Call Inquiry / ACGME recommendations

[rpkall]

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Hi all,

There are new recommendations from the ACGME that are supposed to go into effect sometime in the future, which basically dictate a call overhaul for programs that utilize PGY1s for overnights or have PGY1s in the hospital alone for calls (obviously with attending supervision or senior residents on pager call for backup). Specifically what has been told to us is that 1st years will not be allowed to do any more than 16 hr shifts and they also will not be allowed to be on call alone in house (i.e., there must be senior resident "supervision", not just backup/pager call).

My program is facing this issue head on this year to preempt any shakeup later on when the recommendations become guidelines or regulations.

I had a few questions to others out there about this.

1) For programs with a night-float system, how does this work? Is it just the PGY2s that take a month or two of "night float" rotation, or is it divided amongst PGY2s, PGY3s, and PGY4s, in decreasing order of time (like 4 weeks for 2nd yrs, 2 weeks for 3rd years, 1 week for 4th years)?

2) For programs that don't utilize night float, what is the average call that 4th years are expected to do? I know in the past a lot of programs "protected" 4th years from doing any call at all--but will this really be a reality with the new recommendations that 1st years don't do more than 16 hrs at a time AND that they cannot be overnight in house alone with only attending supervision? Do we really feel like we'll be able to keep 4th year completely call-free while PGY2s and PGY3s pick up all the slack?

Thanks for any info on this.

 

[nitemagi]

We heard about this too at my program, and it's gonna bring about some major reshuffling. Right now our program covers 2 hospitals. Some discussion includes narrowing our coverage to just 1 hospital, since a "senior resident" in the guidelines only involves someone higher than a PGY-1 level.

Our new nightfloat (being implemented this year) is only 2nd years at one of the hospitals, dividing each 4-week block into 2-week sections. Each resident gets two 2-week blocks over the year.

Some of the brainstorms included mandating vacation at the end of nightfloat for recovery and to get your circadian rhythm reset. We aren't doing that yet.

 

[rpkall]

Thanks for the post. How many PGY2s do you have, then--12 or 13 (each does only 4 weeks in second year). Is your night float a 12 or 14 hr shift? How are weekends (Friday night, Saturdays, and Sunday AM) covered? A common pool, including 2nd, 3rd and 4th years?

We unfortunately have a smaller class size (7 residents per year) so the options are, ask PGY2s to do 6-8weeks of night float each in PGY2 year, or split NF among 2nd, 3rd, and 4th years in decreasing order of time so 2nd years do more NF than 3rd, who do more than 4th, etc, with 4th years doing only 1 week of NF in their entire year.

I personally feel that more than 4 weeks of night float per person per year is a bit much to ask. There will be the odd people who get stuck with 5 weeks to make things even out, but that's not the same as mandatingn 6 or 8 weeks of a night shift. People have families, friends, a life, studying, etc. NF significantly takes a chunk of your life away like no other rotation would (even a 12-14 hr/day busy inpatient rotation has you coming home to see your spouse/significant other, time to decompress, go grocery shopping, whatever.

Curious what other programs are doing with their night floats, and whether they are still keeping PGY4 call free in light of all these new recommendations.

 

[Manicsleep]

Time for hospitalists and other attendings to pick up the slack in smaller programs. In larger programs it will probably mean the PGY4 year is not so easy anymore.

I wonder what internal medicine will do.
BTW, are these changes set in stone? I didn't think they were.

 

[Suedehead]

my program covers 3 facilities, usually split between two residents during the night. Have NO idea how we're going to rearrange things. we just don't have enough residents to cover all our daytime and nighttime obligations.

Even more. On paper, our call is considered 'home call' because we can't be held to be 'in-house' if we're covering more than one facility.... but it's BUSY call. Have no idea how this will play out either.

 

[spaslam]

is there a big panic about ACGME rules, 16 hr maximum calls and first year residents not doing unsupervised calls at your program? do 4th yrs take call at your program?

our program is trying to make a lot of changes as mentioned above. your answers to the above questions would be helpful. thank you!

 

[nitemagi]

Our program is basically 11 residents. 4 weeks total. We're not doing nightfloat during the first 2 weeks or the Christmas holiday month. Thirteen 4-week blocks total. Only 10 of them for nightfloat. Our nightfloat is a 15-hour shift (5pm-8am). This system is at our VA which is traditionally a lighter nighttime than our university hospital.

 

[NJWxMan]

my program covers 3 facilities, usually split between two residents during the night. Have NO idea how we're going to rearrange things. we just don't have enough residents to cover all our daytime and nighttime obligations.

