36 hours a day

[Guest opiedog]

I know this used to be addressed in the missing forums, but am hoping that those already in school or beyond would be willing to discuss their length of day. Historically, it was not unheard of for med students to be literally run in to the ground. Working on-cal land studying 24-36 hrs straight, and then having to head in to class and start afresh.

 

Can anyone comment please on their day as a med student? Do students still have rotations that require them to be dead on their feet yet still functioning?

[Guest UWOMED2005]

Yes. Saturday I'm on call (as a resident) for 24 hours. While at UWO for Gen Surg I did 36-37 hour straight call and shifts.

[Guest satsumargirl]

www.pairo.org/

 

Hey, I recently found the above link and found it to have alot of useful information as to the life of a resident anyway. It outlines, max number of call per month, and what time off residents are entitled to, max hours of work/week. Apparently after call most residents must be relieved of their duties by noon the next day.The exceptions were anaesthesilogy and ob/gyn that required to be relieved at 24hrs. And friends of mine in residency right now (internal medicine) say they get at least a couple of hours of sleep per night (not straight though) and that depending on your chosen specialty you could get 4 or even 5 hours of interupted sleep.

 

I don't think that is enough sleep to be considered fit to work when you have such a high responsibility. I used to work as a sleep techonologist and if the patients didn't get at least 4 or 5 (?can't remember exactly) hours of sleep we weren't supposed to let them drive home. Makes me laugh that as sleep techs who were up all night, we could drive home and it's scary to me that residents are expected to be responsible for people's lives on such little sleep.

 

Anyway, the above site might be helpful. Don't know about med school though. My understanding is that 3rd and 4th year when we are doing clerkship we don't really have that many (if any) classes, so I doubt we'd be on call and then have to go into class the next day. I'm sure it's still alot of work though. And I have heard general Sx is pretty brutal. I think my plan will be to get it over with first.

 

I wonder if there are any MDs that don't drink coffee?

[Guest opiedog]

Geez, and I just weaned myself off of caffiene too! Thanks for the input.

[Guest Steve U of T]

I work for a surgeon who doesn't drink coffee.

[Guest UWOMED2005]

Yeah, I quit coffee just before med school.

 

That didn't last!

 

I will say PARA (resident's advocacy group in Alberta) has negotiated a 28 hr max work policy. . . no resident can work more consecutive hours than that.

 

That policy doesn't, however, apply to medical students! Not sure how long U Cal med students have to work when on-call. . . Kirsteen or Marbledust might be able to help.

[Guest opiedog]

I read the info on the links, but somehow the reason behind making someone work such crazy hours is beyond me. Is this intended as a right of passage of some sorts?? I've often heard others who have been in a field and had tough times behind them say "I had to do it, so you need to too." Does that make it right? Not sure why, but I thought things had improved more than that.

[Guest uteng]

I think part of it is following the progress of patients that present and that you're called for.

 

It's probably also a rite of passage, but the residency system does seem to turn out good doctors.

[Guest cracked30]

The main point is that you need to see a number of cases, including rare ones. This is not an issue for family docs, they are taught to recognize red flags.

 

But, specialists, I would feel more comfortable with a surgeon operating on me that has had an intense residency than someone who has had a relaxing residency.

 

Besides, as the workload decreases per week, the Royal college will increase the number of years to complete residency.

[Guest McMastergirl]

My personal take on the ridiculous hours of residency/med school is that change takes time. In the "old days" there were fewer residents and similar amounts of work, plus it was a boys club primarily where machoism was more motivating than self-care. Obviously times have changed, but the structure of residency has been slow to catch up. I think eventually there will be a change to shift work so that we can get the same number of hours without the gruelling 30 hour marathons. I think this will be much better for patient care as well - I know I think better (and care more!) when I am well-rested than when I'm post-call.

 

In my first year of residency (just finished!) I did mostly internal medicine rotations, and my call nights varied tremendously. Sometimes I got 6 hours sleep and sometimes I got none at all. The average was about 3. Either way, the sleep is @#%$ b/c you always have one ear on your pager.

I found that in med school I tended to get much more sleep, but at Mac we weren't first call so that probably was why!

[Guest aneliz]

At UWO, you do 'call' for surgery, internal med, ob/gyn, paeds, psych and sometimes family (depending on your preceptor and your location).

 

Call varies based on what service you are on. On surg or med - you are first call. Which means you will likely be up most of the night, most nights on call (1-3 hours sleep, usually in several short chunks). There is now a 'post call' policy for UWO clerks (new this year!) that states that clerks are allowed to go home at noon on the day following in-house call. You are required to attend teaching sessions that occur before noon and to attend all rounds/clinical duties with your team until noon - even if you have had ZERO sleep the night before. The average clerk call shift in London is ~28-30 hours long. This is new policy... when I did surg at the beginning of the year, it was not yet policy and I did 34-38 hour shifts (stayed until 4:30-8 PM the day post-call).

