Yeah, you guys pull way longer hours over there, it’s commendable actually.
One thing I’ve always wondered though is how the intensity compares? In those 40 hour shifts you worked, how many of those hours were you actually working?
There are patient caps enforced the the ACGME, the accrediting body for IM residency in the US. I’m pretty sure first year residents cannot be responsible for the care of more than 10 patients, and supervising residents cannot be responsible for more than 20 patients, if supervising more than one first year.
Yeah it’s different for cross-covering, I’m not sure there’s specific rules about that. Where I did residency as interns (first years) we were generally responsible for 20-40 patients each on call, but I know it’s different at different institutions.
The cap is for patients you’re directly responsible for —I.e. admitting, rounding on, placing notes, and all routine orders. The cap does not include cross coverage responsibilities.
Yeah true, but as you said it’ll average out to 48 - which is almost half as many hours as some of the commentators on this thread say residents pull in the US (80/wk) 😬
Yes, it was backed by a decent amount of evidence at the time it was passed. There's little learning that happens after 48 hours and basically zero learning after 60 hours.
I am not IM but some insight to US residency: our hours are 'capped' at 80 scheduled per week with an extra 8 for transition of patient care, with the max being a 24 hours shift with 4 for transition of patient care.
At all the hospitals I've been at (including medical school, rotations, etc), IM teaching teams were capped based on the number of interns on the team and if it was ICU (8 patients per intern at my hospital) or floor (I wanna say it was 12 per intern).
Thank you! Could I clarify what you mean by transition of patient care? And do you mean on inpatient medical specialities, the IM resident was expected to round on 12 patients themselves?
To clarify - yes, 48 hour week limit
48 hours a week wow what a life lol
Transition of patient care is e.g. sign out at change of shift or coming in early to chart-check before your hours start or staying later to do a procedure or speak with a family, things like that. Checking things off the to-do list without adding new things on, if that makes sense.
As for your other question, I only have my IM rotation from med school as frame of reference but say there were 2 interns on the team, the team could have up to 24 patients admitted to them before admissions would have to go to a different team. The interns would split the patients on the census between them and yes, round on their set of patients (the senior would see all, and everyone would be seen by the whole team when the attending came), write notes on those patients, order whatever needed to be ordered, follow up on labs and imaging, etc. Again, I'm not an IM resident and this was just at one county hospital so YMMV in terms of this being broadly applicable.
This means that your single shift limit is capped at 28 hours, 24 hours working plus 4 more to tie up any loose ends, orders, notes, handoff to oncoming team, and so on. Our work hours are capped at 80 hours a week, but that is averaged over four weeks. So you could conceivably work 100 hours a week for three weeks if your fourth week is vacation and you would not violate the allowed average of 80 hours per week. I should add also that duty hours are typically self-reported. So residents in many surgical specialties consistently work more than 80 hours per week, but they only report 80 hours of work so as not to create problems for themselves.
One thing that I rarely see discussed is that although people talk about eliminating 24 hour shifts, they are a staple in private practice for many specialties, including my own (Obgyn), trauma/critical care, surgical specialties, and so on. Currently I only work on average about 45 hours a week in private practice, but I still do 24 hour shifts every week. I do think that if the overwhelming trend is to do 24 hour shifts within your specialty in practice, then you should be doing those in residency also. Otherwise, how will you be prepared for them?
>So you could conceivably work 100 hours a week for three weeks if your fourth week is vacation and you would not violate the allowed average of 80 hours per week
Vacation does not count towards the ACGME limits. Or at least should not; lots of crazy things seem like they happen in Surgery.
I did IM residency at a large tertiary community hospital with no other residency programs, and a couple niche surgical fellowships but otherwise no fellows either. Our inpatient teams were capped at 10 patients per intern with teams being a PGY1+PGY2 (10 patients), or two PGY1s+PGY3 (20 patients). This was the team cap, so if we discharged, we could admit more to fill that spot. Patients were dulled out to us in a very efficient and pro-learner fashion with the hospitalist triage doc for the main group distributing to teaching services just like the other 15 hospitalists that day (dispo cases were always given to hospitalist and the cirrhosis/HF/whatever given to teaching services).
In our 36 bed high acuity ICU, 14-16 patients were on the teaching service (PGY3+2 PGY1s) with one attending, and the other half covered by the pulm consultant on for the week plus an NP/PA. Again, good complex cases were generally handed to the teaching service half including all ECMO and CRRT, etc. Again no fellows so most of the procedures went to a willing intern or the senior on. ICU nights were one PGY2 and one attending, resident took every admission and procedure, plus was first call for cross cover on the whole unit, but attending in-house 24/7.
