Work Hours Question

[signomi]

I have studied the work hour rules over at acgme.org and while the program in question appears to stay within them technically, the program hours don't past the smell test. Here's the situation:

The fellows work standard hours 7/7:30am-5-6pm M-F. In addition, they work "home pager call" 24 hours a day for 7 days straight every third week (three fellows total) for the enitre year. That's 17-18 weeks total. This means that twice a month the fellow is "on" for all 168 hours in the week. During home call, the pager goes off day and night for the outpatients, the inpatients, the ER, the ward teams, consults, nurses, etc. The fellow must go in for urgent consults, obviously. That's twelve days straight total, seven of which are never free of duty. The average hours is 106.5 hr/week, averaged over 4 weeks.

Am I wrong that this is insane? The PD feels home call doesn't count towards duty hours. Don't they? You are working and missing out on sleep! I heard the program is on probation for work hours, but this has not been changed. Can anyone tell me if this crazy schedule is in compliance?

[madtowngirl]

home call does not count toward work hours, even if you're up all night answering your pager. If you have to come back into the hospital, that does count toward work hours.

[medicinesux]

Geesh, this sounds almost as torturous as being waterboarded by the US military.

[signomi]

I can see how if a resident/fellow is on home call maybe 4-5 days per month (with a max of say two in a row), this might not be an issue. But 14 out of every 28 days???!! Seven in a row twice a month? I'm knee deep in it and I assure you, it is worth quitting over.

[dynx]

Originally Posted by signomi

I have studied the work hour rules over at acgme.org and while the program in question appears to stay within them technically, the program hours don't past the smell test. Here's the situation:

The fellows work standard hours 7/7:30am-5-6pm M-F. In addition, they work "home pager call" 24 hours a day for 7 days straight every third week (three fellows total) for the enitre year. That's 17-18 weeks total. This means that twice a month the fellow is "on" for all 168 hours in the week. During home call, the pager goes off day and night for the outpatients, the inpatients, the ER, the ward teams, consults, nurses, etc. The fellow must go in for urgent consults, obviously. That's twelve days straight total, seven of which are never free of duty. The average hours is 106.5 hr/week, averaged over 4 weeks.

Am I wrong that this is insane? The PD feels home call doesn't count towards duty hours. Don't they? You are working and missing out on sleep! I heard the program is on probation for work hours, but this has not been changed. Can anyone tell me if this crazy schedule is in compliance?

You're obviously not in surgery.

People are still going over 80 hours Golly gee wizz, why...I do believe thats against the rules sir!

[IndyXRT]

Our program does home call 7 days at a time, although it's every 6-7 weeks (on average). We get much less call vollume (on average) than it sounds like you get (there are always busy weeks). However, it is only a work hours violation if you are called back into the hospital over night and you fail to either: get 10 hours off before you come in the next day (i.e. come in late) or spend less than 30 hours total, calculated from the time you came in the day before (i.e. leave early). This happens rarely for us, but we have a backup call schedule to take care of it.

[DrDre311]

I take home call between 10-12 days each month, usually not more than 4 days in a row. It's definitely a double-edged sword because it's nice to sleep in your own bed if it's a quiet night and you can take care of minor stuff from home, but there are definitely nights when a multiple digit replant/nightmare hand comes in at 1 a.m. and you're operating for the next 7-9 hours...and then not only are you working the entire next day but you're on again that night. I don't need a lot of sleep, but that just isn't all that much fun.

As far as hour reporting goes, I do what a lot of surgery residents do and simply report my hours as 80/week. If I really bothered to calculate them out, a rough week easily goes over 100.

[Dr.McNinja]

Originally Posted by DrDre311

As far as hour reporting goes, I do what a lot of surgery residents do and simply report my hours as 80/week. If I really bothered to calculate them out, a rough week easily goes over 100.

During my surgery year, some magical fairy reported my hours, because I sure as hell didn't ever write any of them down anywhere.


