How does your program deal with resident absences?

[Doctor Bagel]

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So this has unfortunately been too common of an issue with my program recently. We had an intern who was gone most of the year last year, and now we have an intern on leave. Both left the busiest psych service (our university ward) down one resident, and our system just doesn't have enough backup to deal with this stuff.

I occasionally feel like we're cursed, but surely we're not the only program dealing with these issues. Do you guys have programs with residents being on extended leave for various reasons? How is the work absorbed?

 

[Sneezing]

*knock on wood* Not happening. We have had some things pop up but its in residents who are 3rd or 4th years when we don't have call.

My class is pretty close and we all understand the basic concept of not screwing each other over. It looks like the interns are pretty good to. Hopefully nothing changes that!

Sorry, I'm no help.

 

[Doctor Bagel]

*knock on wood* Not happening. We have had some things pop up but its in residents who are 3rd or 4th years when we don't have call.

My class is pretty close and we all understand the basic concept of not screwing each other over. It looks like the interns are pretty good to. Hopefully nothing changes that!

Sorry, I'm no help.

Hmm, maybe we are unusually unlucky. No one's intentionally screwed anyone over or anything. We've just had people who could not do their job for various reasons.

 

[BobA]

we try to spread out the call - but no one is happy getting extra call!!

it's a dis-satisfying situation.

 

[atsai3]

So this has unfortunately been too common of an issue with my program recently. We had an intern who was gone most of the year last year, and now we have an intern on leave. Both left the busiest psych service (our university ward) down one resident, and our system just doesn't have enough backup to deal with this stuff.

I occasionally feel like we're cursed, but surely we're not the only program dealing with these issues. Do you guys have programs with residents being on extended leave for various reasons? How is the work absorbed?

Sorry to hear about the extra workload. Happened in my program at times, as well, and it's not fun.

In terms of the service, at our program the remaining resident (on wards or on consults) just spent the day wishing she had never been born. The director of the inpatient service usually slowed admits down, but the consult resident had no such luck.

In terms of the call, it was spread about the residents who were in that particular call pool. No one liked getting extra call, especially the PGY4's, so extended absences and pregnancies had a way of throwing a little bit of poison into the class well.

 

[Doctor Bagel]

we try to spread out the call - but no one is happy getting extra call!!

it's a dis-satisfying situation.

Yeah, the call is always a contentious issue. Last year, we had a model where the extra call was split between the back up call pool and the primary call pool, which was kind of unsatisfying because the primary call people were already on call a lot. This year, the extra calls have been handled by the back up call pool (3rd and 4th years). The good thing is that interns are a pretty minimal part of the overall call pool due to all the hours changes, making us less exposed that way. A 2nd year absence might kill our call pool though. 😱

Our big problem now is honestly day to day coverage on the ward where the resident is gone. It's a busy service, and everyone is overstretched as it is. Right now, the residents on that service (thank god not me) are stuck covering for one resident who's been gone for almost the whole year so far. When stuff like this happens at your program, are the attendings able to pick up the extra slack? Do the unlucky residents on that service just get screwed, or do you call in other residents to help staff that service? Note, we're broke, so hiring temporary people to fill in isn't going to happen.

 

[Sophie]

Luckily we haven't had that issue, but there was an intern who might have had to start several months late this year, and the plan had been to make those months his medicine months, and then just have him make them up later. This didn't end up happening, but psychiatry would have been protected. And actually, our only rotation that's resident run is consult - so if that resident were out they'd have to pull someone from another service to cover - but the other services are learning-based and have plenty of attending coverage to pick up any slack.

Call is another issue, though, because we already have pretty frequent call. Having one resident out would really mess the call schedule up.

I'm not sure of any possible solutions for you. Do the attendings seem willing to help out? Are there residents on light rotations that could help?

 

[Doctor Bagel]

Luckily we haven't had that issue, but there was an intern who might have had to start several months late this year, and the plan had been to make those months his medicine months, and then just have him make them up later. This didn't end up happening, but psychiatry would have been protected. And actually, our only rotation that's resident run is consult - so if that resident were out they'd have to pull someone from another service to cover - but the other services are learning-based and have plenty of attending coverage to pick up any slack.

