Longer First-Year Resident Shifts May Equal More Burnout

The Accreditation Council for Graduate Medical Education (ACGME) announced that medical residency programs can begin increasing shift hours for first-year residents starting in July 2017. While this new policy is aimed at improving outcomes for both patients and residents, it has many critics who claim that it may lead to increased burnout. I am agnostic on the hours, but I am passionate about burnout prevention.

Shift Increases

Currently, shift hours for first-year residents are capped at 16 per shift. In July, that number of maximum shift hours will increase to 24 (with an additional four hours devoted to taking care of patient hand-offs). Despite this change, 80 hours is still the maximum weekly amount for first-year residents. 

The change is aimed at improving all of the following:

  • Patient Care Continuity
  • Clinical Teamwork
  • Resident Learning Experience

Using The 8 PRACTICEs of Highly Successful Surgeons, we should start with a Passion for Performance Improvement. 

Critics of the New Policy

The new shift policy has its fair share of critics – among them the American Medical Student Association. These critics contend that increased hours will lead to increased stress, burnout, sleep deprivation, and mistakes. I am not saying it is good, but reality is that sleep deprivation, stress and mistakes are a part of medicine. Our shared goal is to minimize all three and maximize care continuity, teamwork and resident learning experience.

Sure, total weekly hours are still capped at 80, but that doesn’t mean that residents are using that time for rest and effective stress reduction. There are also many stories of the pressures placed on residents to bend or break the rules. 

Can we all agree that the human body, mind and soul needs time to rest and recharge? 

If we all aim for improvement, mistakes are less likely to occur, and we will also improve patient care continuity, clinical teamwork and resident learning experience.

The 8 PRACTICEs of Highly Successful Surgeons

I have struggled first-hand with burnout in my time as a medical student, through residency, and in private practice. Through these experiences I have developed my own signature methodology for preventing burnout. I call it the 8 PRACTICEs of Highly Successful Surgeons. This system is designed to help all physicians across all specialties prevent burnout by encouraging healthy habits, and finding your own rhythm. Drop me a line today to learn more about the 8 PRACTICEs and prevent burnout before it strikes.

Performance Training in Golf, Yoga & Surgery

Golf

My golf game improved the most when others were tracking my handicap. In fact, that summer I received the “Most Improved Award.”

At the time, I didn’t realize the correlation. Why? Because I wasn’t focused back then. I was given the opportunity to practice regularly. I also received some private and group coaching. I wasn’t intending to be competitive. I was just given an opportunity by my father to get better at something I might enjoy doing. The intention was to have more fun.

The Game of Golf / The Game of Life

In many ways, the game of golf is a reflection of the game of life—a long journey laden with ups, downs, hazards, rules, difficult shots, easy putts, and an ample sprinkling of both misfortune and good luck.

Golfers like that.

The sport offers its players beauty, unpleasantness, hilarity, disappointment, exuberance, heartbreak, and just about every other feasible emotion. No two rounds are alike and, in much the same way, no two days are alike.

Golfers like that as well.

Handicapping

But, most importantly, golf transcends skill or athleticism—it employs handicapping which makes it possible for any group to go out and compete.

I can go out tomorrow and play competitively with professional golfer Jordan Spieth, President Jimmy Carter, and Serena Williams, not because we’re all equally skilled and athletic, but because our respective handicaps level the playing field.

I like that aspect of the sport the most.

Age, strength, speed, height, skill—the handicap accounts for and then offsets all of these differences and more.

Golf brings people together, but not at the expense of competition. Handicapping offers golfers a way to measure their development and performance, but against the game as opposed to against the opponent.

It is an incredible principle, and one that would be fascinating if we could adapt it to other segments of life and Surgery!

Yoga

I really enjoy yoga—but I’m not nearly as talented at its practice as many others. During the early part of my yoga practice, I would only measure my performance by the standard of “I’m still not as good as that person.”

With yoga, I give myself the opportunity to practice regularly. I also receive some private and group coaching. I am not intending to be competitive. I am giving myself the opportunity to get better at something that is good for me. My intention is physical wellness.

In fact, I should receive “The Most Improved Award!”