 

Even though there are very few 'classes' in third year (there is at most a few lectures a day - usually one), you are REQUIRED to attend them post call - so you will go to several when you are totally exhausted. You may also write exams post call - which is a rare and special treat occuring once every 6-12 weeks. Usually, your resident will have mercy on you and let you go home/to bed at midnight the day before an exam if you are the unlucky one on call - but this is NOT official policy, and requires your resident to both feel sorry for you and agree to covering for you (ie doing extra work).

 

On some of the other rotations - you will get more sleep. Paeds is generally quieter - you are not first call to the floor in paeds... and ob is hit or miss - you may get 7 hours of sleep, you may never sit down for dinner.... you never know.

 

Psych is 'home call' after midnight. Meaning that at midnight you get to go home... but you go home with your pager and you have to come back if they call you. This can mean a long night of driving back and forth to the hospital... depending on how close you live, you may wish that it wasn't home call, and that you just had to stroll back to a call room in the hospital when there is a break in the action. And, because it is 'home call', the post call policy doesn't apply and you work the next day.... unless you have had a brutal night (no sleep) and you appeal to your team to go home at noon the next day.... (not automatically granted.)

[Guest DrSahsi]

Caffeine is your friend.

[Guest endingsoon]

Yeah its common...I did about 36hrs when on call for surgery...I acutally did not mind the call, b.c you learn so much more on call when you see consults and admit people then you do when you spend the days doing scut work and rounding.

[Guest Ian Wong]

I've managed to get this far without drinking coffee. Somehow, everyone manages to suck it up and get through those hours. What makes it tough is when your call schedule has you pulling these shifts every few nights on a regular basis; you become chronically sleep-deprived even if you sleep for 12-14 hours immediately following one of these shifts.

 

I think my record was sleeping some 16-17 hours post-call once. After a really gruelling 30 hour shift where I got no sleep, and patients were crashing and burning all over the place, I got home at 2 pm, and promptly slept for 16 straight hours, waking up around 6 am the following morning just in time to head back to the hospital for my 7 am shift. Not fun...

 

The problem is that the manpower isn't currently there for residents to work less shifts or less hours. The other two dilemas are that continuity of care is important (you invariably know your patients better than anyone else in the hospital), and secondly, a large portion of your learning occurs on call where you are forced to figure things out on your own because there's much less help available to know. On an intuitive level, it seems that those are exactly the instances you would want to be most well-rested for, but that's not what happens in the real world!

 

Ian

[Guest satsumargirl]

Well, I'm not sure I buy the whole exposure to more cases argument as justification for the crazy hours.

 

I'm not there yet, but I can say that I would rather see fewer cases and be awake and be really able to absorb what I"m learning, than tired and seeing cases I probably am too sleep deprived to remember anyway.

 

How many rare cases do you see anyway? A friend of mine doing his residency says that some of the things he gets called for is not necessary. It's 3 am and the pt is stable. His opinion is, they call 'cause they can. The pt could wait and be fine for the next few hours. He also said that he felt that if communities treated their practicing physicians the same as the residents, they'd have no practicing physicians 'cause they'd all quit. I think I would agree. Why is it necessary to call someone in the middle of the night when the pt is stable?

 

And I'd be happy to miss a few of those rare cases in order to sleep. This may sound crazy, but if they are rare, chances are I might not see it again. And if I'm not going to see it for another 10 years, I probably won't remember the details and will have to look stuff up anyway. Not so sure I'm hung up on the rare things....give me exposure to the things I am going to have to treat on a regular basis!

 

I do think that alot of it is rite of passage though.

 

I would venture and say (and this is just my opinion) that alot of it is financial. Our residents do alot of work, for very little pay. If they were actually paid fairly for the work they do, or of more residents were needed to create better hours, then I think the cost to our healthcare system would increase alot.

Not to mention they would need to increase medical school enrollment in order to graduate more residents at one time.

If I had to bet, I would say it's the $$$ factor that keeps residents working crazy hours.

 

I guess the one thing to keep you going is that you know it is temporary. And everyone that has gone before us seems to have survived. But for now, I'm trying not to think about it too much since it's a few years away!

[Guest endingsoon]

I'm not there yet, but I can say that I would rather see fewer cases and be awake and be really able to absorb what I"m learning, than tired and seeing cases I probably am too sleep deprived to remember anyway.

