a scan.

[ralk]

well they have done for many fields the impact on patient care - as you get tired you make more mistakes but if you hand over all the patients to someone else they don't know the patient so there are mistakes from that. We know its impact on resident quality of life but on some level there is a bottom to how much you can care about that because the alternative is to stretch out residency to be even longer for many fields.

 

Part of all this is a bit of "ok, so it is isn't perfect but what is the alternative?" - I mean you have so many residents, and so much to cover. Staff aren't coming in to cover over night shifts etc, and you need staff to be awake the next day so they are fully functional as the buck stops with them". Cannot take on more residents as there are no jobs in the end if you do that.

 

I think in some fields it matters more than others as you really can fly on autopilot for parts of every job in medicine (I am sure some of the surg residents do simple surgeries basically almost in their sleep - I know I was rattling off consults instinctively by the end of pgy1 on simple stuff (oh look it is another COPD exacerbation - what ever will we do? Ha)). I find I am able to do less of that in radiology than I could in first year in other rotations even now that I am 9 months into pure call on Rads. No muscle memory as it were for reading CTs. I am tired most of the time if that makes sense - never really rested at any point. Kind of drifting from day to day, and usually preparing for call, on call or post call mathematically speaking. 

 

Our first year of call is the worst - we don't know much yet so are slower reading scans, and we do the most call in our first 12 months (62% of it actually - of the total call we do over the 3 years we do call - 7 call shifts every 28 days for 13-14 straight blocks. We start a bit later doing call than other services as a new pgy 2 rad knows nothing initially and thus cannot do call until we learn, and we stop call about month 5 in year 5 so you can spend every single moment of your life preparing for the exam (and I mean every. single. moment.). Total on service call time is about 3 years). Rad call is pretty bad to be honest - quite often there is absolutely no time to rest for the full shift. You only stop if literally ever other service in the hospital is also doing nothing. Otherwise someone, somewhere wants a scan.

 

Those same studies on work hour restrictions showed that the reduction in work hours didn't lead to a reduction in measures of resident competency either. Some of the work coming out on competency-based education shows an opportunity to meaningfully reduce training times in years in a good proportion of learners, without a proportional increase in hours worked. It's not as though there's a hard-fast relationship between hours spent per week as a resident and number of years necessary to complete trading - there are numerous counter-examples in the literature of that not being the case. It's not a zero sum game.

 

Covering all the work done by residents is a bit trickier, but the obvious answer is to hire more staff physicians to cover that work. That might not be feasible in some fields where there is a true shortage of available physicians, but in many fields there's a line-up of physicians interested in positions at major academic centres. Especially in some of the surgical fields, there are many unemployed, underemployed, or over-training physicians. It'd be costly to shift work from residents to full-trained physicians, but that gets down to the other reason resident work hours are so long - comparatively cheap labour. In some cases, minimum-wage-violating-ly cheap labour. Nevermind the ethics of having residents work that long - not paying them sufficiently for that time is plainly illegal.

[goleafsgochris]

Yep, i think more people need to realize that on the onset - before they get to that point and are flabergasted. But i assume most adjust, and those who can't find fields that they can survive better/acclimatize too. 

 

I would like to see impartial longitudinal studies though, on the safety of functioning on some of these longer shifts, and situations like yours of long days, continually without break etc.   Though, it would be hard to really get good data out of it, as the human element is always there - some people can handle it better than others etc.

 

People should really note that the insane hours are not common to all MDs.  Remember 50% of MDs are family docs, and a fair portion of the remainder are path, psych, some other chill ones.

 

The insane hours are if you are in surgery or internal med (and some others but not many).  These hours are by choice.  Don't want to work these hours?  Just don't do medicine or surgery.  You can pretty much have 50hr work weeks even as a resident.  The insane hours people just described are basically self-inflicted by picking tough residency programs.  I wouldn't want that, and neither do most MDs...again as you can see by 50% being in fam med.

