How much call is too much?

[Doctor Bagel]

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So in the context of concerns about next year where my class is going to be hit with pretty much all the overnight/weekend burden for my program and where we're down a resident currently, how much is too much?

Theoretically, we're supposed to work approximately every 2 out of 4 weekends. Our weekend call is either a 24 hour Saturday call or both a Friday and Sunday call (Friday being an overnight call, and Sunday call being from 8 am to 8 pm). I'm right now of the opinion that going over this at all is not OK. I'm honestly not even sure if it complies with ACGME requirements of getting 4 days off a month.

But looking at a recently released call schedule, we have people working for example 8 out of 13 weekends. Other people are working 4 full weekends on a six week rotation. And again, these weekend calls aren't like a Friday call or a Sunday call where you get either Saturday or Sunday off. They essentially mean you work the whole freaking weekend, or you're dead tired and post call.

Have you guys encountered call schedules like this at your program? Am I wrong in thinking this is just totally not acceptable?

 

[futurepsychdoc]

So in the context of concerns about next year where my class is going to be hit with pretty much all the overnight/weekend burden for my program and where we're down a resident currently, how much is too much?

Theoretically, we're supposed to work approximately every 2 out of 4 weekends. Our weekend call is either a 24 hour Saturday call or both a Friday and Sunday call (Friday being an overnight call, and Sunday call being from 8 am to 8 pm). I'm right now of the opinion that going over this at all is not OK. I'm honestly not even sure if it complies with ACGME requirements of getting 4 days off a month.

But looking at a recently released call schedule, we have people working for example 8 out of 13 weekends. Other people are working 4 full weekends on a six week rotation. And again, these weekend calls aren't like a Friday call or a Sunday call where you get either Saturday or Sunday off. They essentially mean you work the whole freaking weekend, or you're dead tired and post call.

Have you guys encountered call schedules like this at your program? Am I wrong in thinking this is just totally not acceptable?

Dr. Bagel,
I'm under the impression that across the boards, second year residents are bearing the brunt of the new duty hours. It's a bummer and not fair to your class. It seemed as though most programs were trying to keep call free 4th years (if they had that previously). Maybe this will evolve/even out amongst classes over time, but at least initally, second years are going to have it tough.

OHSU is my second choice. If I match there, I certainly hope to have time to enjoy Portland! What's the point of living in an awesome city if you don't have any time. I guess fun and flexibility might be tabled till third year.

I at least remember seeing a gorgeous view of Mt. Hood (?) from the call room. 🙂

 

[whopper]

Hard to say because call isn't the same in every program in hours and difficulty. In one hospital in my residency program, call was you were up all night working pretty much all the time. In another hospital, while on call, you could go home at 10-11 pm but you could've been beeped while at home. Sometimes you were hardly ever beeped at all.

 

[Doctor Bagel]

These calls are inhouse, busy calls. As mentioned above, a weekend on call in our program means you don't get a day off that weekend at all.

 

[Doctor Bagel]

Dr. Bagel,
I'm under the impression that across the boards, second year residents are bearing the brunt of the new duty hours. It's a bummer and not fair to your class. It seemed as though most programs were trying to keep call free 4th years (if they had that previously). Maybe this will evolve/even out amongst classes over time, but at least initally, second years are going to have it tough.

OHSU is my second choice. If I match there, I certainly hope to have time to enjoy Portland! What's the point of living in an awesome city if you don't have any time. I guess fun and flexibility might be tabled till third year.

I at least remember seeing a gorgeous view of Mt. Hood (?) from the call room. 🙂

I can see putting off some "fun and flexibility," but the recent call schedule released (admittedly not for next year) is plain brutal and possibly not feasible. I'm not even sure it provides for the 4 days off a month that the ACGME says we have to have.

Of course the problem for next year with us, too, is that the program is trying to free both 3rd and 4th years from the primary call pool. So the 8 2nd years (hoping there's 8 because there might not be) are it for two hospital systems that require 24 hour coverage.

 

[billypilgrim37]

The ACGME does allow for a 24 hour post-call day to count towards the four days off under some special circumstances. The medicine program we rotated in during pgy1 took advantage of this provision as well, which we thought was pretty dirty too. So technically it's probably in the clear, but the spirit of your frustration is very understandable.

 

[Doctor Bagel]

The ACGME does allow for a 24 hour post-call day to count towards the four days off under some special circumstances. The medicine program we rotated in during pgy1 took advantage of this provision as well, which we thought was pretty dirty too. So technically it's probably in the clear, but the spirit of your frustration is very understandable.

Wow, that seems so wrong. "Dirty" is a good word for it. I didn't even encounter that type of stuff in my ob/gyn or surgery rotations in medical school. I certainly wouldn't expect a psych program to claim this.