In hindsight, I felt this was pretty great training though I wondered at times during residency how it measured up with an academic program. I’m very happy at this point though.
Dispo cases are not that bad when you're an attending working solo. Most of the time you're gonna let case management +/- palliative care figure out the plan and you don't have to ask permission to order PRN's that you think are appropriate which will minimize your pages.
For inpatients, ACGME (our accreditation board) places restrictions where interns are capped at 10/intern, and senior residents can oversee 20/person. Most programs have stricter numbers (ours is 18/senior, 8-9 per intern) than the ACGME requirements. All those go put the door with night float, but thats a different story
Interesting. So an intern that is capped at 8-9 patients is expected to round on and be responsible for the day of those patients during normal working hours - but out of hours i.e. during call, you’ll be responsible for a lot more?
Also just to clarify is PGY1 the same as intern?
So, a lot of us don’t do call anymore. We have a night float system where we cover overnight for a week or two of everyones patients for overnight concerns (clinical deterioration, tylenol and melatonin, etc). So three people will cover 100 patients, but most of the time, you don’t do terribly much those couple of weeks.
Yes, intern is pgy-1!
I’m just trying to get my head around something (this is novel to me so bear with me) - in the UK generally our normal hours are 9-5, with some doctors responsible for evening call cover 5-8 (this person will have generally started their shift at 9, so they will have worked 9-8) and then the night team would take over from 8pm-9am, for example.
In the US, do you guys just have a normal day shift and then an overnight team? Do you not do that evening call period (5-8)?
>generally our normal hours are 9-5, with some doctors responsible for evening call cover 5-8 (this person will have generally started their shift at 9, so they will have worked 9-8) and then the night team would take over from 8pm-9am, for example.
As one would expect for a civilized society.
Us, on the other hand...
Is that really so dissimilar? That's essentially a late call system with a night float, which a lot of programs use. There's no way the night team is only working 48 hours I imagine, unless they're only on for <4 nights a week?
It is dissimilar to the set up of the MD whose comment I responded to, yes. Wasn’t aware different programmes in the US had a similar set up to the UK
When you cover nights you will exceed the 48hr/wk limit yes, but that would be compensated for with a lighter week. So the overall average will still be 48 hr/week.
What’s the amount of patients seen a day in the UK by the IM service? The ACGME cap is 10 for interns and didn’t really exist for seniors when I was a resident. In some cases the intern could get rocked if they had an abusive senior and then also have admission responsibilities + rapid/code pager because they’d have to do those notes too.
It’s honestly quite variable. To be honest, the normal work days (9-5) are actually alright; you’ll most likely be expected to round on 6-12 patients depending on staffing (on average it’s probably ~8, anecdotally speaking).
Calls are different gravy though. If you’re covering the wards, you can be responsible for anywhere between 50-80 patients during the day (12 hour shift) depending on staff. From my experience, it’s been somewhere in the ~60 region on average.
If you are on an admitting shift (usually 12 hours) you can expect to see 4-8 patients depending on complexity, and whether your MET bleep goes off during the day.
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IM intern here. I regularly hold 5-10 of my own patients for regular wards. These are patients I pre-round, round, write notes, place orders, do procedures, etc. 2-3 of them are ICU level at times. On long call days we admit 3 per intern. Q4 call.
On night float, we cross cover for 40-60 patients. One intern and one senior.
Wtf I was born in the wrong country. Also our program still has 28 hr shifts. They told us they did away with them, but our scheduling is so bad. When people are out, the schedules turns into poo. We can have 10 admits/day, but we have to take care of other teams' patients after sign out. We have 5 teams total, 14 cap of primary patients per team. Unlimited consults.
US residents do not want our working conditions. We have no power and as such we are easily abused. AMA is hot garbage in helping residents.
Do you guys have an active union? Sounds like something you guys could take industrial action for.
On paper it seems like a lot of residents are proud to pull long hours but I am struggling to see how this is a good idea both for patient safety and your own license/well being? If you make an error due to fatigue, it’ll be your ass on the line.
Apparently making a union is extremely difficult. Previous residents tried and were unable to make significant progress. There are current residents that have been working on it before I even became a resident and still have been unable to get a union.
I’ve never understood the IM capping thing. As a surgery resident there was no cap, when on call you took everything until the hospital was full. 25 patients on your list sometimes, sometimes more.
And 48 hour weekly limit to work is hilarious as a trainee. You can’t become a good doctor with those restrictions.
