A few years ago, the ACGME residency accreditation body placed a limit on the number of hours a resident is allowed to be in the hospital working, both in a week and before having to go home.  Now, no research went into the numbers (80/week, 30 straight) they chose, but at the time it was being said residents were working as much as 120+ hours each week.  There were also reports of residents being so worn out after 36-40 hours straight on duty they were having fatal accidents on the way home afterwards.  Since the advent of this rule, programs have come up with a wide variety of systems to overcome this limitation while taking care of the same number of patients with the same number of residents, all while minimizing the number of times responsibility for any given patient changes hands.

During  the past two months, I went on 9 internal medicine interviews and saw that no two places are anything alike when it comes to this rule.  First, because different hospitals have different inpatient services.  Some have just a general medicine service with all the other sub-specialties functioning as consult services.  Others have an inpatient service for all feasible medicine sub-specialties in addition to general medicine.  And then there’s everything in between.

A few examples of what I have seen, to see the breadth of ideas different institutions have come up with: one hospital has zero night float, all overnight coverage is provided by residents on the inpatient services taking overnight call, from every 3rd to 4th night, depending on the inpatient service; a few other institutions have dedicated 2-week or month long night float rotations to allow the day teams assigned to each inpatient service to go home for the night; another institution has the inpatient teams rotate through a week of night float each; still others use some mix of residents (usually interns) from the inpatient team staying overnight while upper-level resident supervision is provided by a resident pulled from an outpatient rotation.  And everything in between.  I never would have imagined that there could be such variety with everyone working under the same rule.

Of course, I shouldn’t have been surprised.  Anytime a governing body dishes out an unfunded mandate without any research into how or why, the people actually on the ground doing the work must be innovative.  Now, of course, the rules are on the verge of changing again.  Last year, the Institute of Medicine (IOM) released a report saying residents should work no more than 16 hours straight or be given an uninterrupted 5-hour nap in the middle of whatever length shift.  This time, at least, there is some sleep deprivation research that went into the numbers that they chose.  Of course, they took no consideration into how anything of this sort could actually be implemented.  Seriously, a 5-hour nap?  I have issues falling asleep on desire when I’m tired, I can’t imagine trying to fall asleep any faster than an hour into laying down if I’m amped up from running around taking care of patients.  And what about surgical residents, is there going to be someone there to pull them out of surgeries at 16 hours?  I sure hope not.  That’s not going to happen in the real world of practice, and I sure as heck want the person operating on me to have had some supervised experience doing it tired before putting the knife to me.

Now, of course, the IOM has no real power.  So the ACGME is taking a look at the above and everything else in the IOM’s report, and they are supposedly going to be making a decision sometime this year that would need to be implemented in the summer of 2011.  I was fortunate enough to discuss these coming changes on a few of my interviews with some people that are in position to potentially have a little more insight into the inner-goings on of the committee studying this.  As with the first set of rules changes, there’s a variety of opinions of what is going to happen.  Anywhere from increased oversight and regulation of the current rules to no more overnight call whatsoever.  Who really knows?

For now, 73 days until Match Day.  At least I will know how the first year will work, the two years after that seems to be up in the air.

Well, the first road trip is over.  Actually long over, I’ve been back for a week (hey all of that turkey wasn’t gonna eat itself).  So here are the final stats on that one.

• Total Mileage:  1500 miles
• Worst Traffic:  I-66 East (40 miles in 1.5 hours)

Washington, D.C. – Our Nation’s Capital

DC was okay, as you can see from the picture it was a rainy day.  I learned a few lessons, one of them is to avoid Dupont Circle at all hazards, especially during rush hour.  The other is that bigger is not necessarily better when it comes to residencies.  Despite being the highest paying residency I’ve looked at, the cost of living in DC would mean that I would have to pay double to live in a smaller place than I am currently in.  I just don’t think I’m comfortable with that.  I also learned that DC residents are SEIU members, another fact that I am not cool with.

I’m starting the second road trip today, mileage wise it should be similar.  More updates eventually.