I do think that not reporting hours because you feel you are preventing the RRC from sanctioning the program is not helpful. The work hours rules are in place for a reason. If someone is violating them routinely as a matter of course, then something needs to be done. Occasional violations are completely acceptable. Not everyone gets a whipple/liver resection/lap spleen all the time. However, if you're doing it to cover scopes, pilonidal cyst removals, and trauma call, then there is a manpower issue at hand.

[exPCM]

Originally Posted by signomi

I have studied the work hour rules over at acgme.org and while the program in question appears to stay within them technically, the program hours don't past the smell test. Here's the situation:

The fellows work standard hours 7/7:30am-5-6pm M-F. In addition, they work "home pager call" 24 hours a day for 7 days straight every third week (three fellows total) for the enitre year. That's 17-18 weeks total. This means that twice a month the fellow is "on" for all 168 hours in the week. During home call, the pager goes off day and night for the outpatients, the inpatients, the ER, the ward teams, consults, nurses, etc. The fellow must go in for urgent consults, obviously. That's twelve days straight total, seven of which are never free of duty. The average hours is 106.5 hr/week, averaged over 4 weeks.

Am I wrong that this is insane? The PD feels home call doesn't count towards duty hours. Don't they? You are working and missing out on sleep! I heard the program is on probation for work hours, but this has not been changed. Can anyone tell me if this crazy schedule is in compliance?

They pulled this kind of call situation on the three new renal fellows at the hospital where I trained. 2 of the 3 quit before the end of August and the upper level felllows then were pulled into the call schedule.

[sirus_virus]

Originally Posted by DrDre311

I take home call between 10-12 days each month, usually not more than 4 days in a row. It's definitely a double-edged sword because it's nice to sleep in your own bed if it's a quiet night and you can take care of minor stuff from home, but there are definitely nights when a multiple digit replant/nightmare hand comes in at 1 a.m. and you're operating for the next 7-9 hours...and then not only are you working the entire next day but you're on again that night. I don't need a lot of sleep, but that just isn't all that much fun.

As far as hour reporting goes, I do what a lot of surgery residents do and simply report my hours as 80/week. If I really bothered to calculate them out, a rough week easily goes over 100.

So how can we tell if the 80hr/week limit is effective in improving outcomes if it's not being practiced?

[DrDre311]

Originally Posted by sirus_virus

So how can we tell if the 80hr/week limit is effective in improving outcomes if it's not being practiced?

That's an excellent question. I think, without the 80 hour limit, there would definitely be weeks I'd have to go over 120 hours and I think my worst week has been maybe 110-115 hours rather than routinely going over 120.

Also, the home call situation I describe is for my plastics months, which is something I obviously really enjoy so it doesn't bother me to work the longer hours. When I'm on GS/trauma/SICU rotations, the call is in-house and my hours are lower. I still go over 80 pretty routinely, but not as far because I don't feel bad about telling my chiefs that I've been over on hours for the past few weeks--so I need to get out earlier a couple of days this week (because I hate trauma and GS isn't really my thing). I definitely wouldn't report going over 80 on plastic surgery because I've got a golden ticket into plastic surgery and it isn't like I could get another spot easily if something untoward happened with respect to my program and the RRC.

So although I don't think the 80 hour limit (at least for surgery residents) actually keeps hours below 80, I think it does protect us from 110-120+ hour weeks.

[aProgDirector]

The problem with "home call" is that it means different things to different people.

Some "Home call" is nightmarish -- as mentioned above.

Some is not. Derm, Rheumatology, Endo, etc often get few, if any, calls. Even when I take GIM outpt call, I rarely get a call after 11PM. (ED calls go to the inpatient doc).

That's the problem. Small Endo programs have their fellows on a week at a time, and it's no big deal. When they wrote the rules, this is what they had in mind. The type of scenarios above are really unacceptable.

As mentioned above, if you come in it "counts" -- towards the 30 hour rule and the 10 hour rule. So, if you work today starting at 7AM and get called in tonight at 11PM, even for 2 minutes, technically you are done tomorrow at 1PM.

I can't wait for some creative program to "rent" a call room to their residents, and then consider any time spent in the call room as home call.

[DrDre311]

Originally Posted by aProgDirector

The problem with "home call" is that it means different things to different people.