Informal Handicapping

While yoga doesn’t have a formal handicapping system, it does have an informal one.

Yoga is about self-improvement which can be measured in our well-being.

I have learned that I’m "competing" against myself—getting incrementally better—but sparing me the indignity of having to measure my talents or skills directly with someone who is lightyears ahead of me in practice.

Yogis like that as well.

Measuring Development Against the Practice, Not Others

Yoga encourages us to strengthen, stretch, balance, focus, and look inwards without judgement. Yoga allows us to appreciate how each day is different. We can come in tired, stiff, sore, stressed or steeped in emotion, but we will almost always leave each session stronger, more energized, flexible, relaxed, focused and healing.

Yogis like that as well.

Yoga offers a way to measure our development and performance, but against the practice as opposed to against the others without a specific handicap.

Surgery

How is performance improvement tracked in surgery? What about a handicap for surgery?

What if surgeons were given a handicap based upon their performance in their ten most recent cases?  

Surgical Handicapping System

I think this would be an incredibly interesting way to measure competence in surgery—I’m not saying it would be the best way, I’m just saying a handicap (or something like it) might be a way to stimulate performance improvement directed at the positive outcomes or final outcomes, without focusing on our background experience, years in practice, or negative outcomes.

Applied to surgery, a handicap could help us closely monitor our development—or regression—as surgeons, and that’s a benefit to us, our employers, and our patients.

And like in golf, the decision to share our handicap should be up to us or “the club” that we belong to.

Or like in yoga, the informal handicap could encourage each of us to improve our performance and development without judgment and against the practice of surgery as opposed to against others.

As a result of my practice of yoga, I am leading a healthier, more sustainable life and practice. I am more recharged, mindful, and a better surgeon. I give myself the opportunity to practice regularly. I also receive some private and group coaching. I am not intending to be competitive, though I could be. I am giving myself the opportunity to get better at something that is important to me. Being a surgeon.

Patients like that.

My intention is quality patient care.

Patients like that as well.

But, what do you think?

If the “handicapping” system isn’t right for surgery, what is? Is there something we as surgeons can adopt? Or something unique that we can create?

I’m curious to hear your thoughts. Share them below.

The Jeff Smith Time-Out: It is NOT a Checklist!

The term "Time-Out" means different things to different people, but to Surgeons it means something specific. 

Surgical Time-Out

Personally, I'm not a fan of the "surgical time-out."

It's not because I'm uninterested in patient safety or the avoidance of wrong-site surgery--It's just I've rarely felt that Surgical time-outs increase my team's quality of care or patient safety. 

To date, I have never had a wrong site surgery (knock on wood) and the current surgical time-outs will NOT help me avoid having one. 

OK, let me back up a little...

There was a time I wasn't totally against the time-out.

In the early years of the surgical time-out, things were simple; it was the final confirmation that we were operating on the left or right side of the patient. That was it.

Did wrong site surgery problems completely go away? No. But a team focus to help us better avoid the most tragic surgical errors is very well intentioned.

The Problem with Checklists

The problem I have is that we have added everything critical to the surgical time-out to create Checklists!

Guess what? From a surgeon's viewpoint, most everything in the operation is critical.

Keep in mind that many surgeons are overworked and are being asked to carry heavier and heavier clerical burdens even just before operations that require us to be “on our game!” 

The time out is just one MORE thing that many surgeons consider a burden and a distraction from our performing at our best.

Unfortunately, reversing this trend of checklists and multifaceted time-outs might be impossible, even though there has been minimal evidence to suggest these measures have lowered the incidence of wrong-site surgery or improved patient safety.

But what if we as surgeons looked at the "Time-Out" through a lens of opportunity?  

What if we let our team do whatever they are required to do during the time-out? 

What if we then CHOSE to do whatever WE need?

For me, I now CHOOSE to use the time-out to privately calm my frustrations and stresses from the pre-op hassles. I also make the final confirmation of patient identity and surgical site.

What will you CHOOSE to do?

P.S. Check out my friend Philip Stahel’s new book Blood, Sweat and Tears: Becoming a Better Surgeon Chapter 16 for a different perspective on the surgical time-out.