How does your residency handle sick days?

[Perrotfish]

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Well that's the issue, isn't it. For most IM programs, you're looking at 6-10 months a year where you're on rotations that "need resident coverage". For Gen Surg (and most other surgery subspecialty programs), that number is more like 11-12 months a year. If you're in a specialty where <20% of your rotations require inpatient resident coverage, your sick call policies are going to be a lot different.

I think you're missing his point. He's not saying his rotation has 10 outpatient months a year, he's saying that culturally his attendings pick up the slack when the resident calls out sick, so no one gets called in when one person calls out sick. When a program says there is no give in the schedule for the resident to call out sick, what that usually means is not that there is no one to do the work, but rather than everyone who is not a resident has decided that a 9-3 schedule is a sacred rite, and that writing a full note is an unthinkable indignity.

 

[gutonc]

I think you're missing his point. He's not saying his rotation has 10 outpatient months a year, he's saying that culturally his attendings pick up the slack when the resident calls out sick, so no one gets called in when one person calls out sick. When a program says there is no give in the schedule for the resident to call out sick, what that usually means is not that there is no one to do the work, but rather than everyone who is not a resident has decided that a 9-3 schedule is a sacred rite, and that writing a full note is an unthinkable indignity.

No, I got his point. I figured he was either psych or derm (I was right). The reason his attendings pick up the slack is that it's actually not that much more work as an outpatient doc to manage patients without residents than it is with them. You'll note that the exceptions to his "attendings just deal with it" rule was the few inpatient months that they do.

 

[Law2Doc]

Yes, but this post is a general post about how your residency handles sick days and I'm answering the question. Most inpatient services survive without us for a day and sick days are not a problem at my program. That's all I'm saying.

I think the point is you are at a place where you can be out and nobody has to cover you, which is a luxury many (maybe most) places don't have, so how your program handles it falls into the "must be nice" category.

 

[Mass Effect]

I think the point is you are at a place where you can be out and nobody has to cover you, which is a luxury many (maybe most) places don't have, so how your program handles it falls into the "must be nice" category.

Yup. That's why I said I'm so thankful for my program.

 

[Mass Effect]

No, I got his point. I figured he was either psych or derm (I was right). The reason his attendings pick up the slack is that it's actually not that much more work as an outpatient doc to manage patients without residents than it is with them. You'll note that the exceptions to his "attendings just deal with it" rule was the few inpatient months that they do.

Um, how many ways do I need to say that the 10 additional months I was talking about are inpatient? Our INPATIENT attendings survive without us. Not sure how many more ways I can say it (and even @Parrotfish said it) before it's clear.

 

[22031 Alum]

Um, how many ways do I need to say that the 10 additional months I was talking about are inpatient? Our INPATIENT attendings survive without us. Not sure how many more ways I can say it (and even @Parrotfish said it) before it's clear.

Don't worry about making it clear. Simply posting your own experience is helpful, to illustrate that (gasp!) different specialties are different, and different programs within the same specialty are different.

Just the other week I had a resident out with a migraine, which meant Resident #2 had to pull a surprise 24-hour shift. And Resident #3 got pulled from a different rotation to cover for Resident #2, who couldn't work the next day. The resident who missed would probably think our sick days policy was great. Not so much the other two. Meanwhile, where I trained, migraineurs got dim lights and quiet in the team room- but they still worked. Sucks for Resident #1, but other residents could be relatively secure in the fact that they wouldn't get pulled for coverage very often. I find it hard to say that one program's policy is automatically better than the other's.

 

[Perrotfish]

Just the other week I had a resident out with a migraine, which meant Resident #2 had to pull a surprise 24-hour shift. And Resident #3 got pulled from a different rotation to cover for Resident #2, who couldn't work the next day. The resident who missed would probably think our sick days policy was great. Not so much the other two. Meanwhile, where I trained, migraineurs got dim lights and quiet in the team room- but they still worked. Sucks for Resident #1, but other residents could be relatively secure in the fact that they wouldn't get pulled for coverage very often. I find it hard to say that one program's policy is automatically better than the other's.

Again, if you limit yourself to the option that only residents can cover for residents, and you limit yourself to coverage where each resident is taking the absolute maximum number of patients, then yes: allowing and disallowing sick days are equally ****ty options. Either way a resident gets hurt. What not everyone agrees on is that those are your only two options.

When a resident gets sick, the attending should cover.

