Officially obsessed -- how does your program interpret 1 day off in 7?

Doctor Bagel · Mar 13, 2011

So we all know the ACGME requires that we get one day off in seven averaged over 4 weeks. My understanding prior to being a resident was that this meant a full day off and not a post call day. Well, apparently I was wrong, but I seriously never encountered any programs (including the brutal surgical ones) using a post call day as an off day.

Now, though, my program is claiming it's acceptable to count that day as your day off. So you'd be on call until 8 am and not have to report to work until 8 am the next day. That's 24 hours, I guess.

Anybody else have programs that do this. Just trying to see how typical this is out there in the rest of the residency world.

NotAProgDirector · Mar 13, 2011

I have seen other programs do this. Not with all of the days off, but usually one of them looks like this. I personally think it's bogus.

Of note, you have to have a full 24 hours off. That means that all signout is done by 8AM after your shift, and you don't come back until 8AM. That's usually impossible, since the person on call the next day has to sign out by 8AM (in order to have the same "day off"), so you'd usually have to arrive earlier to get sign out.

Doctor Bagel · Mar 13, 2011

aProgDirector said:
I have seen other programs do this. Not with all of the days off, but usually one of them looks like this. I personally think it's bogus.

Of note, you have to have a full 24 hours off. That means that all signout is done by 8AM after your shift, and you don't come back until 8AM. That's usually impossible, since the person on call the next day has to sign out by 8AM (in order to have the same "day off"), so you'd usually have to arrive earlier to get sign out.

You know, that is an issue. With one of our call locations, we're expected to hang around until about 8:30 am to do signouts. And lots of residents feel the need to show up before 8 am to cover their regular daily workload here -- some teams even meet before 8 am. I guess we can throw all that stuff out as an expectation if that day counts as your day off.

nitemagi · Mar 13, 2011

This manipulating loopholes is exactly why the upcoming guidelines are a lot more clear in spelling out # of hours in time off.

Doctor Bagel · Mar 13, 2011

nitemagi said:
This manipulating loopholes is exactly why the upcoming guidelines are a lot more clear in spelling out # of hours in time off.

From my understanding, it still doesn't change the rules on this particular issue. Especially important for those of us who won't be interns who are facing possibly increasing call burdens.

nitemagi · Mar 13, 2011

Doctor Bagel said:
From my understanding, it still doesn't change the rules on this particular issue. Especially important for those of us who won't be interns who are facing possibly increasing call burdens.

Intermediate-level residents, as defined by the RRC, should have 10 hours free of duty, and must have 8 hours between scheduled duty periods. They must have at least 14 hours free of duty after 24 hours of in hospital duty.

Time off:
24 hrs off per 7 day period, (when averaged over 4 weeks). Home call cannot be assigned on these free days.

From :
http://acgme-2010standards.org/proposed-standards.html

Doctor Bagel · Mar 13, 2011

nitemagi said:
Intermediate-level residents, as defined by the RRC, should have 10 hours free of duty, and must have 8 hours between scheduled duty periods. They must have at least 14 hours free of duty after 24 hours of in hospital duty.

Time off:
24 hrs off per 7 day period, (when averaged over 4 weeks). Home call cannot be assigned on these free days.

From :
http://acgme-2010standards.org/proposed-standards.html

I'm still not sure that totally protects us. Couldn't your 24 hour free day and your 14 hours free of duty overlap? Honestly, I'm still a little foggy on this one, but my program is adamant that this is OK and that it will be OK next year, too. Apparently individual universities can set guidelines on this stuff.

Winged Scapula · Mar 13, 2011

Doctor Bagel said:
Apparently individual universities can set guidelines on this stuff.

They can. The ACGME may recommend that it cannot be a post-call day, but does not mandate it. It is up to the individual programs to decide. In reference to your first post on the subject, my program did this (ie, called the post-call day the day off; this was especially common with the Fri-Sun call weekends).

Buzz Me · Mar 13, 2011

I've always taken it to mean a full 24 hours off - so if you leave at 7 am post-call, you could show up late and come into work at 7 am the next day (to have your "day off").

If you get to go home on Saturday afternoon and don't have to come back to the hospital until Monday morning, well, then that's just an extra bonus.

Doctor Bagel · Mar 13, 2011

Winged Scapula said:
They can. The ACGME may recommend that it cannot be a post-call day, but does not mandate it. It is up to the individual programs to decide. In reference to your first post on the subject, my program did this (ie, called the post-call day the day off; this was especially common with the Fri-Sun call weekends).

But you're a surgeon.

I'm in one of those supposedly lifestyle specialties. I honestly never imagined a psych program that would do this.

Winged Scapula · Mar 14, 2011

Doctor Bagel said:
But you're a surgeon. I'm in one of those supposedly lifestyle specialties. I honestly never imagined a psych program that would do this.

True, but in your first post you mentioned that in your experience, even the surgical programs didn't do this and wanted to know if others did.

