I recently had dinner with a good friend and former resident who runs a busy ACS program. He asked me “how many hours a week do you think an ACS surgeon should work?” I didn’t have an immediate answer other than “it depends”.
It depends on how busy each service is, how much the surgeon is up after 11PM on a typical night, do they get home at 5PM when they are on a “normal” service, how much elective surgery they do, how much research is expected of them, how many administrative jobs they have, etc. And finally, it depends on how well compensated they are if they were born before 1980-1985.
All ACS division chiefs and service line directors deal with these issues, and I believe we are driving our people into the ground, and its our own fault. For the past 10 years, in order to prove the worth of ACS, many of us have gathered more and more responsibilities under the ACS banner. In my own institution, for 15 years, I would be able to round on trauma and surgical ICU in about 2-3 hours (at most 15-20 patients), Now each of those services have 15-20 ICU patients (in my facility TICU is separate from SICU) and rounding on both would be unsafe and would too greatly delay care every day to wait for one attending to complete 5 hours of rounds.
But in addition to critical care responsibilities, most ACS services cover:
- Trauma acute care
- EGS acute care
- EGS call
- Trauma call
- Elective general surgery
- Trauma clinic
- EGS clinic
Also, more and more hospitals are demanding direct attending presence and involvement for all initial and daily patient encounters, and all non-OR procedures. This changes phone calls in the middle of the night to bleary eyed face to face encounters. Whether this change was necessary for patient safety is irrelevant to this discussion. What is relevant is less sleep, more getting out of bed, and more hours in the hospital.
It may be important for us as a specialty to determine how many weekends (and how many weekend hours), how many nights, and how many weekly hours are too much.
What is most concerning about this is the disparity between our hourly load and those of our departmental partners. Our group is the only group in our surgery department that is in the hospital 24/7. We are the only ones expected to be sitting in the ICU, and in the OR for every case or admission. The disparity in time away from home and time away from sleep is becoming huge, while there is little or no positive disparity in remuneration.
ACS needs to address these issues, or we will contract as a specialty. We will need to give up responsibilities simply because we can no longer cover them. We will be continually recruiting because faculty will stay for 2-3 years and move to a community hospital where ACS only covers ICU and trauma call. We will get into a tremendously destructive spiral where we will be paying new faculty more than old faculty since we will be unable to recruit for the salaries we provided previously.
Many programs have addressed this through higher and higher call and coverage stipends. This is good, but will only work for a while. Millennials have been shown to be less motivated by money. If a 32 year old ACS faculty is asked whether they would like to make an extra $50,000/year or have an extra weekend off each month, I believe they will go for the latter.
What can we do? First, we can realistically gather responsibilities based on a reasonable work load. We can increase the number of NPs and PAs on our services and EMPOWER them to do the work independently. There are few if any trauma acute care patients and trauma clinic patients that can not be completely cared for by these practitioners. We need to work with our hospitals to get rid of bylaws that prevent them from doing this.
We also need to be very careful to be cognizant of the workload our faculty are under. Having one surgeon on call at night for SICU, trauma admissions, trauma service, EGS service, and new EGS admissions is not rational. EGS on call faculty do not need to be in house, since its unlikely you can get an EGS patient in the OR in less than 2 hours. So this does not need to be covered by in house faculty.
Also, when divisions contract due to faculty departures, there needs to be flexibility with general surgery partners to offload some responsibilities so the remaining faculty do not leave as well. They used to do appendectomies, they probably still can.
To start the conversation, I propose the following as the upper limit of ACS responsibilities:
-no more than 3 weeks out of 4 with daily rounding responsibilities. The fourth week can be for elective surgery and Administrative duties
– no more than 6 nights in house nighttime call monthly
-average no more frequent than 1 in 2 weekend coverage with any in house rounding or call responsibilities Saturday or Sunday
– average no more frequent than 1 in 3 inhouse or home first response weekend call responsibilities.
We are victims of our own success, but we can still fail if we don’t address these issues.