 

[22031 Alum]

Again, if you limit yourself to the options that only residents can cover for residents, and you limit yourself to coverage where each resident is taking the absolute maximum number of patients, then yes: allowing and disallowing sick days are equally ****ty options. Either way a resident gets hurt, everyone agrees with that. What not everyone agrees on is that those are your only two options.

In another thread I mentioned a time when my coworkers and I stepped in to cover for residents, so I definitely don't think it's out of the question as an option if absolutely necessary for patient safety.

But having an agreement isn't the point of this thread, nor is it ever going to happen. Just the way you describe "taking patients" is different from the way I have to look at things as a proceduralist. It's not a service with admissions that really could have an H&P written by anyone, or pages that just need answering. It's an OR day. It's deliveries. I don't need to do 25 vaginal hysterectomies as a minimum to graduate, or X (where X >> 25) to prepare me for all the variations/complications I can encounter in independent practice. I'm done and licensed and independent. My guys (I call them that) aren't there yet. They need to get in there and do as many as possible before I set them free upon the populace.

So yes, 99 times out of 100, if somebody is out and something needs to be covered, we will move heaven and earth to have a resident do the covering and get that experience. 1 times out of 100, it's something like changing birth control prescriptions or doing doptones x 100 in clinic, or carrying the patient phone call pager. Those times, we (the attendings) will take the easier route and just jump in to get stuff done.

 

[marsh20]

Wow, I'm looking at this thread and just grinning. In my Psychiatry residency, we had inpatient our first two years without any clinic or elective experience (actually there was just one month of FM clinic) and calling in sick was simply out of the question. We could not do that at all.

 

[22031 Alum]

When a resident gets sick, the attending should cover.

Statements like these were what I was alluding to in my response to @Mass Effect. You declare that an attending should cover as if that is the only correct solution. Doesn't it make at least a little sense to you that different specialties/programs would maybe have a different approach because of different goals or needs??

I'm in the OR tomorrow, with one resident doing some cases that they don't get a lot of (barely over 10th percentile). If that resident calls in sick, by your logic I should just do the cases myself. I suppose I'll have to use the scrub (or an MS3??) as my first assist, since my partners will all be occupied with teaching other residents in clinic, on L&D or in the OR. I can say with 100% certainty that a resident would benefit from participating in the case, especially if it turns out to have some unique aspects. But you said that shouldn't happen, so that must be the universal rule.

I'll readily describe my own experiences, and what I've heard through the grapevine, but I'd never be so presumptive as to say "This must happen. The end." There are too many variables for that.

 

[Perrotfish]

But having an agreement isn't the point of this thread, nor is it ever going to happen. Just the way you describe "taking patients" is different from the way I have to look at things as a proceduralist. It's not a service with admissions that really could have an H&P written by anyone, or pages that just need answering. It's an OR day. It's deliveries. I don't need to do 25 vaginal hysterectomies as a minimum to graduate, or X (where X >> 25) to prepare me for all the variations/complications I can encounter in independent practice. I'm done and licensed and independent. My guys (I call them that) aren't there yet. They need to get in there and do as many as possible before I set them free upon the populace.

So yes, 99 times out of 100, if somebody is out and something needs to be covered, we will move heaven and earth to have a resident do the covering and get that experience. 1 times out of 100, it's something like changing birth control prescriptions or doing doptones x 100 in clinic, or carrying the patient phone call pager. Those times, we (the attendings) will take the easier route and just jump in to get stuff done.

Are you seriously going to pretend that you're yanking someone from one of their few electives and forcing them to cover a surprise 24 hour call, not because you don't want to do it, but for their own good? Because the chance to cover another 24 hours of routine gyn surgeries is just too sweet an opportunity for you to give it to anyone but a resident?

Lets be honest, you're not showing 1/1000th the same sense of urgency about resident education when its not important to your schedule. Is your program using some of that 130K/resident-year that it gets to buy them off site rotations where they can get their numbers up, rather than spending it on your own salaries? When the OR schedule is light, or boring, do you 'move heaven and earth' to rush the resident off of your service and to somewhere that's higher yield? Are you aggressively vetting each and every elective, and exploding into a rage when you find out that the education is poor? I'm going to go out on a limb and say no: if your services are covered you either don't care or care in a 'we'll discuss that in next quarter's committee' kind of way. Education is an emergency when the alternative is the attending coming in, a problem to be fixed 'eventually' when the alternative is attending-neutral, and a luxury the hospital can't afford when it requires any real sacrifice from the hospital or its employees.