Next Stop:  ATL

Well, interview season has officially begun for me.  I thought I’d keep everyone (which according to my site statistics is all 4 of you) in the loop with updates on my travels.  I’ll try to post a little information on all of the cities I visit and keep a running mileage of my trips.

First Stop – Charlottesville, VA – Home of Thomas Jefferson and the Dave Matthews Band

• Trip Distance:  625 miles
• Time:  9 hours
• Choice Tunes:  Wilco – Yankee Hotel Foxtrot
• Way-points of Interest:  Chattanooga and Knoxville, TN

The drive wasn’t all that bad.  Admittedly I was a bit nervous when I stopped at a Pilot station in Knoxville, but seeing no Priuses in the parking lot, I was a bit calmer.  The scenery for the trip was gorgeous as was the weather.  Almost 300 miles of my trip was spent on Interstate 81, which parallels the Blue Ridge Mountains.  If you’re going to have to stare at the road for your entire day, it is nice to have something decent to look at.

I spent a little bit of time in Charlottesville earlier this year and really enjoyed it.  The program is medium sized and the hospital facilities are excellent (which is the case with most of the programs I’m applying to).  Local attractions include great scenery, hiking, over 20 local wineries, several historic places, and a great music scene.  Sadly, I will not be enjoying any of those items on this quick stop, however it’s nice to know they’re there.

Next Stop:  Washington, DC

Adult Endotracheal Tube

Pediatric Endotracheal Tube

Okay, not really, but wouldn’t that make the Peds ICU more of a festive place?

Here’s a funny patient quote I heard about recently.  Granted, I didn’t hear it myself, but I wouldn’t be surprised if it were true.

Doc, I don’t think I should be on NuvaRing anymore.  I just can’t chew another one of those things.

Perhaps the doctor should’ve been a bit more clear about the proper route of administration.

 

We have a new winner for highest BAC (Blood Alcohol Content) over in medical records.  This particular person tested with a level of 0.409, roughly five times the legal limit.  You sir/ma’am are a true champion, yes, nothing can stop you 409.

When diabetic patients are in the hospital, we put them on a special diabetic diet.  It’s the type of food that they should be eating at home, but usually don’t.  It also helps to keep their blood sugar within a reasonable range.

Today I realized that I too am on a diabetic diet, or more accurately a diabetogenic diet.  I’ve finally reached that point where a Mountain Dew and a 4 pack of Oreos counts as breakfast.  I’m not saying I’m proud of it.  It is what it is.  Incidentally, I’m pretty sure that it has less total calories than a Starbuck’s Mocha, but that’s neither here not there.

The point is, that I’m pretty sure the overweight MD gets there by being too tired to eat anything that doesn’t come from a vending machine or the freezer.  Maybe I’ll start working out tomorrow.  Now if you’ll excuse me, I think I’m going to go warm up a frozen pizza…  Hey, a man’s gotta eat.

Since attorney’s think they know how to reform the medical profession, why not let doctors reform theirs.  Here’s a link to a great op-ed in the WSJ.

Just finishing up a couple of night shifts in a row.  Now I’m trying to switch back to a normal, non-vampiric schedule.  In the meantime, I’m feeling about like this runner.

Today’s issue of Chief Complaint comes from a lovely lady who was picked up on a routine traffic stop.  The following quotes did not come from someone running down the Interstate naked, they came from someone who ran a stoplight.

They’re after me, the white folks.  I jumped off a bridge and died tonight.

An intriguing chief complaint if ever there was one.  Interestingly, when she was asked to give more details, she informed the room that.

My hormones are raging.  I could (fornicate under consent of king) all of you tonight!

The folks in the room decided to pass on that generous offer.   I tell you all of this to get around to my point, which is that the number of psychiatric beds here, and in many other places, is woefully low compared to the demand for them.  At our hospital, psych patients are routinely boarded in the ED for 48 hours or more waiting to be admitted.  Thankfully for this lady, she got to take the express lane to the psych ward.