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At Some Point I Had to Write This

August 26, 2018
by Mark David Siegel

Hi everyone,

Greetings from Gorham, NH! Francesca and I are closing out a father-daughter adventure that’s taken us from Portland ME, to Moosehead Lake, to Quebec City, to Mount Washington and, finally, to Lake Champlain today before the long ride home tomorrow. We finished one audiobook (Anne of Green Gables) and are half way through another (Huck Finn), which we should finish somewhere on I-91.

At some point I had to address this mind numbing topic, so while Francesca dozes a little longer on her air mattress, let’s get this done.

Documenting work hours. In MedHub. Every week. So Brett doesn’t have to hound you.

Here’s why. The ACGME makes all residencies track work hours so we adhere to the rules- most importantly these two: 1) No more than 80 hours of work per week and 2) At least 1 day off per week. The limits are averaged over a rotation (i.e., no more than 160 hours over two weeks, at least 4 days off over four weeks, etc.).

The reasons for these rules should be self-evident. In the dark past, before work hours limitations, residents worked to utter exhaustion. As a resident, I often logged 100+ hours per week. We had no days off during the first two months of the academic year and none during ICU rotations. We were on call every fourth night and stayed a full day post call and sometimes had clinic on those days. At times I was an unshaven, red-eyed, hallucinating mess. We rationalized this system as essential for education and patient care. It was a rite of passage that few questioned.

Thirty years after my own residency, we should look back on those days and recognize them for what they were- a misguided system that exploited residents and fostered short tempers, cynicism, and burnout. We didn’t realize it then, and sometimes it’s not even acknowledged today, that any advantages resulting from those long hours were negated by foggy brains, a near-total inability to study, and, too often, insufficient empathy and bad attitudes.

For all these reasons, we need to ensure residents have days off and don’t exceed work hour limits. The days off issue is easy- they’re built into your schedule. The 80-rule creates bigger challenges because we don’t adhere to strict shifts. For each rotation, we’ve built a typical day structure that should ensure that residents work fewer than 80 hours per week, but we know specific patient care issues can impose challenges.

So we need your help, and here’s the boring part. We need you to set time aside each week to report your work hours and to do so honestly. No one “gets in trouble” and no one gets the program in trouble if you exceed work hours. If you’re staying under 80, that’s great. If you’re not, your information helps us address the problem. But we can only fix what you tell us about.

For some residents, the reports identify efficiency issues we can work on together. More commonly, the reports identify systems problems (i.e. too much work for anyone to do in the time allotted). When systems issues are identified, we can fix them, for example by adding residents, lowering caps, or adding resources. For example, because of resident reports, we went from one resident to two on oncology and Klatskin, went from four to six interns to the MICU (and lowered caps), and hired APRNs and PAs in the MICU.

Your comments are especially important. As an example, a resident recently told us she had to exceed work hours in the MICU because she had to pre-round frequently because of her interns‘ days off. Her report will lead to discussions with MICU leadership to address work hours for the MICU PGY2s.

So please, please, please, report your work hours every week, and if you do “violate” work hour rules, just let us know what happened so we can help. The whole point is to take the best possible care of our patients and to ensure that you get the rest you need to stay well and thrive.

With that said, it’s time for this teenager and me to hit the road.

See you soon, everyone,

PS On a related note, I am know many of you have questions and concerns about the new “Surge Algorithm” and its potential impact on residency education and workload. We are scheduling a Town Hall Meeting to address these issues. In the meantime, please feel free to reach out to me, Chris Sankey, the Chiefs, or your Executive Council Leadership (Mark Connor has taken a lead role as a liaison) with any questions. Until then, thank you for stepping up during this challenging time.

Pictures attached.

Submitted by Mark David Siegel on August 27, 2018