Even more. On paper, our call is considered 'home call' because we can't be held to be 'in-house' if we're covering more than one facility.... but it's BUSY call. Have no idea how this will play out either.

Busy call? C'mon. Tylenol orders, agitation, Ambien orders, and falls is NOT difficult. Where I take call, I have to evaluate and determine disposition on 10-13 patients each night in our psychiatric emergency room.

 

[heyjack70]

Whatever you do, don't give someone demerol if they're taking an MAOI.

 

[rpkall]

We have 7 PGY1s, 7 PGY2s, 7 PGY3s, and 3-5 PGY4s (some people fast track out for Child) and 4th years don't take call at all under the current arrangement. We covered between 2-3 hospitals (one of which was a 90+ bed state facility, although it looks like in the coming year they might be using their own attendings to cover that). The other 2 hospitals which we will continue to cover--one is a VA, with ER and inpatient unit; another is the city University Hospital with an ER and inpatient unit, for one primary resident with a backup resident on call from home.

PGY1s were utilized for 24 hr overnight calls on Saturdays and holidays (covered completely by that class), and were in a rotating call pool with the PGY2s for Monday, Tuesday, and Thursday. PGY2s covered Mon, Tues, Thurs with PGY1s and also Friday overnight; PGY3s covered Wed and Sun. It worked out to be about 380 call hrs per resident for PGY1 year (but very frequent since the pool was only 3-4 PGY1s at a time since the other half were off service and not doing psych call); 320 hrs per person for PGY2, and 260-300 for PGY3 (but much less frequent as Wed/Sun were both Q7); PGY4s--no call.

These recommendations are not set in stone to start right now--but our Program Director has his own ideas about how fair it is to rely on PGY1s for overnights alone in house without senior resident supervision. Thus, we're all going a little nutty trying to reshuffle things ASAP. I think overall things will work out to be fairer for PGY1s, better for patient care, etc, but it may mean that 4th years have to do more than they were expecting...

I wonder how many programs that had previously "protected" 4th years from manditory call will now be pressured to add them into the schedule to keep everyone else sane. At small and medium sized programs it doesn't seem possible to reshuffle coverage without making this change.

 

[masterofmonkeys]

We cover 3 hospitals, with one being home call only. 11-13 per class.

PGY1 and PGY2 each cover one month of night float a piece. It looks like we may be able to survive with minimal impact because one of the hospitals has 24/7 attending coverage in the PER. 1s will have to take weekend call twice as often as currently, and only at the hospital with a PER, but only one 12 hour shift per weekend. So the main effect is to end up with 1s having fewer whole days off.

I have no idea where these guidelines came from and honestly feel like neuropsychiatric testing is indicated for cognitive disorders in the people that came up with this. Not even interns like this.

What I was hoping for was a mandated limit on number of months over 60h/wk and less than 80h/wk. i.e. no more than 5 or 6. My program had 10 of those months in our intern year last year lol.

 

[nancysinatra]

I have no idea where these guidelines came from and honestly feel like neuropsychiatric testing is indicated for cognitive disorders in the people that came up with this. Not even interns like this.

No kidding. From what I could tell there was not a single representative of psychiatry on the committee that made the guidelines. They seem to be made with surgery and its problems in mind, not psych.

I don't know how it is at other programs, but at my own I feel like psychiatry is already micromanaged. It's weird how psych attendings will enforce their own ideas and get bent out of shape over a patient missing one dose of risperdal, for example. On medicine, residents ran the show. Attendings came by every morning to round and be updated, basically. Little things that would freak out a psych attending (like, oh, even the whisper of a prospect of a possibility of etoh withdrawal 4 days in the future) would seem like nothing to medicine attendings. They seem to have a higher threshold for freaking out.

IMHO psych doesn't need more supervision--attending by phone is ok. If 4th years have to cover this, I forsee a huge spike in child fast track apps next year...

 

[masterofmonkeys]

No kidding. From what I could tell there was not a single representative of psychiatry on the committee that made the guidelines. They seem to be made with surgery and its problems in mind, not psych.

I don't know how it is at other programs, but at my own I feel like psychiatry is already micromanaged. It's weird how psych attendings will enforce their own ideas and get bent out of shape over a patient missing one dose of risperdal, for example. On medicine, residents ran the show. Attendings came by every morning to round and be updated, basically. Little things that would freak out a psych attending (like, oh, even the whisper of a prospect of a possibility of etoh withdrawal 4 days in the future) would seem like nothing to medicine attendings. They seem to have a higher threshold for freaking out.