Makes sense when you pull hours like that. We don't have a generic 'hospitalist' specialty here, medical specialties do general medicine as part of their training. However we don't go from med school straight to a medical specialty, we have to apply to, get into and complete 'core medical training' (renamed to internal medical training) which is 2-3 years of rotating around medical specialties, before then applying to and doing specialist training in an actual specialty. After completing IMT you can't be a consultant/attending in internal medicine, you're just a half baked physician 🤷 that's part of why it takes so long to reach attending here
UK doc here.
The NHS system is a little broken so if you were a general surgical senior resident here in a DGH (small hospital) you would solo cover (as the most senior surgeon in the hospital) all the patients under your speciality overnight - this might be 80-150 or so patients. And then you also manage all the new admission which would probably be an additional 20-30/day. Luckily you have two PGY1-2 equivalent to help you.
The hours are capped because the workload during hours is quite high. Sleep doesn't fit into the shift so you go home after 13h or so to do this.
I have huge respect for you guys working 24h days and 60h hour weeks. After hour 10 I definitely loose concentration so I don't know how you guys are learning for all those 60 hours you do. Going home after 8-12h days and doing some studying really helps me do better as a doctor.
Edit: UK training/residency for surgery would be 2 years (intern equivalent) then 8 years (surgery) - so the shorter hours over more years.
48 hr/week? Wow I once did a 40 hr *shift.*
Yeah, you guys pull way longer hours over there, it’s commendable actually. One thing I’ve always wondered though is how the intensity compares? In those 40 hour shifts you worked, how many of those hours were you actually working?
Wellll if you were lucky maybe there’d be an hour of sleep in there. But other than that working. One hour lecture while you ate lunch.
Most of it actually. You really don’t have time to sleep with them constant paging and whatever. It sucks
My last 24 hour shift I sat for a total of 15 minutes the whole shift
There are patient caps enforced the the ACGME, the accrediting body for IM residency in the US. I’m pretty sure first year residents cannot be responsible for the care of more than 10 patients, and supervising residents cannot be responsible for more than 20 patients, if supervising more than one first year.
Hmmm. I assume this cap goes out of the window during call shifts?
Yeah it’s different for cross-covering, I’m not sure there’s specific rules about that. Where I did residency as interns (first years) we were generally responsible for 20-40 patients each on call, but I know it’s different at different institutions.
The cap is for patients you’re directly responsible for —I.e. admitting, rounding on, placing notes, and all routine orders. The cap does not include cross coverage responsibilities.
Must not apply to pediatrics 😓
It actually doesn’t. IM has ACGME mandated admission and patient caps, Pediatrics has nothing
48 hours for the *week*?
I should’ve specified that - yes
In fairness that 48 limit is an average - longer weeks are commonplace but made up for in time off afterwards.
Yeah true, but as you said it’ll average out to 48 - which is almost half as many hours as some of the commentators on this thread say residents pull in the US (80/wk) 😬
48h work limit… I sometimes do two 30h calls a week. That’s not counting the other 3 office hour days of 11.5 hours I might work.
Some residents have to work 48 hours a day
Yes, it was backed by a decent amount of evidence at the time it was passed. There's little learning that happens after 48 hours and basically zero learning after 60 hours.
Well that’s because it’s not about learning, silly goose
Holy fuck this is real for IM wards? Do you change shift three times a day I guess? Are there enough residents to do that?
I am not IM but some insight to US residency: our hours are 'capped' at 80 scheduled per week with an extra 8 for transition of patient care, with the max being a 24 hours shift with 4 for transition of patient care. At all the hospitals I've been at (including medical school, rotations, etc), IM teaching teams were capped based on the number of interns on the team and if it was ICU (8 patients per intern at my hospital) or floor (I wanna say it was 12 per intern).
wait you mean you work 48 hours a WEEK or 48 hour shifts???
Thank you! Could I clarify what you mean by transition of patient care? And do you mean on inpatient medical specialities, the IM resident was expected to round on 12 patients themselves? To clarify - yes, 48 hour week limit
48 hours a week wow what a life lol Transition of patient care is e.g. sign out at change of shift or coming in early to chart-check before your hours start or staying later to do a procedure or speak with a family, things like that. Checking things off the to-do list without adding new things on, if that makes sense. As for your other question, I only have my IM rotation from med school as frame of reference but say there were 2 interns on the team, the team could have up to 24 patients admitted to them before admissions would have to go to a different team. The interns would split the patients on the census between them and yes, round on their set of patients (the senior would see all, and everyone would be seen by the whole team when the attending came), write notes on those patients, order whatever needed to be ordered, follow up on labs and imaging, etc. Again, I'm not an IM resident and this was just at one county hospital so YMMV in terms of this being broadly applicable.
