Alberta residents, interns first in Canada
,Alberta residents, i*nterns, frst i*n Canada to enjoy mandatory limit of 28 on-call hours
Lynne Sears Williams
A lberta will soon become the first province to have a mandatory limit of 28 oncall hours for interns and residents. The agreement follows contract negotiations with the Council of Teaching Hospitals of Alberta (COTHA). The on-call limit, to be implemented June 30, 1992, is a breakthrough that is being viewed cautiously by educators and clinicians throughout the province. Most agree the change is long overdue. "The reason for the legislation is clearly a concurrence that patients are sicker and on many on-call rotations individuals may be awake an entire night," said Dr. George Goldsand, associate dean of postgraduate medical education at the University of Alberta. "It's simply based on the fact that it is inappropriate for an individual who has not slept to [try to] continue to work and continue to provide safe and responsible patient care." The 28-hour call day, negotiated by the Professional Association of Internes and Residents of Alberta (PAIRA), is the most controversial clause in a contract that included a 5.5% wage increase retroactive to January 1991. Dr. Michele Kalny, past president of PAIRA, took the unprecedented move of making the issue of "intern overload" public before the contract negotiations began.
Extensive media coverage sympathetic to the interns' cause may have influenced negotiations. "[Going public] was a very hard decision to make because physicians in general really are a quiet group," said Kalny, a fourth-year resident in pediatrics at the Alberta Children's Provincial General Hospital in Calgary. "We don't usually go to the press with our issues and concerns but we felt strongly enough about our issues in respect to long hours and patient care that we thought it was time the public should know." PAIRA members were concerned about the quality of patient care and whether a system in which house staff are routinely asked to work 36-hour shifts provides the best educational experience. "Nobody likes to think they might be doing more harm than
good or putting a patient at risk," Kalny said. The "28-hour day" is already a staple in many medical departments in the province. Dr. William Black, a physician in the coronary care unit (CCU) at Edmonton's Royal Alexandra Hospital, says that for many years the department has routinely dismissed residents after a night on call. "We recognize that sometimes a night on the CCU is a disaster," Black said. "I think to work a whole weekend, or day after day the way we used to, is kind of silly." Dr. Keith Brownell, associate dean of graduate clinical education at the University of Calgary, says the technologic revolution going on in medical science has made a medical residency in the
"It is inappropriate for an individual who has not slept to try to continue to work and continue to provide safe and responsible
patient care." -
Dr. George
Goldsand
Lynne Sears Williams is a freelance writer living in Edmonton. 1028
CAN MED ASSOC J 1992; 146 (6)
LE 15 MARS 1992
'90s very different from his own experience. "I graduated in 1964, when ICUs [intensive care units] were just beginning to be formed," he said. "You weren't dealing with patients who required constant monitoring and reassessment of their medical conditions every 20 minutes. It just didn't happen. People who were that sick died. "Now we just see in the hospital those critically ill patients or patients who are waiting to go to a nursing home. There's very little of the in-between." The change in on-call hours will create some staffing headaches. "That's one of the reasons we felt we needed the extra time in order to implement this," said Wayne Strudwick, chairman of COTHA's negotiating team. He hopes that residents who do manage to sleep while on call will not automatically leave the hospital at noon, but concedes that innovative plans may be needed to ensure continuity of patient care. Dr. Ernest Schuster, chairman of the Medical Education Committee at Misericordia Hospital in Edmonton, said solutions have been suggested that range from hiring GPs to assist during surgery to establishing paramedics in ICUs. The least-liked solution is perhaps the most obvious: let attending physicians provide on-call care for their patients. "If you look to regional hospitals where there are no house staff, I think the view is they tend to provide patient services very well," said Dr. David Moores, chairman of family medicine at the University of Alberta. "I think one of the risks I see in big-city teaching hospitals is that a dependency [on house staff] in regard to servicing the hospital has slowly increased over the years." Relying on house staff to handle routine admissions and on-call duties is acceptable, Moores believes, if the attending physicians 1030
CAN MED ASSOC J 1992; 146 (6)
provide sound educational opportunities. "Those attending physicians who really have no interest in teaching should not be placed in that awkward role of having to teach, or of being able to rely upon taxpayers' money for the servicing of their own personal practices," he said. Moores takes attending physicians' teaching duties seriously. In his previous position at Memorial University in St. John's, Nfld., he and the members of a residency training committee pulled an entire team of residents from an obstetric service, citing failure of the department to meet educational objectives. Residents generally agree that the sometimes brutal on-call hours are an acceptable trade-off if they have received good teaching. Dr. Chuck Samuels, a family medicine resident at the Misericordia Hospital, said he is willing to make concessions about on-call schedules if the educational return is equitable. "I don't like doing work and getting nothing in return," he added. "We're caught between a rock and a hard place. I don't like doing this, but the fact is I've got to learn medicine." He describes his philosophy as "a trade-off. Basically, the at-