Some "Home call" is nightmarish -- as mentioned above.

It might sound nightmarish, but people like to do some seriously retarded things involving alcohol, sharp objects, power tools, and their hands. Got to come in to take care of that stuff. I will never own a saw that is powered by anything but elbow grease, though--some of the mangled hands I've seen seriously make me cringe whenever I look back through the preop photos. And it's always the wee hours when they come in...

Originally Posted by aProgDirector

As mentioned above, if you come in it "counts" -- towards the 30 hour rule and the 10 hour rule. So, if you work today starting at 7AM and get called in tonight at 11PM, even for 2 minutes, technically you are done tomorrow at 1PM.

I've never gone home early after home call whether I came in overnight or not. I didn't know the rule was meant to be applied in that fashion.

[yaah]

Home call doesn't count towards the 80 hr/week limit. But home call does count towards the "you need one day off every 7 days" limit. The one day off includes all responsibilities, including home call. Of course, that's averaged over a month, so in one week you can have some responsibilities every day.

[Winged Scapula]

Originally Posted by DrDre311

I've never gone home early after home call whether I came in overnight or not. I didn't know the rule was meant to be applied in that fashion.

I never did either (go home early after coming in from home call, never going home or come in late because it violated the 10 hour rule).

[signomi]

It seems like they need to set limits on this home/pager call. It is clear that PDs have found a way around work hours.

[Blade28]

Many fellowship programs use home call as a way around the 80-hour workweek as well. If you don't have to come in very often but spend all night, every night, answering pages...well you'll technically still be in compliance with the duty hour rules.

I'm doing my fourth day (and night) of home call/consults so far this month, and let me tell you, it's brutal. Sure there's something to be said for sleeping in your own bed...but to continually have to drive into the hospital for every ER call, consult, sick patient, etc.? Painful.

[Winged Scapula]

My rule was that I would not drive back and forth more than twice...third time, I stayed in the call room because it was so painful driving back and forth.

[BabyPsychDoc]

I was doing home call during my psych rotations. I would not come home more than once in the middle of the night; if I were called second time, I would stay in oncall room. Otherwise, you lose even more sleep by bouncing back and forth between home and hospital.

[Blade28]

Originally Posted by Winged Scapula

My rule was that I would not drive back and forth more than twice...third time, I stayed in the call room because it was so painful driving back and forth.

I usually have a "time" rule, like if I get called in after 2 am I just stay in-house to nap and then round.

[Winged Scapula]

Originally Posted by Blade28

I usually have a "time" rule, like if I get called in after 2 am I just stay in-house to nap and then round.

Yes, a time rule is a good one as well.

[aProgDirector]

I stand corrected:

Question: Which standards apply to time in the hospital after being called in from home call?

Answer: For call taken from home (pager call), the time the resident spends in the hospital after being called in is counted toward the weekly duty hour limit. The only other numeric duty hour standard that applies is that one day in seven must be free of all patient care responsibilities, which includes home call. The ACGME also requires that programs monitor the intensity and workload resulting from home call, through periodic assessment of the frequency of being called into the hospital and the length and intensity of the in-house activities.

This is so open ended, I can see why it is being "abused".

[elwademd]

aprogdirector, do these rules apply to fellowship as well, or only residency? seems like some institutions treat residents and fellows the same, and others treat them differently (i.e. don't apply acgme rules to fellows).

[aProgDirector]

Originally Posted by elwademd

aprogdirector, do these rules apply to fellowship as well, or only residency? seems like some institutions treat residents and fellows the same, and others treat them differently (i.e. don't apply acgme rules to fellows).

If the fellowship is ACGME approved, then the rules apply to all programs.

[dragonfly99]

Yes some programs use home call to get around work hours rules.
If someone is getting very few calls, then being on call for 1 week at a time might not be bad (rheumatology or derm home call, etc.).
However, if the pager is blowing up like when you were an intern, and you have to go in to the hospital any way, that isn't "home call".
I agree that fellowship programs often don't treat the fellows as if the 80 hours/30 hours applied to them. For some reason, they get away with this. I think the ACGME looks closer at residency programs.