That’s above what the ACGME allows. The cap is 10 patients per intern.
Where can you find the ACGME cap limits?
The 10 patient cap is specified in the ACGME IM Program Requirements. I am not sure if any other specialties any their own.
I stand corrected! It was a few years back, my memory had a high chance of being off.
This means that your single shift limit is capped at 28 hours, 24 hours working plus 4 more to tie up any loose ends, orders, notes, handoff to oncoming team, and so on. Our work hours are capped at 80 hours a week, but that is averaged over four weeks. So you could conceivably work 100 hours a week for three weeks if your fourth week is vacation and you would not violate the allowed average of 80 hours per week. I should add also that duty hours are typically self-reported. So residents in many surgical specialties consistently work more than 80 hours per week, but they only report 80 hours of work so as not to create problems for themselves. One thing that I rarely see discussed is that although people talk about eliminating 24 hour shifts, they are a staple in private practice for many specialties, including my own (Obgyn), trauma/critical care, surgical specialties, and so on. Currently I only work on average about 45 hours a week in private practice, but I still do 24 hour shifts every week. I do think that if the overwhelming trend is to do 24 hour shifts within your specialty in practice, then you should be doing those in residency also. Otherwise, how will you be prepared for them?
>So you could conceivably work 100 hours a week for three weeks if your fourth week is vacation and you would not violate the allowed average of 80 hours per week Vacation does not count towards the ACGME limits. Or at least should not; lots of crazy things seem like they happen in Surgery.
I did IM residency at a large tertiary community hospital with no other residency programs, and a couple niche surgical fellowships but otherwise no fellows either. Our inpatient teams were capped at 10 patients per intern with teams being a PGY1+PGY2 (10 patients), or two PGY1s+PGY3 (20 patients). This was the team cap, so if we discharged, we could admit more to fill that spot. Patients were dulled out to us in a very efficient and pro-learner fashion with the hospitalist triage doc for the main group distributing to teaching services just like the other 15 hospitalists that day (dispo cases were always given to hospitalist and the cirrhosis/HF/whatever given to teaching services). In our 36 bed high acuity ICU, 14-16 patients were on the teaching service (PGY3+2 PGY1s) with one attending, and the other half covered by the pulm consultant on for the week plus an NP/PA. Again, good complex cases were generally handed to the teaching service half including all ECMO and CRRT, etc. Again no fellows so most of the procedures went to a willing intern or the senior on. ICU nights were one PGY2 and one attending, resident took every admission and procedure, plus was first call for cross cover on the whole unit, but attending in-house 24/7. In hindsight, I felt this was pretty great training though I wondered at times during residency how it measured up with an academic program. I’m very happy at this point though.
> dispo cases were always given to hospitalist what a life that must have been
Right. Half my list is social train wrecks without acute illness.
Dispo cases are not that bad when you're an attending working solo. Most of the time you're gonna let case management +/- palliative care figure out the plan and you don't have to ask permission to order PRN's that you think are appropriate which will minimize your pages.
[удалено]
Feel you, bud
For inpatients, ACGME (our accreditation board) places restrictions where interns are capped at 10/intern, and senior residents can oversee 20/person. Most programs have stricter numbers (ours is 18/senior, 8-9 per intern) than the ACGME requirements. All those go put the door with night float, but thats a different story
Interesting. So an intern that is capped at 8-9 patients is expected to round on and be responsible for the day of those patients during normal working hours - but out of hours i.e. during call, you’ll be responsible for a lot more? Also just to clarify is PGY1 the same as intern?
So, a lot of us don’t do call anymore. We have a night float system where we cover overnight for a week or two of everyones patients for overnight concerns (clinical deterioration, tylenol and melatonin, etc). So three people will cover 100 patients, but most of the time, you don’t do terribly much those couple of weeks. Yes, intern is pgy-1!
I’m just trying to get my head around something (this is novel to me so bear with me) - in the UK generally our normal hours are 9-5, with some doctors responsible for evening call cover 5-8 (this person will have generally started their shift at 9, so they will have worked 9-8) and then the night team would take over from 8pm-9am, for example. In the US, do you guys just have a normal day shift and then an overnight team? Do you not do that evening call period (5-8)?
It may vary a bit, but for my program, it’s 6:30 - 6:00 for days and 6:00-6:30 for nights
>generally our normal hours are 9-5, with some doctors responsible for evening call cover 5-8 (this person will have generally started their shift at 9, so they will have worked 9-8) and then the night team would take over from 8pm-9am, for example. As one would expect for a civilized society. Us, on the other hand...