tending physician is saying, 'If you want to play with my patients, you'd better do my admissions and I'll teach you if I have time.' Will residents take advantage of their legislated hours? Some residents worry that unless hospitals work hard to adjust to the shorter hours, things may not change. "It's not possible," said Dr. Doug Hamilton, an internal medicine resident at Foothills Hospital in Calgary. "There's no way I'm going to be able to walk out at noon. There's no one to take the patients." In the past, said Kalny, peer intimidation and fear of receiving a bad evaluation have kept many residents from complaining about scheduling. Unless residents begin to force the issue of the 28-hour day, some departments may not respect the contract. "You have to get together and stick to this and do it en masse, because otherwise you undermine everybody else and in the long run you hurt yourself," Kalny said. Brownell said residents and interns must learn that it is acceptable to report abuses, and that such reports will not be detrimental to their careers. "All these
"We don't usually go to the press with our issues and concerns but we felt strongly enough about our long hours that we thought it was time the public should know." Dr. Michele Kalny
For
prescribing information see page 11 16
-
institutions have appropriate structures in place to deal with these situations," he maintains. "If people are afraid to deal with this because they're worried they'll get a bad evaluation, then they're contributing to the status quo." He said medical education committees are the appropriate place to make complaints. "Point it out to people who are in a position to deal with it," he argued. Brownell, who lobbied hard for the 28-hour day, said "wethem" confrontations between interns and residents and their medical committees are a mistake. "We are colleagues and we're all interested in the same thing effective patient care. It's unfortunate that these things have to be solved by arbitration." The issue of whether residents may voluntarily work longer than 28 hours may ultimately be settled by a third party, the Canadian Medical Protective Association (CMPA). PAIRA has asked the CMPA to decide whether residents and interns will still receive insurance coverage if they work more than the number of hours stated in the contract. Fear that residents will find themselves without insurance coverage may
"One of the risks I see in big-city teaching hospitals is that a dependency on house staff in regard to servicing the hospital has slowly increased over the years." Dr. David Moores
1032
CAN MED ASSOC J 1992; 146 (6)
force the issue more definitively than either COTHA or PAIRA had originally planned. Samuels, on the final week of a 1 -in-2 call schedule on an ICU, believes that difficult schedules do not necessarily reflect the attitude of an uncaring bureaucracy. "They see the mistakes we make," he said. "They see our disinterest and our miserable attitudes. They don't want us to be doing this [working long hours]." The fine line between what portion of the postgraduate medical experience qualifies as training, and how much can be described as salaried work, contributed to lengthy wage negotiations. Kalny said the 5.5% increase, which pegs annual salaries during the sixth year of training almost $8500 below those of Ontario residents, was inadequate. "I don't think Ontario costs that much more a year to live in," she said. "The interns and residents there don't do any more work than we do here. We still feel we deserve substantially more." Kalny said salary figures used in the negotiations - they compared residents to workers in the public service sector - were misleading, since PAIRA forgoes the right to strike and members
don't operate on a 39-hour workweek. But Strudwick said the wages are fair for work performed during an educational program. "These people are in an educational experience program, designed for a discipline that offers considerable return on their time investment in terms of getting themselves prepared as a specialist of one sort or another," he said. "It's a period of their lives for 4 or 5 or 6 years, where they are earning money while they train. Then when they do become specialists the return as perceived by most people is substantial." Some doctors are worried that residents on the high end of the interning pyramid will use the mandated 28-hour day to work shifts in emergency and family medicine departments. "It's my conviction that they are not appropriately trained to function as a primary care doc," Moores commented. He agrees that most residents just want to go home and sleep, though. "My senise is that it's a move in the right direction."' In the meantime, interns and residents will continue to provide service in a system where balance may be only theoretically present, because these students' desire to work will be fuelled by their wish to gain the best possible education. Samuels, 3 days before the conclusion of his ICU schedule, had already arranged to take another ICU elective in a different Alberta hospital. "I'm very, very worn out and I know my health is compromised but that's the way it is. I have learned a phenomenal amount that I couldn't have learned in any other arm of the hospital. The cost, because it's only 30 days, is OK, though I don't think that justifies doing it. "We make mistakes. Thank God there are nurses there to look at every order we write."LE 15 MARS 1992
,Alberta residents, i*nterns, frst i*n Canada to enjoy mandatory limit of 28 on-call hours
Lynne Sears Williams
A lberta will soon become the first province to have a mandatory limit of 28 oncall hours for interns and residents. The agreement follows contract negotiations with the Council of Teaching Hospitals of Alberta (COTHA). The on-call limit, to be implemented June 30, 1992, is a breakthrough that is being viewed cautiously by educators and clinicians throughout the province. Most agree the change is long overdue. "The reason for the legislation is clearly a concurrence that patients are sicker and on many on-call rotations individuals may be awake an entire night," said Dr. George Goldsand, associate dean of postgraduate medical education at the University of Alberta. "It's simply based on the fact that it is inappropriate for an individual who has not slept to [try to] continue to work and continue to provide safe and responsible patient care." The 28-hour call day, negotiated by the Professional Association of Internes and Residents of Alberta (PAIRA), is the most controversial clause in a contract that included a 5.5% wage increase retroactive to January 1991. Dr. Michele Kalny, past president of PAIRA, took the unprecedented move of making the issue of "intern overload" public before the contract negotiations began.