IMHO psych doesn't need more supervision--attending by phone is ok. If 4th years have to cover this, I forsee a huge spike in child fast track apps next year...

Well, we are one of the few specialties that does not use a resident team-based approach (i.e. multiple residents taking care of same patients), so the whole upper level or in house attending thing isn't an issue for most specialties.

I agree that we don't need more supervision and phone attending is ok. There might be a huge spike in child fast track apps next year, but there's also a chance they'll eliminate fast-tracking if that's what they have to do. Or reduce outpt time in order to get seniors in the hospital to oversee interns.

The overall trend, and it's not a good one, is more time for no discernable purpose in all aspects of training. There are now 4th year GI fellowships for more endoscopy time, CHF fellowships in cards, trauma requiring an extra year for many surgical specialties, etc. Mostly because we're at their mercy and because it's much cheaper to have a fellow/resident running the show...Wouldn't be surprised if psych tries to do the same...

 

[Faebinder]

Busy call? C'mon. Tylenol orders, agitation, Ambien orders, and falls is NOT difficult. Where I take call, I have to evaluate and determine disposition on 10-13 patients each night in our psychiatric emergency room.

A busy home call meaning they are getting called every half hour to an hour... not getting sleep and expected to be there at 8 am to continue working as normal. You are going home to sleep when you are done in the ED by the sound of it.

 

[rpkall]

Home call in psych if you're the primary resident on is not a reality for us at all. There are some times when there is a NP covering one of the hospitals so the resident is just covering the VA. If it's a slow night at the VA only, perhaps 30% of the time, you could theoretically go home but that means you're not available for psych emergencies on the inpatient unit so we just sleep at the hospital period.

I agree that attending backup from home is okay for psych. But the issue is whether PGY1s can and should handle this on their own with no other supervising resident in the hospital. That means there are plenty of times that a PGY1 would be faced with a situation requiring more immediate decisions or interventions (verbal, behavioral, restraints, etc) and they will have never dealt with that situation before. So some part of me agrees that it would be better for PGY1s to not be alone for when situations like that arise.

Is night float that terrible, for people who have done it? Sure the hours suck and whatnot, but don't you get *good* at handling call? I mean, the time management, the multitasking, the efficiency at dispositions, when to call backup and when not to, how to handle communicating with other services, etc, etc? These things simply can't be as anxiety producing in your second, third, fourth, fifth, or sixth week on night float as they would be in week one, or even as anxiety producing as they are on every overnight call if it is infrequent enough...

 

[NJWxMan]

A busy home call meaning they are getting called every half hour to an hour... not getting sleep and expected to be there at 8 am to continue working as normal. You are going home to sleep when you are done in the ED by the sound of it.

A) That's illegal. Home call counts as "call". Per ACGME rules, you cannot work more than 24 HR. (30 with sign in/out)

B) What psych service gets calls every half hour? I'm at a large, university setting, and when I was on medicine, I usually didn't even get called every half hour.

C) On Sunday nights, after 12 hour PER shift, we still have to work the next day. During the week, we are done for the day after our 24 HR shift.

D) It's very difficult to discuss calls between programs.

 

[Faebinder]

A) That's illegal. Home call counts as "call". Per ACGME rules, you cannot work more than 24 HR. (30 with sign in/out).

Been like that for years... I will admit that our program doesnt get a call every half hour all the time.. but it has happened. Especially covering multiple hospitals and no, they are not disasterous calls.. just minor dumb stuff.

 

[nitemagi]

A) That's illegal. Home call counts as "call". Per ACGME rules, you cannot work more than 24 HR. (30 with sign in/out)

B) What psych service gets calls every half hour? I'm at a large, university setting, and when I was on medicine, I usually didn't even get called every half hour.

C) On Sunday nights, after 12 hour PER shift, we still have to work the next day. During the week, we are done for the day after our 24 HR shift.

D) It's very difficult to discuss calls between programs.

A) You're incorrect. Per the ACGME website: "the frequency of at-home call is not subject to the every-third-night,or 24+6 limitation. However at-home call must not be so frequent as to preclude rest and reasonable personal time for each resident."

See: (E-4) http://www.acgme.org/acWebsite/dutyHours/dh_ComProgrRequirmentsDutyHours0707.pdf

B) Ours has been that busy, though isn't as such as a rule. When you're covering an ED with 5+ consults going on at the same time, plus cross-covering an inpatient unit, plus floor consults, you can stay pretty busy.