[rmorelan]

Those same studies on work hour restrictions showed that the reduction in work hours didn't lead to a reduction in measures of resident competency either. Some of the work coming out on competency-based education shows an opportunity to meaningfully reduce training times in years in a good proportion of learners, without a proportional increase in hours worked. It's not as though there's a hard-fast relationship between hours spent per week as a resident and number of years necessary to complete trading - there are numerous counter-examples in the literature of that not being the case. It's not a zero sum game.

 

Covering all the work done by residents is a bit trickier, but the obvious answer is to hire more staff physicians to cover that work. That might not be feasible in some fields where there is a true shortage of available physicians, but in many fields there's a line-up of physicians interested in positions at major academic centres. Especially in some of the surgical fields, there are many unemployed, underemployed, or over-training physicians. It'd be costly to shift work from residents to full-trained physicians, but that gets down to the other reason resident work hours are so long - comparatively cheap labour. In some cases, minimum-wage-violating-ly cheap labour. Nevermind the ethics of having residents work that long - not paying them sufficiently for that time is plainly illegal.

 

absolutely - although there are two issues I should point out - the fields tests were pretty specific, and also a reason it worked out similar was hand over - and we are right now basically pretty terrible with hand over. Not exactly a subject that is understand or taught well at medical school

 

You don't hire staff physicians at all (except for a few fields) - you mere allow them to practise at your hospital. They get paid only if they can bill for services done, and during the night the total number of things done would be usually less than during the day. Hard to motivate people to cover crappy hours for less than the during the day rate (there are some overnight bonuses in some fields but still). Plus the overnight work does get billed for by the staff the following day, so effectively overall staff income would fall under that scheme. Not exactly a lot of motivation - that is in part why residents are doing all the work in the first place. Sometimes fellows cover the overnight parts to a degree which is a middle ground.

 

Since we are all on salary there is no mimimal wage issues as there is no hourly rate of pay at all. Same with most salaried (ie most mid to higher end) positions in the "real world"

[rmorelan]

People should really note that the insane hours are not common to all MDs.  Remember 50% of MDs are family docs, and a fair portion of the remainder are path, psych, some other chill ones.

 

The insane hours are if you are in surgery or internal med (and some others but not many).  These hours are by choice.  Don't want to work these hours?  Just don't do medicine or surgery.  You can pretty much have 50hr work weeks even as a resident.  The insane hours people just described are basically self-inflicted by picking tough residency programs.  I wouldn't want that, and neither do most MDs...again as you can see by 50% being in fam med.

 

They are by choice for sure - although it does seem off to completely restrict amazing people from doing say internal medicine/surg/rads/etc, etc simply because they cannot handle a few years of intense overnight work in their potentially 40 year careers - careers which often don't involve anywhere near that level of activity. I think the bigger question we are struggling with as a field is there another way that gets to the same end point without the "torture phase". If so, then we should do that. If there isn't then at least we really seriously looked at the problem - as opposed to just doing what we always have been doing just because we always did it that way.

[ralk]

absolutely - although there are two issues I should point out - the fields tests were pretty specific, and also a reason it worked out similar was hand over - and we are right now basically pretty terrible with hand over. Not exactly a subject that is understand or taught well at medical school

 

You don't hire staff physicians at all (except for a few fields) - you mere allow them to practise at your hospital. They get paid only if they can bill for services done, and during the night the total number of things done would be usually less than during the day. Hard to motivate people to cover crappy hours for less than the during the day rate (there are some overnight bonuses in some fields but still). Plus the overnight work does get billed for by the staff the following day, so effectively overall staff income would fall under that scheme. Not exactly a lot of motivation - that is in part why residents are doing all the work in the first place. Sometimes fellows cover the overnight parts to a degree which is a middle ground.

 

Since we are all on salary there is no mimimal wage issues as there is no hourly rate of pay at all. Same with most salaried (ie most mid to higher end) positions in the "real world"

 

I agree that handovers are a major confounder. Proper communication in general seems to be a major roadblock to positive change in medicine...