And lifestyle specialty is highly program dependent. I can tell you our psych residents did not think of it as a lifestyle specialty (at least not during their nights on call). Programs can choose to interpret anyway they wish...there are some "nice" surgical programs and some less than nice psych ones, apparently.

Doctor Bagel · Mar 14, 2011

Winged Scapula said:
True, but in your first post you mentioned that in your experience, even the surgical programs didn't do this and wanted to know if others did.

And lifestyle specialty is highly program dependent. I can tell you our psych residents did not think of it as a lifestyle specialty (at least not during their nights on call). Programs can choose to interpret anyway they wish...there are some "nice" surgical programs and some less than nice psych ones, apparently.

Definitely, true. I can say the surgery program at my medical school did not do this. And the medicine program where I'm at now doesn't do this, either, hence my surprise in finding a psychiatry program that does it. And of course maybe where I'm really irritated, my program really wasn't presented as a workhorse program to me. But then, I didn't see it because maybe I didn't want to see it. Actually the programs that I thought were the workhorse programs all have less call than us. WTH.

Overall, just wondering how common it is in all sorts of programs, and how people feel about it. I'm really with APD in thinking it's "bogus." Too bad those ACGME folks don't spell it out a bit more clearly. I found something where they implied it wasn't a good idea to count postcall days as a day off, but they didn't state it wasn't allowed.

Winged Scapula · Mar 14, 2011

Doctor Bagel said:
Definitely, true. I can say the surgery program at my medical school did not do this. And the medicine program where I'm at now doesn't do this, either, hence my surprise in finding a psychiatry program that does it. And of course maybe where I'm really irritated, my program really wasn't presented as a workhorse program to me. But then, I didn't see it because maybe I didn't want to see it. Actually the programs that I thought were the workhorse programs all have less call than us. WTH.

That may be the case or perhaps they were less than open with you about it.

Overall, just wondering how common it is in all sorts of programs, and how people feel about it. I'm really with APD in thinking it's "bogus." Too bad those ACGME folks don't spell it out a bit more clearly. I found something where they implied it wasn't a good idea to count postcall days as a day off, but they didn't state it wasn't allowed.

I also agree its bogus.

ACGME doesn't state it isn't allowed because they currently have no regulations about this. As you note, they imply that it isn't recommended but they have not required programs to do this.

dpmd · Mar 14, 2011

They get a little less vague about it in the FAQ section. It is allowable but not desired. Hope your post call days off aren't your only days off. My program has never done this, but when working on some mock schedules for the new guidelines, it might be necessary once in a while (we are still working out the kinks as we are one of those small programs the answer refers to)

Question: The common duty hour standards state that residents must be provided with one day in seven free from all responsibilities, with one day defined as one continuous 24-hour period. How should programs interpret this standard if the "day off" occurs after a resident's on-call day?
Answer: The common duty hour standards call for a 24-hour day off. Many Review Committees have recommended that this day off should ideally be a "calendar day," e.g., the resident wakes up in his or her home and has a whole day available. Review Committees have also noted that it is not permissible to have the day off regularly or frequently scheduled on a resident's post-call day, but understand that in smaller programs it may occasionally be necessary to have the day off fall on the post-call day. Note that in this case, a resident would need to leave the hospital post-call early enough to allow for 24 hours off of duty. For example, if the resident is expected to return to the hospital at 7:00 a.m. the following day, he/she would need to leave the hospital at 7:00 a.m. on the on-call session day. Because call from home does not require a rest period, the day after a pager call may be used as a day off.

Doctor Bagel · Mar 16, 2011

So it sounds like even if it happens, the ACGME recommends and other programs recommend that it be limited. Maybe at most one of your days off in 4 weeks could be a post-call day rather than several.

And it also sounds like most people don't think it's a good idea.

I don't know, I'd prefer to train at a program that tries to follow the recommendations/suggestions of the ACGME instead of just trying to get by on the bare minimum of time off and protection for residents.

kappa1 · Mar 16, 2011

Doctor Bagel said:
Now, though, my program is claiming it's acceptable to count that day as your day off. So you'd be on call until 8 am and not have to report to work until 8 am the next day. That's 24 hours, I guess.

I'm a 3rd year Peds resident, and for many rotations, especially ED, my "day off" was essentially a "DOMA", which is 24hr off (ie, 8am-8am the next day, after and overnight shift). With the new work hour schedules next year (and the model schedules we tested this year), the weekdays off will likely be DOMAs (after a 24hr shift). In our old system, our only days off on inpatient months were split between weekends/holidays.

Doctor Bagel · Mar 16, 2011

kappa1 said:
I'm a 3rd year Peds resident, and for many rotations, especially ED, my "day off" was essentially a "DOMA", which is 24hr off (ie, 8am-8am the next day, after and overnight shift). With the new work hour schedules next year (and the model schedules we tested this year), the weekdays off will likely be DOMAs (after a 24hr shift). In our old system, our only days off on inpatient months were split between weekends/holidays.