 

[22031 Alum]

Are you seriously going to pretend that you're yanking someone from one of their few electives and forcing them to cover a surprise 24 hour call, not because you don't want to do it, but for their own good? Because the chance to cover another 24 hours of routine gyn surgeries is just to sweet an opportunity for you to give it to anyone but a resident?

Lets be honest, you're not showing 1/1000th the same sense of urgency about resident education when its not important to your schedule. Is your program using some of that 130K/resident-year that it gets to buy them off site rotations where they can get their numbers up, rather than spending it on your own salaries? When the OR schedule is light, or boring, do you 'move heaven and earth' to rush the resident to get the resident off of your service somewhere that's higher yield? Are you aggressively vetting each and every elective, and exploding into a rage when you find out that the education is poor? I'm going to go out on a limb and say no: if your services are covered you either don't care or care in a 'we'll discuss that in next quarter's committee' kind of way. Education is an emergency when the alternative is the attending coming in, a problem to be fixed 'eventually' when the alternative is attending-neutral, and a luxury the hospital can't afford when it requires any real sacrifice from the hospital or its employees.

Not going to bother answering you. Let's just agree to disagree. Or I'll agree to disagree, while you keep making declarations about what you think are universal truths. The rest of us will keep doing our jobs in our own realities.

 

[Perrotfish]

Not going to bother answering you. Let's just agree to disagree. Or I'll agree to disagree, while you keep making declarations about what you think are universal truths. The rest of us will keep doing our jobs in our own realities.

If you want to argue that making residents work 90 hours/week, or 36 hours in a row, is vital to their education, I would understand your argument. I would disagree. But there's an argument to be had there. In those cases you're talking about hundreds or even thousands of hours of training, and that does add up. While I think that a lighter schedule actually means better learning I can see where you would think that the main thing is just the number of hours worked. I get it.

If you wanted to argue that covering for sick days causes undue strife amongst the attendings, and that you would lose top quality staff if that became part of your culture, I would understanding your argument. I would disagree. But there's an argument to be had there. **** does run downhill, attendings do feel that they've earned a certain standard of living, and its hard to be the first one to change the culture you're in. You would probably lose some staff if you pushed for attendings to cover sick days, and though I think the sacrifice would be worth it from both an ethical and educational standpoint I can see where you might not. I get it.

On the other hand, you're pretending that it impacts resident education if you let residents miss 2-4 days a year due to illness. You are stating that its worth moving heaven and earth to get someone who is not an attending to cover their procedures, to make sure they don't go to waste, and you're doing it selflessly for the safety of their future patients. I'm not just disagreeing with that, I'm saying that that's ludicrous. Heck, if the extra 4 days/year of procedural experience makes all the difference, then lengthen residency so that everyone can get two more weeks experience, and use those two weeks to make up for the sick days the attendings cover. I don't know many residents that would tolerate an 8 year residency in exchange for a 40 hour work week, but I'm pretty sure 100% of them would happily add on an extra two weeks if it meant they never needed to worry about passing out from dehydration in the OR, or gasping their way through rounds. This isn't about resident education, this is about attendings not wanting to cover resident shifts. I'm sure.

 

[RadOncDoc21]

Perrotfish, I agree with almost everything you said except for the additional 2 weeks part. I would rather die in the OR then do additional time in residency.

I do believe that residency training is valuable but there is a plateau where "real-world" experience is neccessary and believe it or not, some attendings are not good teachers no matter how much scut you do for them.

 

[RadOncDoc21]

A sick day is a sick day and you shouldn't have to explain to anybody why you're taking one. A resident missing one procedure/case is not the end of the world, if so, it sounds like that program doesn't have the volume it should have.

I always wonder why academic places always seem to "need" resident coverage all the time. In the community, we don't have residents and life still goes on.

 

[Law2Doc]

...
I always wonder why academic places always seem to "need" resident coverage all the time. In the community, we don't have residents and life still goes on.

You likely have the applicable number of attendings and midlevels needed to cover your volume. At the smaller teaching hospitals, they may have fewer of both those groups because they have residents. So you can't look at residents as "additional" to what you have but "instead". So for example if you were doing a procedure and needed a colleague to assist, and that assistant was out, you'd be in the same kind of jam.

 

[22031 Alum]

Anyone who thinks that, among other things:

1) Night call as an Ob/Gyn involves doing "routine gyn surgeries." (Yeah, that's why we have 24/7 in-house attendings. For that 3am hysteroscopy.)

2) Off-site rotations can be arranged and implemented with a snap of the finger. Forget about months (at the very least!) of meetings, negotiations, proving that they are necessary/worthwhile, and making sure there won't be detrimental effects on other aspects of the program, etc.