 

I understand that staff physicians aren't hired in the traditional sense, but hospitals do set the number of physicians given practicing privileges there is a split of responsibilities among those who have practice rights at a hospital. Every field has their undesirable shifts, even for staff physicians, and those manage to get divided in a (presumably) fair manner. Community hospitals operate largely without residents and still have many of these sorts of shifts in many fields. It's not as though a ton of shifts need to be switched over to staff physicians to reduce resident work hours either, or even that it has to be predominantly the undesirable shifts that need be switched - I would still expect residents to cover the majority of overnight shifts, just not necessarily all of them. I agree that such a scheme wouldn't sit well with many staff physicians, but that's kind of the point - residents are cheap labour not just for hospitals, but for staff physicians as well.

 

Salaried positions are still subject to minimum wage laws. If someone works a given number of hours, their overall compensation has to provide at least the minimum wage per hour, regardless of compensation scheme. However, looking at the regulations again, I see an exemption for physicians and those training to be physicians, so yay for legal loopholes I guess.

[shikimate]

I like the idea of NYU's guaranteed residency with only 3 years of med school (can't remember the name of the program). The students save a year, don't have to worry about matching, and can start basically getting used to their hospital and residency while in med school. Programs don't have to do the match and gets to mentor their future residents from day 1 of med school. I don't think there's data but I would assume this makes transition to residency much easier to students. This is a good idea for people who are sure of what they want.

[rmorelan]

I agree that handovers are a major confounder. Proper communication in general seems to be a major roadblock to positive change in medicine...

 

I understand that staff physicians aren't hired in the traditional sense, but hospitals do set the number of physicians given practicing privileges there is a split of responsibilities among those who have practice rights at a hospital. Every field has their undesirable shifts, even for staff physicians, and those manage to get divided in a (presumably) fair manner. Community hospitals operate largely without residents and still have many of these sorts of shifts in many fields. It's not as though a ton of shifts need to be switched over to staff physicians to reduce resident work hours either, or even that it has to be predominantly the undesirable shifts that need be switched - I would still expect residents to cover the majority of overnight shifts, just not necessarily all of them. I agree that such a scheme wouldn't sit well with many staff physicians, but that's kind of the point - residents are cheap labour not just for hospitals, but for staff physicians as well.

 

Salaried positions are still subject to minimum wage laws. If someone works a given number of hours, their overall compensation has to provide at least the minimum wage per hour, regardless of compensation scheme. However, looking at the regulations again, I see an exemption for physicians and those training to be physicians, so yay for legal loopholes I guess.

 

exactly Plus doctors are self employed (should have stated that clearer). No such minimum applies.

 

Not just cheap labour - although I suppose actually for the doctors we are quite expensive - staff rads for instance in the community make a pile more than the ones at a teaching hospital for instance as we slow them way, way down. We are convenient labour Same with surgeons. One of the rewards they get for a drop in salary is they have residents overnight. You drop their salary, potentially drop it more as you recruit other doctors in the same field (with all the added costs of that and pressures for OR time etc, etc) and make them work overnight and well you probably would have a recruiting problem.

 

Not saying it shouldn't be done/considered but it is complex - there is a lot of give and take already in the system and residents aren't the only one paying a price.

[Renin]

People should really note that the insane hours are not common to all MDs.  Remember 50% of MDs are family docs, and a fair portion of the remainder are path, psych, some other chill ones.

 

The insane hours are if you are in surgery or internal med (and some others but not many).  These hours are by choice.  Don't want to work these hours?  Just don't do medicine or surgery.  You can pretty much have 50hr work weeks even as a resident.  The insane hours people just described are basically self-inflicted by picking tough residency programs.  I wouldn't want that, and neither do most MDs...again as you can see by 50% being in fam med.

 

Dude. Psych call isn't that chill ... and we still do call as residents, remember. As I'm more and more senior, I find call more difficult because we cover for medical issues too. Try to remember your basic protocol when you haven't done it at all for years. 

[rmorelan]

Dude. Psych call isn't that chill ... and we still do call as residents, remember. As I'm more and more senior, I find call more difficult because we cover for medical issues too. Try to remember your basic protocol when you haven't done it at all for years. 