 

I have to disagree...I want to see more cases, b.c I don't care if I see that appy that presenstes as knee pain at 3pm or 3am...it will stick!

 

I think the whole problem is that if they cut down on call hours to less time (ie - 12hr shifts, etc.), then residency will need to be exteneded. Its a trade off, spend less years but mroe time or less time but more years.

 

Think of it as a donation...these are the worst years of your life, just foucs on the light.

[Guest kosmo14]

I agree with endingsoon as I have seen some of the most interesting things while on call as opposed to the normal daily scut work stuff on the ward where the learning is limited. I find I learn a lot more by seeing even if only a couple of times. I would much rather see it once than be taught it w/o seeing it 10 times.

[Guest Littlest Zooropa]

During the first two years of med school, we had regular school hours. But once we became clerks, we were treated like residents. And I thought that slave labour had been outlawed!

 

We were first call. Some rotations were fine (home by six pm, no call). But others (all surg, internal, peds, OBS, psych) we were first call all night one in four. That means up by six am to round, then you're in the hospital until six pm the next day(that's 36 hours if you're counting, no sleep). We did all the scut stuff that didn't require a resident (blown IVs, fevers, complaints of every stripe, suicide threats, pain pain pain, ativan ativan ativan), and even if it did require a resident we got called first and then we called the resident. Then the next morning, try to stay away for a six hour surgery when you're the human retractor.

 

Med school is all about being taken advantage of as a pair of hands. In our place, the family MDs didn't bother assessing their own OB patients who presented in ?labour - the clerks (supervised by the nurses) did it. We were expected to follow them their entire labour and then call the MD in time for the delivery. Lots of times they didn't make it. It's great experience if you want to be an OBGYN, but it's miserable for everyone else. And again, 36 hour days. I remember (sort of) doing my OBGYN OSCE after having been on call for thirty hours (sleep? ha ha! I barely got time to sit down!)

 

But residency is better than med school (in my opinon). Provincial resident associations prohibit the sort of abuse that happens to med students from being visited on the residents (in theory). My hours as a PGY-1 during the BCT year were much less than as a clerk, mostly because there was a contact dictating that they couldn't work me into the ground (and there were people willing to rat out the institution if they tried to violate the contract).

 

So, the moral is: Get your sleep now. Clerkship is hell. Residency is better (unless you're a general surgery resident - those guys have it hard).

[Guest UWOMED2005]

Clerkship is hell.

 

I don't know - bizarre as it might sound, I LOVED clerkship despite the lack of sleeping.

 

Even my gen surg rotation. . . one week I worked 105 out of 168 possible hours in the week.

 

Of course, the greatest thing about a gen surg rotation in clerkship is realizing that it was over in 4 weeks and I might not ever have to do something like that ever again, unless I CHOSE that residency/career.

 

I don't know how I'd handle a surgery residency where I'd have to deal with the fact that it would be possible THE REST OF MY LIFE would involve working those kind of hours. I have no problem working hard and working insane hours, but if there was no "out" I'm not sure I'd be as willing to deal with the hours.

[Guest satsumargirl]

I agree with endingsoon as I have seen some of the most interesting things while on call as opposed to the normal daily scut work stuff on the ward where the learning is limited.

 

This is interesting. You see more interesting cases while on call. Is this because the resident is in charge and all the staff physicians have gone home? Do people just get more sick at night? Why don't they have resident's doing more productive stuff during the day?

 

And why can't resident's just work in shifts so they still get night shifts and exposure to these things but also get to sleep? (if each clerk/resident works x hours in a week, does it matter if it is broken into more manageable shifts?)

 

If there is actually an advantage to calls then maybe I will be able to tolerate them better. I'm still not going to like it though I don't think. I am someone who really needs their sleep. 24 hrs awake and I feel pretty hazy, burry eyed and slow to process anything...if anything gets processed at all!

 

But somehow I and everyone else will get through it though!

[Guest cheech10]

It's because you get new and emergent cases when you are on call. The other days have you mostly following patients that you've already seen before and not that much happens compared to a brand new patient.

[Guest Ian Wong]

There's also usually a lot less help available at night. You learn to fend for yourself, and usually the stress and hecticness of that tends to burn those patients into your memory much better. Chances are good that I could lecture you over and over again about the presentation of xyz disease, but it'll really stick the most once you see it on call, and actually go through the process of seeing the patient, ordering diagnostic labs and tests, and writing out your treatment orders and plan.

 

As far as why can't the shifts be broken up some other way, well, many US institutions have gone to something called a night float, where you have a dedicated night team working nights, and day teams working only days. One downside to this system is that you are constantly changing off patients to the incoming team, and you rarely get to see a patient's course change (or worsen, for that matter) in response to the treatments you've given them.