Extensive media coverage sympathetic to the interns' cause may have influenced negotiations. "[Going public] was a very hard decision to make because physicians in general really are a quiet group," said Kalny, a fourth-year resident in pediatrics at the Alberta Children's Provincial General Hospital in Calgary. "We don't usually go to the press with our issues and concerns but we felt strongly enough about our issues in respect to long hours and patient care that we thought it was time the public should know." PAIRA members were concerned about the quality of patient care and whether a system in which house staff are routinely asked to work 36-hour shifts provides the best educational experience. "Nobody likes to think they might be doing more harm than
good or putting a patient at risk," Kalny said. The "28-hour day" is already a staple in many medical departments in the province. Dr. William Black, a physician in the coronary care unit (CCU) at Edmonton's Royal Alexandra Hospital, says that for many years the department has routinely dismissed residents after a night on call. "We recognize that sometimes a night on the CCU is a disaster," Black said. "I think to work a whole weekend, or day after day the way we used to, is kind of silly." Dr. Keith Brownell, associate dean of graduate clinical education at the University of Calgary, says the technologic revolution going on in medical science has made a medical residency in the
"It is inappropriate for an individual who has not slept to try to continue to work and continue to provide safe and responsible
patient care." -
Dr. George
Goldsand
Lynne Sears Williams is a freelance writer living in Edmonton. 1028
CAN MED ASSOC J 1992; 146 (6)
LE 15 MARS 1992
'90s very different from his own experience. "I graduated in 1964, when ICUs [intensive care units] were just beginning to be formed," he said. "You weren't dealing with patients who required constant monitoring and reassessment of their medical conditions every 20 minutes. It just didn't happen. People who were that sick died. "Now we just see in the hospital those critically ill patients or patients who are waiting to go to a nursing home. There's very little of the in-between." The change in on-call hours will create some staffing headaches. "That's one of the reasons we felt we needed the extra time in order to implement this," said Wayne Strudwick, chairman of COTHA's negotiating team. He hopes that residents who do manage to sleep while on call will not automatically leave the hospital at noon, but concedes that innovative plans may be needed to ensure continuity of patient care. Dr. Ernest Schuster, chairman of the Medical Education Committee at Misericordia Hospital in Edmonton, said solutions have been suggested that range from hiring GPs to assist during surgery to establishing paramedics in ICUs. The least-liked solution is perhaps the most obvious: let attending physicians provide on-call care for their patients. "If you look to regional hospitals where there are no house staff, I think the view is they tend to provide patient services very well," said Dr. David Moores, chairman of family medicine at the University of Alberta. "I think one of the risks I see in big-city teaching hospitals is that a dependency [on house staff] in regard to servicing the hospital has slowly increased over the years." Relying on house staff to handle routine admissions and on-call duties is acceptable, Moores believes, if the attending physicians 1030
CAN MED ASSOC J 1992; 146 (6)
provide sound educational opportunities. "Those attending physicians who really have no interest in teaching should not be placed in that awkward role of having to teach, or of being able to rely upon taxpayers' money for the servicing of their own personal practices," he said. Moores takes attending physicians' teaching duties seriously. In his previous position at Memorial University in St. John's, Nfld., he and the members of a residency training committee pulled an entire team of residents from an obstetric service, citing failure of the department to meet educational objectives. Residents generally agree that the sometimes brutal on-call hours are an acceptable trade-off if they have received good teaching. Dr. Chuck Samuels, a family medicine resident at the Misericordia Hospital, said he is willing to make concessions about on-call schedules if the educational return is equitable. "I don't like doing work and getting nothing in return," he added. "We're caught between a rock and a hard place. I don't like doing this, but the fact is I've got to learn medicine." He describes his philosophy as "a trade-off. Basically, the at-