Call is another issue, though, because we already have pretty frequent call. Having one resident out would really mess the call schedule up.

I'm not sure of any possible solutions for you. Do the attendings seem willing to help out? Are there residents on light rotations that could help?

I guess with us we haven't had the greatest chance of predicting who would be unable to work. Otherwise, shifting people around would make sense, especially from rotations where we're not needed -- outpatient medicine, neurology and ED. Us being out for inpatient medicine forces the IM program to jeopardize residents, which btw did happen last year for a whole month. Also, the VA can usually survive without us because they have full time attendings for everything, so maybe being more proactive with shifting residents from the VA to the university service would make sense.

As for attendings, our university attendings are traditionally fairly overburdened and not really in a spot to take on more obligations. It's kind of a strength and weakness of our university inpatient rotations -- they're super resident dependent, which gives you autonomy, but also leaves you without as much support as would be ideal. I guess this is the big advantage of resident independent programs; you don't get hit with extra work when someone else is on leave.

It's so bizarre that this has been such an ongoing issue for us. So I guess it's not normal to have a resident out for extended periods of time in almost every class? 🙄 I'm not talking about people having babies or getting sick either. And I honestly don't think these people are out because my program is malignant either.

 

[Flushot]

Maybe I'm missing something since I'm just a lowly 3rd year who is now considering psych but, shouldn't these individuals be reprimanded for taking that much time off? It seems strange to me that they can just do this and the rest of you who show up have to pick up the slack.

 

[DD214_DOC]

Maybe I'm missing something since I'm just a lowly 3rd year who is now considering psych but, shouldn't these individuals be reprimanded for taking that much time off? It seems strange to me that they can just do this and the rest of you who show up have to pick up the slack.

They are probably on either a medical leave of absence or administrative leave of absence. It happens, and isn't very uncommon.

Usually the workload is just absorbed by the people who can still function.

 

[notdeadyet]

They are probably on either a medical leave of absence or administrative leave of absence. It happens, and isn't very uncommon.

Pregnancy is the most common one that I know. Post-intern year psych residency is just a pretty appealing time to squeeze out little ones.

Scenarios like the one above is the reason I ruled out programs that were too small. I knew someone in a five person residency that was absolutely slammed when one of the residents came down with pregnancy. The reaction was pretty much praying that no other resident did the same.

 

[Doctor Bagel]

They are probably on either a medical leave of absence or administrative leave of absence. It happens, and isn't very uncommon.

Usually the workload is just absorbed by the people who can still function.

Yep, this and generally the latter. 6 week absences for pregnancy are nothing. 🙂 3 to more month absences for various work difficulties are a lot more challenging.

The weird thing is we're actually a mid-sized program with 8 residents in a class.

 

[atsai3]

Yep, this and generally the latter. 6 week absences for pregnancy are nothing. 🙂 3 to more month absences for various work difficulties are a lot more challenging.

The weird thing is we're actually a mid-sized program with 8 residents in a class.

My program was one of the larger programs, i.e., probably 80-90th percentile for size, and dealing with extended resident absences was still a challenge. Then again, although we had more residents, we had greater coverage requirements.

 

[whopper]

Unless they had a legitimate excuse, IMHO, there should be zero tolerance.

I've seen some residents take all their vacation time on the hardest rotations. So be it so long as they met the minimum requirements for those rotations.

IMHO a program should have a minimum of residents doing certain services in case things go bad. Where I did training, for example, if no one was on a specific service, they would pull residents off of other rotations to temporarily cover.

 

[Doctor Bagel]

Unless they had a legitimate excuse, IMHO, there should be zero tolerance.

I've seen some residents take all their vacation time on the hardest rotations. So be it so long as they met the minimum requirements for those rotations.

IMHO a program should have a minimum of residents doing certain services in case things go bad. Where I did training, for example, if no one was on a specific service, they would pull residents off of other rotations to temporarily cover.