 

and 50% are not Family docs either - the max we hit was 38% this year and that was a record. It is more like 2/3 are not family docs, and family docs in their first year also are off service and thus have off service call demands. Again something you just have to go through but also something to be aware of

[ralk]

exactly Plus doctors are self employed (should have stated that clearer). No such minimum applies.

 

Not just cheap labour - although I suppose actually for the doctors we are quite expensive - staff rads for instance in the community make a pile more than the ones at a teaching hospital for instance as we slow them way, way down. We are convenient labour Same with surgeons. One of the rewards they get for a drop in salary is they have residents overnight. You drop their salary, potentially drop it more as you recruit other doctors in the same field (with all the added costs of that and pressures for OR time etc, etc) and make them work overnight and well you probably would have a recruiting problem.

 

Not saying it shouldn't be done/considered but it is complex - there is a lot of give and take already in the system and residents aren't the only one paying a price.

 

The self-employment consideration would apply to practicing physicians, but not residents, who are decidedly not self-employed. Interesting the see the exemption explicitly apply to those training to be physicians, as well as physicians themselves.

 

Granted in many/most fields, academic salaries are lower than community salaries, but I wouldn't lay that disparity solely - or even primarily - at the feet of residents. Residents have costs, but also have benefits, especially when averaged over the whole training time. Most of the senior residents I've worked with certainly seem to be contributing more to workflow than they're costing in teaching time. Patient populations and procedures are different at tertiary centers than they are in most community hospitals. Academic physicians frequently take on responsibilities that are lower-paying than clinical work, such as research, but which are a main draw for being an academic physician in the first place.

 

Admittedly, big changes in compensation would cause a recruitment problem, but considering we have the opposite issue of too many candidates right now, there's wiggle room to play with. I'm also talking about relatively small changes, especially to start. Would one night shift a month scare that many people off?

 

I agree that where residents fit into medicine is part of a much broader issue of how the medical system is organized and that residents are hardly the only ones who get the short end of the stick in this system. However, I get more concerned about residents (and students) because their control over their situation is virtually non-existent. I've heard plenty of stories from staff physicians unhappy with the number of hours they work, yet who could easily reduce their hours worked. The catch is that their salary (which in many cases was above $500k a year) would go down. These physicians may not like their long hours, but they have them as a balance of priorities, not because of an absolute requirement. Residents don't really get that choice. The only choice a resident really gets is which residency to go into.

 

Ultimately, for me, it's the culture of medicine, which I've already seen beat people down for simply being human. People aren't meant to work 80-100 hours a week on a regular basis. There's plenty of research to demonstrate the negative effects of such a schedule on health and well-being. Would you ever advise a patient that working 100 hours a week was good for them, or even benign? Yet in medicine, it's expected and rather than trying to change to system, a good number of people (certainly not all, but enough), say that such work hours are too hard to change, necessary, or even (laughably) beneficial. It's a culture that creates its own enablers for what in many cases amounts to abuse by neglect. Everyone in the system suffers when we take it for granted that physicians - at any career stage - shouldn't be treated like normal people. I'll go through it, because I signed up to be a physician and right now that's mandatory for many of the fields I'm considering, but I hope I don't think for a second that such a system is justified.

[LittleDaisy]

Is it common that internal medicine residents (R1-R3 for the common branch) work more than 80 hours per week? It is common in all the programs across Canada??? It is more common in big programs I guess??

If I pursue internal medicine later, I would probably likely to specialize in endocrinology. So another 3 years of hard work in the road. 

They are by choice for sure - although it does seem off to completely restrict amazing people from doing say internal medicine/surg/rads/etc, etc simply because they cannot handle a few years of intense overnight work in their potentially 40 year careers - careers which often don't involve anywhere near that level of activity. I think the bigger question we are struggling with as a field is there another way that gets to the same end point without the "torture phase". If so, then we should do that. If there isn't then at least we really seriously looked at the problem - as opposed to just doing what we always have been doing just because we always did it that way.