tending physician is saying, 'If you want to play with my patients, you'd better do my admissions and I'll teach you if I have time.' Will residents take advantage of their legislated hours? Some residents worry that unless hospitals work hard to adjust to the shorter hours, things may not change. "It's not possible," said Dr. Doug Hamilton, an internal medicine resident at Foothills Hospital in Calgary. "There's no way I'm going to be able to walk out at noon. There's no one to take the patients." In the past, said Kalny, peer intimidation and fear of receiving a bad evaluation have kept many residents from complaining about scheduling. Unless residents begin to force the issue of the 28-hour day, some departments may not respect the contract. "You have to get together and stick to this and do it en masse, because otherwise you undermine everybody else and in the long run you hurt yourself," Kalny said. Brownell said residents and interns must learn that it is acceptable to report abuses, and that such reports will not be detrimental to their careers. "All these
"We don't usually go to the press with our issues and concerns but we felt strongly enough about our long hours that we thought it was time the public should know." Dr. Michele Kalny
For
prescribing information see page 11 16
-
institutions have appropriate structures in place to deal with these situations," he maintains. "If people are afraid to deal with this because they're worried they'll get a bad evaluation, then they're contributing to the status quo." He said medical education committees are the appropriate place to make complaints. "Point it out to people who are in a position to deal with it," he argued. Brownell, who lobbied hard for the 28-hour day, said "wethem" confrontations between interns and residents and their medical committees are a mistake. "We are colleagues and we're all interested in the same thing effective patient care. It's unfortunate that these things have to be solved by arbitration." The issue of whether residents may voluntarily work longer than 28 hours may ultimately be settled by a third party, the Canadian Medical Protective Association (CMPA). PAIRA has asked the CMPA to decide whether residents and interns will still receive insurance coverage if they work more than the number of hours stated in the contract. Fear that residents will find themselves without insurance coverage may
"One of the risks I see in big-city teaching hospitals is that a dependency on house staff in regard to servicing the hospital has slowly increased over the years." Dr. David Moores
1032
CAN MED ASSOC J 1992; 146 (6)
force the issue more definitively than either COTHA or PAIRA had originally planned. Samuels, on the final week of a 1 -in-2 call schedule on an ICU, believes that difficult schedules do not necessarily reflect the attitude of an uncaring bureaucracy. "They see the mistakes we make," he said. "They see our disinterest and our miserable attitudes. They don't want us to be doing this [working long hours]." The fine line between what portion of the postgraduate medical experience qualifies as training, and how much can be described as salaried work, contributed to lengthy wage negotiations. Kalny said the 5.5% increase, which pegs annual salaries during the sixth year of training almost $8500 below those of Ontario residents, was inadequate. "I don't think Ontario costs that much more a year to live in," she said. "The interns and residents there don't do any more work than we do here. We still feel we deserve substantially more." Kalny said salary figures used in the negotiations - they compared residents to workers in the public service sector - were misleading, since PAIRA forgoes the right to strike and members
don't operate on a 39-hour workweek. But Strudwick said the wages are fair for work performed during an educational program. "These people are in an educational experience program, designed for a discipline that offers considerable return on their time investment in terms of getting themselves prepared as a specialist of one sort or another," he said. "It's a period of their lives for 4 or 5 or 6 years, where they are earning money while they train. Then when they do become specialists the return as perceived by most people is substantial." Some doctors are worried that residents on the high end of the interning pyramid will use the mandated 28-hour day to work shifts in emergency and family medicine departments. "It's my conviction that they are not appropriately trained to function as a primary care doc," Moores commented. He agrees that most residents just want to go home and sleep, though. "My senise is that it's a move in the right direction."' In the meantime, interns and residents will continue to provide service in a system where balance may be only theoretically present, because these students' desire to work will be fuelled by their wish to gain the best possible education. Samuels, 3 days before the conclusion of his ICU schedule, had already arranged to take another ICU elective in a different Alberta hospital. "I'm very, very worn out and I know my health is compromised but that's the way it is. I have learned a phenomenal amount that I couldn't have learned in any other arm of the hospital. The cost, because it's only 30 days, is OK, though I don't think that justifies doing it. "We make mistakes. Thank God there are nurses there to look at every order we write."LE 15 MARS 1992