It's not really a tolerance issue. In the cases I'm aware of, the people have not been able to work and might even have wanted to work. The bigger question is when do you deal with stuff for long term decisions, and I'm sure that's super complicated.

My program has also in some ways tried to be nice to people in these short staffed situations in that people are still allowed to take vacation and ed leave. Unfortunately, that leaves situations like we have this week where we have one resident covering our super busy inpatient service when there should be 3. Maybe pulling people from other services really is the best solution.

 

[Doctor Bagel]

My program was one of the larger programs, i.e., probably 80-90th percentile for size, and dealing with extended resident absences was still a challenge. Then again, although we had more residents, we had greater coverage requirements.

True. That's part of our problem. We have 8 residents but cover call for two hospitals. My medical school program had 4 to 5 residents but only covered one hospital. The biggest program I interviewed at was I think UW, and I know they covered at least 3 hospitals. Maybe it's not really the residency size that matters and instead, it's the faculty resources.

 

[Flushot]

Unless they had a legitimate excuse, IMHO, there should be zero tolerance.

I've seen some residents take all their vacation time on the hardest rotations. So be it so long as they met the minimum requirements for those rotations.

IMHO a program should have a minimum of residents doing certain services in case things go bad. Where I did training, for example, if no one was on a specific service, they would pull residents off of other rotations to temporarily cover.

I figured there was not that much tolerance to begin with, but if people are taking months off at a time and making life miserable for everyone else, I can't see it being acceptable, even if the reason is legitimate. I mean, would future interview invites and interviews for new blood try to filter out those who may have a propensity to behave in this way?

 

[Doctor Bagel]

I figured there was not that much tolerance to begin with, but if people are taking months off at a time and making life miserable for everyone else, I can't see it being acceptable, even if the reason is legitimate. I mean, would future interview invites and interviews for new blood try to filter out those who may have a propensity to behave in this way?

You know, I don't think any program wants someone who's not going to be able to work pretty much the whole time. Things like 6 week leaves for pregnancy and other random (short termed) absences are probably also tolerable to programs. These extended absences, though, are hard, but I don't know that they're predictable.

As a resident coming from a program that's been burned, though, I feel like I probably would be a little less accepting of residents with any known medical or psychiatric issues if I were the one to make the decisions about who gets into the program. Long term potential is one thing, but dude, these absences kill everyone else.

 

[whopper]

I feel like I probably would be a little less accepting of residents with any known medical or psychiatric issues if I were the one to make the decisions about who gets into the program. Long term potential is one thing, but dude, these absences kill everyone else.

Runs into the same problem discussed with other threads. This pretty much meets the legal definition of discrimination, unless it were established that because of that medical/psychiatric issue, they couldn't do the job well.

Medschools, IMHO, aren't willing to address these things for the same reasons why residency programs think twice about getting rid of bad residents, lawsuits. Unless the resident is in the beginning of the 4 year program, the school might try to scoot them by.

As a PD told me, it's hard as hell to get in, but once in, it's hard to get them out.

 

[Scorcher31]

Our program only has 6 residents per year and because of that we have a strict vacation schedule with 4 weeks off per year but only 1 per rotation. For years the residents have had a mutual understanding don't get pregnant during 1st or 2nd year and dont call out sick from call unless you are dying. It sounds like your problem is more coverage during the day, but this is kind of where Im at a loss. How can the inpt service be resident run. By law don't your attendings have to see the patients every day and write a note on them also? They should always have enough attending coverage to see every pt and write a note on every pt on the unit if need be. In the end legally it's usually the attendings note that matters at least in this state.

 

[atsai3]

I figured there was not that much tolerance to begin with, but if people are taking months off at a time and making life miserable for everyone else, I can't see it being acceptable, even if the reason is legitimate. I mean, would future interview invites and interviews for new blood try to filter out those who may have a propensity to behave in this way?