3) The money that comes from having residents goes straight to my salary as an employee of the medical school, and I (as a relatively new faculty member who has met the Dean once) have any say at all in how that money is allocated.

... is utterly clueless about the reality of what I do. I'm tempted to say it's ignorance about graduate medical education in general, but I haven't yet fallen into the way of thinking so prevalent here on SDN, which is that my experience = the only valid one.

The program I'm at is new, and definitely isn't perfect, but it is exactly what I signed up for in order to be able to make a positive impact in helping create providers for the region. So @Perrotfish I would love to hear how you use your influence to make the program you work for so flawless, instantly. I'm afraid neither my colleagues or the ACGME is going to buy that I'm doing my job as a teacher if I just do surgeries and deliveries by myself as often as my small program's culture lets residents miss days. It would definitely be faster for me, but if I'd wanted to do procedures quickly and by myself, I wouldn't have taken this job (where my personal productivity doesn't even matter, incidentally).

If you can wrap your mind around the concept of hospital work involving something other than rounding and writing H&Ps, I'd actually love your input. But if you're just going to show off your ignorance by saying I'm lining my pockets with residency money because writing a note is below my dignity, than you can take your input somewhere else.

 

[Law2Doc]

Also to add to the prior post, that attendings generally already have full time jobs, in some fields logging as much or more hours than the residents (no 80 hour limits after residency), so it's not like they are really more available to cover residents when they are out. It's not that they find it undignified to write notes or whatever you are categorizing as resident work, but rather that they have their own jobs, productivity requirements etc and need to go where their employer dictates. An attending can't not do his own job to do the residents -- That doesn't make any sense.

At the programs where there are abundant personnel doing nothing they can't put aside for the day I agree you would never have an issue but those programs are few and far between in most specialties, and generally aren't the lean programs or fields that can't tolerate sick days that we are talking about. A few of you guys seem to be in light psych residencies where you can function adequately with a fraction of the personnel, and are trying to extrapolate that model to everywhere else.

 

[mimelim]

Holy ****, this is a count your blessings thread for me...

If a resident is sick, they stay home and one of their co-residents cover them and we make it work between us. I mean we are small by residency standards, but damn, y'all have some crazy angst/issues with this stuff...

 

[Mass Effect]

Also to add to the prior post, that attendings generally already have full time jobs, in some fields logging as much or more hours than the residents (no 80 hour limits after residency), so it's not like they are really more available to cover residents when they are out. It's not that they find it undignified to write notes or whatever you are categorizing as resident work, but rather that they have their own jobs, productivity requirements etc and need to go where their employer dictates. An attending can't not do his own job to do the residents -- That doesn't make any sense.

At the programs where there are abundant personnel doing nothing they can't put aside for the day I agree you would never have an issue but those programs are few and far between in most specialties, and generally aren't the lean programs or fields that can't tolerate sick days that we are talking about. A few of you guys seem to be in light psych residencies where you can function adequately with a fraction of the personnel, and are trying to extrapolate that model to everywhere else.

When, exactly, did I try to extrapolate any model to anywhere else, let alone everywhere else? All I did was answer a question asked in the original post. That's it. Considering I'm the only one on this thread who is in a "light psych residency," your comment appears misplaced. The other psych residents on this thread have posted the opposite.

As to attendings having their own full time jobs outside the hospital, is their appointment to a teaching hospital supposed to be considered moonlighting then? Because I'm pretty sure they have to see all the patients the residents see. They're there to teach and supervise, so how would seeing the patient on their own soak up so much time that they couldn't make it to their "full time job"?

 

[Law2Doc]

When, exactly, did I try to extrapolate any model to anywhere else, let alone everywhere else? All I did was answer a question asked in the original post. That's it...

It actually wasn't you I was referring to...

But no, in many fields there isn't a mere redundancy between attendings and residents as you describe. It's not every field that's all about attendings merely rounding on the same patients as residents after the residents finish, signing the notes the residents drafted. In some fields the residents actively assist and are the second set of hands some of the time, or are on the floor when the attending needs to be physically doing other things. It's a pyramidal structure, with the attending really not able to be both the top and bottom pieces of the pyramid at the same time. So no, we are really talking about a second full time job in some cases.

 

[Doctor4Life1769]

I'd venture to say it's probably harder in a field like anesthesia, but even the faculty make it work by switching over residents and even attendings with the assignments. I know we did that a lot of times. Sometimes, an attending had to do the case solo.