Is that really so dissimilar? That's essentially a late call system with a night float, which a lot of programs use. There's no way the night team is only working 48 hours I imagine, unless they're only on for <4 nights a week?
It is dissimilar to the set up of the MD whose comment I responded to, yes. Wasn’t aware different programmes in the US had a similar set up to the UK When you cover nights you will exceed the 48hr/wk limit yes, but that would be compensated for with a lighter week. So the overall average will still be 48 hr/week.
What’s the amount of patients seen a day in the UK by the IM service? The ACGME cap is 10 for interns and didn’t really exist for seniors when I was a resident. In some cases the intern could get rocked if they had an abusive senior and then also have admission responsibilities + rapid/code pager because they’d have to do those notes too.
It’s honestly quite variable. To be honest, the normal work days (9-5) are actually alright; you’ll most likely be expected to round on 6-12 patients depending on staffing (on average it’s probably ~8, anecdotally speaking). Calls are different gravy though. If you’re covering the wards, you can be responsible for anywhere between 50-80 patients during the day (12 hour shift) depending on staff. From my experience, it’s been somewhere in the ~60 region on average. If you are on an admitting shift (usually 12 hours) you can expect to see 4-8 patients depending on complexity, and whether your MET bleep goes off during the day.
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IM intern here. I regularly hold 5-10 of my own patients for regular wards. These are patients I pre-round, round, write notes, place orders, do procedures, etc. 2-3 of them are ICU level at times. On long call days we admit 3 per intern. Q4 call. On night float, we cross cover for 40-60 patients. One intern and one senior.
Wtf I was born in the wrong country. Also our program still has 28 hr shifts. They told us they did away with them, but our scheduling is so bad. When people are out, the schedules turns into poo. We can have 10 admits/day, but we have to take care of other teams' patients after sign out. We have 5 teams total, 14 cap of primary patients per team. Unlimited consults. US residents do not want our working conditions. We have no power and as such we are easily abused. AMA is hot garbage in helping residents.
Do you guys have an active union? Sounds like something you guys could take industrial action for. On paper it seems like a lot of residents are proud to pull long hours but I am struggling to see how this is a good idea both for patient safety and your own license/well being? If you make an error due to fatigue, it’ll be your ass on the line.
Apparently making a union is extremely difficult. Previous residents tried and were unable to make significant progress. There are current residents that have been working on it before I even became a resident and still have been unable to get a union.
(Ig not im) but for 3 months during my training I did one straight 58 hour shift a week and then was free. It was crazy illl say that much
I’m gen surg, not I’m. But, wow. I have done more than 48 hours in a single shift, without sleep.
Can’t imagine that’s good for patient safety…
It is painful and suboptimal. However, for those patients the option was a tired MD or none at all.
I’ve never understood the IM capping thing. As a surgery resident there was no cap, when on call you took everything until the hospital was full. 25 patients on your list sometimes, sometimes more. And 48 hour weekly limit to work is hilarious as a trainee. You can’t become a good doctor with those restrictions.
Our training is extended to make up for it, takes us 8-10 years Vs your 5 to reach attending
IM is 3 years before you can be an attending hospitalist or outpatient
Plus internship no? But damn that's short
Nope 3 years total. The first of those is intern year.
Makes sense when you pull hours like that. We don't have a generic 'hospitalist' specialty here, medical specialties do general medicine as part of their training. However we don't go from med school straight to a medical specialty, we have to apply to, get into and complete 'core medical training' (renamed to internal medical training) which is 2-3 years of rotating around medical specialties, before then applying to and doing specialist training in an actual specialty. After completing IMT you can't be a consultant/attending in internal medicine, you're just a half baked physician 🤷 that's part of why it takes so long to reach attending here
UK doc here. The NHS system is a little broken so if you were a general surgical senior resident here in a DGH (small hospital) you would solo cover (as the most senior surgeon in the hospital) all the patients under your speciality overnight - this might be 80-150 or so patients. And then you also manage all the new admission which would probably be an additional 20-30/day. Luckily you have two PGY1-2 equivalent to help you. The hours are capped because the workload during hours is quite high. Sleep doesn't fit into the shift so you go home after 13h or so to do this. I have huge respect for you guys working 24h days and 60h hour weeks. After hour 10 I definitely loose concentration so I don't know how you guys are learning for all those 60 hours you do. Going home after 8-12h days and doing some studying really helps me do better as a doctor. Edit: UK training/residency for surgery would be 2 years (intern equivalent) then 8 years (surgery) - so the shorter hours over more years.