The problem is that this is how/why surgery programs used to filter out women. Your double X chromosome is basically a strong risk factor for your taking a 4-6 week extended absence within the next 5 years. It's no longer as bad as it was -- women are actually getting into surgical programs these days -- but I would bet you a bundle that if you showed up to your residency interview in January telling the program director that you were pregnant, you would have a statistically significant reduced odds of matching to that particular program.

One resident I know did not divulge her pregnancy while she was on the interview circuit. She matched, showed up to orientation, and went into labor the same day. (That day she also revealed that she was going to take her full entitled maternity leave. It's a small program. The chiefs basically went into emergency mode, and her call was split amongst the other interns in her class. They were toxic about it for the next two years.)

 

[whopper]

By law don't your attendings have to see the patients every day and write a note on them also? They should always have enough attending coverage to see every pt and write a note on every pt on the unit if need be.

I don't specifically know how it is in Bagel's program, but where I trained, several attendings actually did a worse job than a resident in terms of getting things done succinctly such as notes. While some of it was due to the attending simply not being a young doc anymore, some of it was the attending was actually in many ways worse than the resident.

Most of the PGY 2s and above were better able to handle a crisis center overloaded better than an attending. Some attendings, when this happened, out of a sense of narcissism (IMHO) intentionally went slower because they were upset.

 

[sunlioness]

That's unfortunate. Our program is small and while call would likely be a problem with extended absences, I don't think day-to-day coverage is. We don't have residents on every service all of the time. I think this month C&L in this hospital doesn't have resident coverage. Residents can take vacations and/or days off, and on the inpatient service it isn't expected that the other resident must pick up the slack. Right now, I'm without a resident for two days and I am rounding, writing the notes, and doing what needs to be done all by myself. I prefer having the help, but people are entitled to their days and to not being run ragged doing more than one person can reasonably be expected to handle.

 

[notdeadyet]

By law don't your attendings have to see the patients every day and write a note on them also?

My understanding is that it's not a "by law" thing but a "for reimbursement" thing. If an attending doesn't at least say hello/touch a patient's shoulder and write a note or addend one, there will not be any reimbursement. This might vary by location, though...

 

[Doctor Bagel]

Our attendings do see and write notes on the patients every day in our university setting. The notes are pretty brief, and the residents are still the ones writing the longer notes, doing admissions and discharges, etc.. With our current model that we're actually transitioning away from, our university attendings are only in the inpatient unit or the c/l service parttime (and are only paid parttime wages for this work). They generally all see clinic patients in the afternoon to make up the other part of their salary.

We're moving to a hospitalist model with fulltime inpatient attendings. We've hired one so far, and I've heard we're still looking for another hospitalist. Once that position is filled, maybe this won't be a big issue, and the attendings really could pick up the extra slack without residents doing more work, which is how it seems to work at most other places. That's how it works at the VA here, too. It's not the current attendings aren't helpful -- they're just overburdened.

 

[Manicsleep]

I saw this a few times in academia and there is an easy fix but it has to be done from the administrative end. Also, this only fixes the intentional absences.

Make it clear up front the total number of calls that you have to do and that you have to make up any work that you may lose as a result of being out. So when a resident is out and they come back, they still have to take the same number of calls. They essentially have to pay everyone back so there is no positive reinforcement. They also have to pay back the resident that got the short end of the stick, especially if they get an easy month as a result of their being gone.

For example, one resident went out for a month leaving a resident alone on a very busy inpatient ward with 6 calls and came back later getting to do his month with 3 residents instead of the usual 2 leaving the other resident alone. He now has to pay back those 6 calls and do the weekend rounding for the other resident during his 'easy' month so the other resident can have an easy month instead as well as take 1 weekend or holiday call from them (decision is up to the resident who was left alone).

This wont stop pregnancies etc but it will stop strategic moves. In fact it usually gets people to plan pregnancies etc during elective months or switch months around. Its amazing how proactive people are in getting the work done early when they know the work will be there waiting for them no matter what.

 

[Doctor Bagel]

Sorry to hear about the extra workload. Happened in my program at times, as well, and it's not fun.