Wow, that sounds pretty brutal. What does DOMA stand for?

Bitsy · Mar 19, 2011

DOMA = Day Off My Ass

alina_s · Mar 19, 2011

We did Friday/Sunday call in my fellowship (psych), but we chose to do this to lower the number of weekends we were on call. Also, it was technically home call, so just about anything would have been legal, but there were many nights when we didn't go home or sleep.
It seems like medicine or pediatrics, or maybe neurology, rotations somewhere along the way used the "DOMA" day as an excuse for the 1 day off in 7, but I can't even remember whether this was as a med student or an intern.

Doctor Bagel · Mar 19, 2011

Bitsy said:
DOMA = Day Off My Ass

I don't know whether this phrase makes me happy or sad.

Doctor Bagel · Mar 19, 2011

alina_s said:
We did Friday/Sunday call in my fellowship (psych), but we chose to do this to lower the number of weekends we were on call. Also, it was technically home call, so just about anything would have been legal, but there were many nights when we didn't go home or sleep.
It seems like medicine or pediatrics, or maybe neurology, rotations somewhere along the way used the "DOMA" day as an excuse for the 1 day off in 7, but I can't even remember whether this was as a med student or an intern.

Yeah, traditionally our Friday/Sunday call works to get us more free weekends. However, we're out somebody in our primary call pool, and my program is claiming that these DOMA things are legit and perfectly OK in our schedule. Our primary call pool is essentially being halved next year because of the duty hours rules, so I'm wondering if we'll see more DOMAs if somebody winds up sick or on some sort of leave. The sad thing is that upper levels could be easily called in for very minor amounts of call to prevent this stuff, but there's huge program resistance to that.

pediadoc · Mar 27, 2011

To comply with the new resident duty hour restrictions my program will be implementing a schedule for certain rotations where each of your 4 days off is post call. A 24 hour call shift 7-7am followed by a 24 hour post call period off.

The is legal per ACGME requirements and I am just wondering if there are any other programs out there that are doing this?

Any input?

peppy · Mar 27, 2011

A psych resident was posting about this same problem recently:
http://forums.studentdoctor.net/showthread.php?t=804836

My own program thankfully was able to find a way to avoid doing this. I agree that it may be following the letter of the law but definitely not the spirit.

pediadoc · Mar 27, 2011

My program is going to start having our days off post call (all 4 of them) for multiple months of our schedule next year. We are as a group trying to get this changed and not getting very far. The program claims there is no other way with the new duty hours.
I have been looking around on the acgme website and there are places where you can file concerns/complaints against your program. If we were to have multiple months that our day off is consistently post call I will be filing a claim for the acgme so they are aware of programs abusing this rule consistently.

Buzz Me · Mar 27, 2011

Merging with earlier identical thread with lots of great posts.

dpmd · Mar 27, 2011

pediadoc said:
My program is going to start having our days off post call (all 4 of them) for multiple months of our schedule next year. We are as a group trying to get this changed and not getting very far. The program claims there is no other way with the new duty hours.
I have been looking around on the acgme website and there are places where you can file concerns/complaints against your program. If we were to have multiple months that our day off is consistently post call I will be filing a claim for the acgme so they are aware of programs abusing this rule consistently.

A more reasonable approach would be to try to come up with a schedule that is new hours compliant, covers all things that need to be covered, and doesn't have post call days off. You will either come up with a better way, or figure out that they aren't just doing it to be mean.

Buzz Me · Mar 28, 2011

pediadoc said:
If we were to have multiple months that our day off is consistently post call I will be filing a claim for the acgme so they are aware of programs abusing this rule consistently.

Just out of curiosity, why would this warrant filing an official complaint to the ACGME/RRC?

Doctor Bagel · Mar 28, 2011

Buzz Me said:
Just out of curiosity, why would this warrant filing an official complaint to the ACGME/RRC?

Yeah, unfortunately the ACGME really doesn't provide much protection here. They suggest against it, then suggest it be limited if done, but don't forbid it or set maximum limits for doing it. So you can file a complaint, but I don't think it'll do a lot of good.

I agree with the advice above, though, to see if there's a way to put together a schedule without these. My frustration with my program is that there was a way. It might involve bringing some more upper levels or people on non-call months into the call pool for minimal amounts of call, but there was a way.

Unfortunately, I do have a classmate who spent hours coming up with a call schedule for our next 3 block period that provided more protection for residents, but it was shot down without good explanations. So, even if you come up with something, don't expect much. Residency politics aren't cool.

Of course, another piece of leverage you have is to bring this up as a recruitment issue. Who's going to want to train at a program that has a schedule like that. Get rid of the culture of not telling applicants the nitty gritty about your call schedule, too.

Officially obsessed -- how does your program interpret 1 day off in 7?

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