 

Continuity of care is a buzzword you will hear again and again, and it refers in large part to the fact that the person who admitted the patient to the hospital is usually MUCH more familiar with that patient than any other med student/physician on the team. Following patients through is an important part of learning to be a clinician.

 

As well, it may be the case that night float people work less hours than the traditional call system (since by definition, your shifts are usually only 12-14 hours long at a time, versus a potential 30 hours doing the call system). This means that either you get less days off a month, or you need more med students/residents on your team to make up for the difference in hours.

 

I'm not trying to defend the call system (I've done my share of 30 hour shifts and hated them through and through), but it's stuck around for a long time partially because people haven't been able to (or perhaps, haven't been forced to) find a better replacement.

 

Ian

[Guest Kirsteen]

Hi there,

 

Sorry, but I can't yet comment on clerkship hours at UofC, but I learned some valuable points during my recent burn surgery elective, echoed above:

 

1) There aren't always enough bodies to go around to provide the manpower required to offer enough expertise over 24 hours. The number of personnel differs from service to service and as such, the workload might vary accordingly.

 

2) Straight from my staff surgeon's (and Residency Committee Member's) mouth: as a resident you need to put in the time to receive adequate training.

 

3) From one of the Plastics residents: you'll discover that sleep is overrated, i.e., how little you actually need to function well.

 

Cheers,

Kirsteen

[Guest endingsoon]

3) From one of the Plastics residents: you'll discover that sleep is overrated, i.e., how little you actually need to function well.

 

100% agree. I always write exams on less than 2hrs of sleep and during clerkship function as a health care provider on even less, and even though intuitively it might seem that it is harder to function/make important decisions on less sleep, it just never seems to be the case.

 

Most people complain about how they are more likely to make mistakes, but you know what? I have not seen it in practice, and in truth there is no compelling evidence (despite some poorly constructed trials) that would prove that you make more mistakes on long call shifts.

 

Most people make the same mistakes at night that they would otherwise also make during the day, and at night, even though you are tired, you often take a bit more time to double check stuff b.c you know you are tired (ie - self correcting your preceived susceptability to error). In fact, I would not at all be surprised to hear that you make less mistakes on call and without any sleep, should a proper trial ever be undertaken on the matter.

[Guest Ian Wong]

From one of the Plastics residents: you'll discover that sleep is overrated, i.e., how little you actually need to function well.

I think this is true on a short-term basis (like if you needed to stay up all night to replant a severed finger or something), but over a longer stretch of time, I can't possibly see how chronic sleep deprivation wouldn't affect your concentration and stamina.

 

I realize that my personal experience is only an n=1, but I can consistently point out that the times I felt most irritable, was least interested in talking at length to patients, nurses, or other members of the healthcare team, and was less inclined to "go the extra mile for my patients" were consistently on my post-call days.

 

I'm good for about a 24 hour shift (like from 7 am to 7 am the next day). That entire post-call morning is pure pain, and those 5-6 hours almost invariably made me feel even worse than the 24 hour-long shift that preceded it!

 

The interesting thing is that early in a call month, I'd usually stay up that post-call afternoon, and then sleep in the evening in order to keep my day/night Circadian schedule at least somewhat normalized. By the time I got late in a call month, the chronic sleep deprivation was usually bad enough that I'd get home by 1 pm post-call, and be in bed by 2 pm (even with daylight blazing through my apartment!), sleep until around 9 pm, eat dinner and do a couple errands, and be back asleep at 10 pm or something ridiculous like that.

 

There have definitely been a few studies looking at sleep deprivation. I haven't read them myself, but one of the sleep medicine physicians here in town noted that there's usually an increased incidence of car accidents post-call vs. pre-call (with a sizeable percentage of those occurring due to lack of attention or sleeping at the wheel), there's a higher error rate (and a slower interpretation time) for junior medicine housestaff reading EKG's post-call vs. pre-call, and that often-quoted statistic that 24 hours without sleep dulls your attention span/motor reflexes (or something like that) similar to a 0.08 blood alcohol level.

 

Me, I think 30 hour shifts suck, and wouldn't wish them on others. Still, I think the potential is there to learn a lot, and certainly, having done the 30 hour shifts myself gives me the confidence to believe that I can do them if needed (and the medical situation warrants it). The only difficulty is that those long shifts start to blur the distinction between service and learning, and really, you need to make sure that your learning isn't getting compromised by the fact that you're sleepy all the time.

 

If it's really that big of a stickler for people, the solution is to find a "lifestyle" specialty where call is either very minimal, or a specialty where the opportunity to do shift-work is present. That still leaves open an awful lot of different specialties from which to pick.

 

Ian