In terms of the service, at our program the remaining resident (on wards or on consults) just spent the day wishing she had never been born. The director of the inpatient service usually slowed admits down, but the consult resident had no such luck.

This is pretty much how it's playing out here now, but no one is slowing down admits. We slow down admits all the time for being short on nursing staff, but it doesn't happen for being short of residents.

 

[HappyGenome]

Pregnancy is the most common one that I know. Post-intern year psych residency is just a pretty appealing time to squeeze out little ones.

I'm not in residency yet, so don't know this - why is post-intern psych residency an appealing time to be pregnant/have kids?

 

[whopper]

and there is an easy fix but it has to be done from the administrative end

Agree. When things like this happened, the dept chair sometimes reorganized the residents and attendings to fill in the missing gaps like a good soccer team. Ever play soccer? If there's an open gap, the team, like a fluid, has to shift players from unneeded areas to places where they are needed.

But for residents, they aren't supposed to contact the top. Sometimes their superiors are too scared or clueless to do so.

Medicine can be like the military. Sometimes you got a master sergeant (e.g. a charge nurse, experienced resident) who has years of experience and knows more than their commanding officer (an attending), but they got to grin and bear the bad leadership of that officer.

 

[atsai3]

I'm not in residency yet, so don't know this - why is post-intern psych residency an appealing time to be pregnant/have kids?

There is another thread around here somewhere on PGY2's who are not having a a great time at their programs, so at some programs a better time may be post-PGY2 psych residency.

In general, the PGY3 & PGY4 years are typically lighter, in terms of the intensity of the rotations and the call schedule.

 

[Doctor Bagel]

There is another thread around here somewhere on PGY2's who are not having a a great time at their programs, so at some programs a better time may be post-PGY2 psych residency.

In general, the PGY3 & PGY4 years are typically lighter, in terms of the intensity of the rotations and the call schedule.

Our PGY2 year has historically been busier than the PGY1 year. People still do have babies, and I'm actually a fan of anybody having a baby when they want to. Residency isn't worth delaying parenthood if that's an important thing to you. None of our significant absence issues have involved pregnancy at all, so maybe I'm not as bitter about this one as I could be.

But yeah, I think post-intern babies in all fields are fairly typical.

 

[BobA]

one of the problems we have is that when someone is out for an extended period of time (>3months), they cannot make up all of the call they missed in a reasonable way. . .

. . although I do like the idea of taking "partial" shifts that wouldn't get in the way of duty hours.

 

[Doctor Bagel]

one of the problems we have is that when someone is out for an extended period of time (>3months), they cannot make up all of the call they missed in a reasonable way. . .

. . although I do like the idea of taking "partial" shifts that wouldn't get in the way of duty hours.

I'm conflicted about the making up call thing, even though I guess you could argue that call is an important part of training that needs to be experienced equally by all residents. Or it's just service work. Eh, don't know.

Anyway, if someone is out for a legitimate reason (and all our people have been), making them make up call in a shortened period of time seems almost punitive.

 

[BobA]

I'm conflicted about the making up call thing, even though I guess you could argue that call is an important part of training that needs to be experienced equally by all residents. Or it's just service work. Eh, don't know.

Anyway, if someone is out for a legitimate reason (and all our people have been), making them make up call in a shortened period of time seems almost punitive.

I don't think it's punitive. Personally, I would WANT to make up call I missed because I was sick. I view it as basic professionalism, and I think there should be a policy supporting that.

 

[Sophie]

At my program you make up all call that you miss. Also, if an emergency comes up and you can't find someone to switch (generally not an issue because everyone tries to help everyone else out) then the chiefs choose someone to take the call and the person with the emergency pays them back 2 calls in exchange. This keeps things fair, decreases the number of "emergencies", and makes for less resentment.

 

[splik]

.

 

[BobA]

Often people are delighted when someone calls in sick because it is an opportunity to make a bit more money! Obviously hospital is less happy and a lot of money is wasted on hiring locums who make 2-3x the amount.

t'.

We've pushed for moonlighting - but the program won't pay for it. . . at least not right now.