Frontloading?

[Doctor Bagel]

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My program has had lots of discussions recently about frontloading, which is a long cultural value of the program. I was just looking for thoughts from other people (mainly current residents and recent grads) about frontloading. Namely, how extreme should it be, and how good of an educational model is it.

Of course, I'm in the midst of the suck part of frontloading and am dreading next year where I've been told by pretty much everyone that I'll experience even more burn out. However, I'm supposed to be able to look forward to a largely call free 3rd and 4th year. I'm just wonder if I and my colleagues are endangering our families, our health, our general well being and most importantly our education by being too fatigued and burnt out during first and second year. Is having a much better 3rd and 4th year worth it?

I know most psych programs are frontloaded. How does it work at other programs? How much of the brunt of the call load is absorbed solely by first and second year residents? How much is the right balance for educational and personal objectives of the residents?

 

[PsychMedStudent]

My program has also been traditionally front-loaded fairly heavily and I always thought that was the best way to go. This way, you work hard the first couple years and then can enjoy your final couple years when you're really figuring out what you're going to do post-residency. That said, I never felt burnt out or overly fatigued even when going through the hardest part of it, so if you and the rest of your interns are feeling that way, maybe there is too much being put on you.

 

[Doctor Bagel]

My program has also been traditionally front-loaded fairly heavily and I always thought that was the best way to go. This way, you work hard the first couple years and then can enjoy your final couple years when you're really figuring out what you're going to do post-residency. That said, I never felt burnt out or overly fatigued even when going through the hardest part of it, so if you and the rest of your interns are feeling that way, maybe there is too much being put on you.

Yeah, I like the idea of frontloading. I'm curious how your program did it without overly burdening early residents. How much call did you have in your early years?

We do approximately q5 24 hour (30 on weekdays) at the VA call and approximately every other weekend at our university with full weekend call (24 hour Saturday call, or call both Friday night and Sunday 8 am to 8 pm). That overall works OK, although it is tiring. However, my program has such a strong devotion to the frontloading concept that even when someone in the primary call pool is out, members of the primary call pool are expected to cover at least half of those extra calls (and in the past, have been expected to cover all of them). That's where the burnout really hits.

Our assistant PDs have even stated that burn out is expected and acceptable during these times. I'm not really sure what I think about that.

 

[Doctor Bagel]

And more horror or horrors, they think it's OK to count a post call day as a day off for your one day off in seven requirement for members of the primary call pool. It's not an issue when we're not short-staffed, but when we are (which is happening now and apparently historically is not super atypical), it's considered reasonable for primary call pool residents to be on call several weekends in a row without a non post call day off.

 

[Sneezing]

Sounds like your program has too much call? In general, I and the rest of my colleagues all defend the frontloading. Last thing any of us want is to take call in 3rd or 4th year. That's moonlighting time to pay down debt and save money for starting a practice.

 

[Doctor Bagel]

Sounds like your program has too much call? In general, I and the rest of my colleagues all defend the frontloading. Last thing any of us want is to take call in 3rd or 4th year. That's moonlighting time to pay down debt and save money for starting a practice.

Well, we've got 2 hospitals (university & VA) that claim they need 24/7 coverage. And I think we always need money, so providing those services helps bring some of that in. I think it's a pretty typical amount of coverage for a residency program.

And as for the moonlighting and paying off loans thing, I'm not sure that's of most value to lots of us now due to the new IBR program. Moonlighting is just going to up my monthly required payments. If you're looking at doing public or academic psych, everything will get forgiven after 10 years anyway, so there's no incentive to pay more.

 

[Sneezing]

I'm currently consolidated and paying under IBR now. However, as you mentioned it is stipulatory on the mode of practice you are doing. Plus you are banking on solvency of a program long term.

I don't trust the government to follow through with this program. Look around you. Every state is buckling under debt. The nation is buckling under debt. If I were a politician that needed to slash programs, this is certainly an easy target. We are just now seeing the start of things with states chasing after unions and benefits connected with government jobs.

Plus I plan on private practice so no matter what the IBR program is not a long term solution. Its only temporary while I get other bills and financial issues under control.

Yeah, covering two sites sucks.

 

[whopper]

Some problems I got with frontloading is that it can make studying for USMLE 3 difficult and that it can contribute to a culture where the PGY-1s are abused.

But I also agree that I'd rather have less call 3rd year.

Where I did residency, at the time (I'm sure things are different now), there was the frontloading policy, but hardly anyone had step 3 out of the way by 2nd year. The problem with that was the residents weren't studying psychiatry for real until they passed step 3. The university made a policy that all residents had to at least take step 3 by year 2 right as I was leaving.

 

[PsychMedStudent]

Yeah, I like the idea of frontloading. I'm curious how your program did it without overly burdening early residents. How much call did you have in your early years?

We do approximately q5 24 hour (30 on weekdays) at the VA call and approximately every other weekend at our university with full weekend call (24 hour Saturday call, or call both Friday night and Sunday 8 am to 8 pm). That overall works OK, although it is tiring. However, my program has such a strong devotion to the frontloading concept that even when someone in the primary call pool is out, members of the primary call pool are expected to cover at least half of those extra calls (and in the past, have been expected to cover all of them). That's where the burnout really hits.

Our assistant PDs have even stated that burn out is expected and acceptable during these times. I'm not really sure what I think about that.

We have a night float system, so we only have to cover 2-3 weekend days when we're in the call pool. And we're only covering 1 hospital. We definitely protect 4th years no matter what, but with the new rules, 3rd years will be taking on additional call responsibilities.

 

[Doctor Bagel]

We have a night float system, so we only have to cover 2-3 weekend days when we're in the call pool. And we're only covering 1 hospital. We definitely protect 4th years no matter what, but with the new rules, 3rd years will be taking on additional call responsibilities.

Yeah, I think the one hospital thing makes a big difference. We have two hospitals and 8 people in our class, which kind of makes us like those small programs with 4 people and 1 hospital.

Any other thoughts? We have program review day soon, and I'm just looking for information about how things work out there in the rest of the world. I do like frontloading, but it seems like there should be a limit, especially when it leads to strange things like not having backup cover calls for resident absences and counting a post-call day off as your one day off in seven.

 

[Cinnameg]

Well, we've got 2 hospitals (university & VA) that claim they need 24/7 coverage. And I think we always need money, so providing those services helps bring some of that in. I think it's a pretty typical amount of coverage for a residency program.

And as for the moonlighting and paying off loans thing, I'm not sure that's of most value to lots of us now due to the new IBR program. Moonlighting is just going to up my monthly required payments. If you're looking at doing public or academic psych, everything will get forgiven after 10 years anyway, so there's no incentive to pay more.

The financial advisor who came to talk to MS4's at OHSU during transition week (2 weeks ago) was pretty certain that when lawmakers realize that doctors are going to qualify for loan forgiveness, the law will be amended or revoked. The law wasn't designed with us in mind, it was designed for underpaid defense attorneys, and it was designed by attorneys who didn't know that the language they were using would qualify a bunch of doctors. So . . . based on what she said, wouldn't hold out hope for this.