 

[Suedehead]

A) You're incorrect. Per the ACGME website: "the frequency of at-home call is not subject to the every-third-night,or 24+6 limitation. However at-home call must not be so frequent as to preclude rest and reasonable personal time for each resident."

See: (E-4) http://www.acgme.org/acWebsite/dutyHours/dh_ComProgrRequirmentsDutyHours0707.pdf

B) Ours has been that busy, though isn't as such as a rule. When you're covering an ED with 5+ consults going on at the same time, plus cross-covering an inpatient unit, plus floor consults, you can stay pretty busy.

Exactly. my program has 'home call' on paper, but treats it like 'in house' call by giving us post call days, etc. but that's because our call is dang busy, we have no place to sleep at one hospital AND we cover multiple facilities per night (can't be considered 'in house' at two places at once).... so technically we're 'home' call.

I'm super curious to know if my program can circumvent any mandated acgme changes by continuing to deem our call 'home call.'

 

[psychres1]

Hi, I'm a PGY1 and My program does the same....we have q2~q4 "at home" call, which requires that we return to the hospital to evaluate ~5 or so patients /night in the ED, work up all after hours transfers, and cover the wards.. They have an in-house call room which most people stay in, and even sleeping there it is rare to get more than 3 hours of sleep in a night. We don't have access to place orders from home, so if anything needs to be placed, we must drive to the hospital to place the order. The hospital attendings usually let us go at noon when postcall, but our program often still gives us responsibilities that afternoon.

Because the program calls this an "at home" call, they say that no duty rules apply... so while I'm not complaining about the work, is there a way to force the program to recognize this as an "in house" call rather than their delusional "at home" call to grant us the post-call day and force them to follow the duty hours guidelines?

maybe some of you have some thoughts?

 

[Doc Samson]

Hi, I'm a PGY1 and My program does the same....we have q2~q4 "at home" call, which requires that we return to the hospital to evaluate ~5 or so patients /night in the ED, work up all after hours transfers, and cover the wards.. They have an in-house call room which most people stay in, and even sleeping there it is rare to get more than 3 hours of sleep in a night. We don't have access to place orders from home, so if anything needs to be placed, we must drive to the hospital to place the order. The hospital attendings usually let us go at noon when postcall, but our program often still gives us responsibilities that afternoon.

Because the program calls this an "at home" call, they say that no duty rules apply... so while I'm not complaining about the work, is there a way to force the program to recognize this as an "in house" call rather than their delusional "at home" call to grant us the post-call day and force them to follow the duty hours guidelines?

maybe some of you have some thoughts?

My understanding is that if you are required to return to the hospital, it is not home call. Home call is phone only. Programs could call any call "home call" so long as they said you could leave the building between evals.

 

[Psych9292]

*bump* Any more thoughts on this as we're coming up on interview season and applicants are going to be asking?

 

[nitemagi]

A lot of ideas are being floated around. Some I've heard include a nightfloat for PGY-1's, adding to the # of residents recruited to add to the pool to work this, putting PGY-3's on a NF as supervisors, shifting everything forward by 6months where interns do no psych for the first 6 months then are supervised for the second half (so you're doing more call into 3rd year), have attendings or moonlighters pick up slack like weekends, cover less hospitals, use mid-level providers where possible, and just wait and see (and hope this doesn't go into effect until 2012).

 

[honsano]

I know these recommendations have not gone into effect yet, but when they do, any idea when they will be enforced? I wonder how long a program will have to change itself around so it can abide by these new rules.

This is going to prove really tricky for psych everywhere though. We have a hard enough time as a specialty to fill up our spots. Of course adding more residents to programs sounds nice, but how many will fill? Will less esteemed programs close down because residents shift to better programs now that they have more openings? Fill up with AMGs? Are we human? Dancer?

You also can't rely on 4th years because as mentioned, some fast track to Child. You could knock off that fast track and you would probably have substantially less individuals going into child further destroying what is already a dry market.

All in all, blanket rules tend to have pretty big effects for some and little for others. My program is small and I'm very interested to see how we can possibly handle this change.

 

[Suedehead]

This is going to prove really tricky for psych everywhere though. We have a hard enough time as a specialty to fill up our spots. Of course adding more residents to programs sounds nice, but how many will fill? Will less esteemed programs close down because residents shift to better programs now that they have more openings? Fill up with AMGs? Are we human? Dancer?

yes! ah, this made my day.