Just found this explanation from the ACGME for the previous rules about what the one day off in seven should be. It implies that there is flexibility, but I get the impression they really don't support using a post call day as a day off for a pretty good rationale.

www.acgme.org/dutyhours/dhfaqs.pdf

 

[TexasPhysician]

I hate these new rules. I'm not even sure if it will effect my program yet, but I empathize with how unfair it is. Really screws people in our year. My buddies in other fields were looking forward to a more relaxed PGY-2, and now everyone gets slammed. Its just wrong.

 

[Doctor Bagel]

I hate these new rules. I'm not even sure if it will effect my program yet, but I empathize with how unfair it is. Really screws people in our year. My buddies in other fields were looking forward to a more relaxed PGY-2, and now everyone gets slammed. Its just wrong.

You know, initially I was cool with our plan to exclude the 3rd and 4th years from the primary call pool, but now I'm thinking that just really penalizes our class too much. And yeah, the rules make it very difficult, especially in fields like psych where we can't get inhouse supervision even for 16 hour night/weekend calls.

BTW, how much communication have you guys gotten from your program about these changes? I've got to admit that I feel like we haven't gotten enough.

 

[Doc Samson]

I tried reading that ACGME FAQ - it reminded me of talmudic scholars interpreting the finer points of religious law. The idea that different RRCs can interpret the rules in a different way is just plain silly. Fewer hours is going to have to mean either more resident slots or (more likely) more years in residency at some point.

 

[peppy]

You know, initially I was cool with our plan to exclude the 3rd and 4th years from the primary call pool, but now I'm thinking that just really penalizes our class too much.

I agree with you. I think that's pretty unfair and poorly thought out. At my program, I know there would be a lot of outcry if they dumped a bunch of call on one particular class. I definitely think that an effort should be made to distribute call fairly. What is the rationale for excluding the seniors? Is it really not feasible because of the rotation structure for them or just another case of the medical world's fondness for hazing and mistreating the people low on the totem pole? 🙄

 

[nancysinatra]

I agree with you. I think that's pretty unfair and poorly thought out. At my program, I know there would be a lot of outcry if they dumped a bunch of call on one particular class. I definitely think that an effort should be made to distribute call fairly. What is the rationale for excluding the seniors? Is it really not feasible because of the rotation structure for them or just another case of the medical world's fondness for hazing and mistreating the people low on the totem pole? 🙄

It doesn't really matter how it is distributed because if you are a 2nd year next year, you will be a 3rd year the following year. You can take the extra call in one year primarily, or spread it out. But unless you quit you'll still have to do it.

I don't even think this is about hazing or mistreatment. It seems like it is just work redistribution guided by pure stupidity. At least at my program there aren't that many options for how to comply. Even program directors can't do much--the issue is resources. Add a lot of 3rd year call and you will have post call residents who can't work in clinics which need to be staffed, for example.

The irony is it will probably harm patient care by overworking the upper levels who will be doing everything now while the interns "nap" or whatever their new job is. In the end nothing will change and it will still be a system without the money to make the improvements it says it is promoting.

 

[TexasPhysician]

Whose idea was the new rules anyway? I feel like they did not consult residents at all in this matter.

 

[Doctor Bagel]

I don't even think this is about hazing or mistreatment. It seems like it is just work redistribution guided by pure stupidity. At least at my program there aren't that many options for how to comply. Even program directors can't do much--the issue is resources. Add a lot of 3rd year call and you will have post call residents who can't work in clinics which need to be staffed, for example.

The irony is it will probably harm patient care by overworking the upper levels who will be doing everything now while the interns "nap" or whatever their new job is. In the end nothing will change and it will still be a system without the money to make the improvements it says it is promoting.

Seriously, we are hit by these huge resources issues. I'm really glad I'm not a PD right having to deal with this, and I honestly don't know the answer. But I know I'm not down with working 8 full weekends out of 13, or down with not getting one full day off in 7 on some lame legalistic justification. I just don't see why my classmates have to bear this particular burden.

So, the other big question, how involved have you guys been in the changes looming in your program? I've been getting updates by a classmate on a committee, but I've gotten pretty much nothing from our admin about what these changes are going to mean to my class. I'm honestly pretty upset about this.

 

[Dogdaysofsummer]

At my program we also work about every other weekend during 1st and 2nd year. How much will you be on call during the week Doc Bagel?

 

[Doctor Bagel]

At my program we also work about every other weekend during 1st and 2nd year. How much will you be on call during the week Doc Bagel?

So theoretically next year, we won't be on call during the week. Instead, we'll have a 2nd year doing night float on weekdays covering everything under the sun (feasible, maybe? need more info from our admins). With this schedule for the next 3 months (that honestly doesn't affect me because I'm off service), the residents being shafted with weekend call are working 1 to 2 shortcalls during the week.

To me, the big thing is how many days should people have off on average. ACGME says 4 out of 7 (about 4.23/month), which shouldn't include post call days. Every other weekend fits with that. Going over every other weekend doesn't. My program is asking people to go over every other weekend, and that's where I'm worried.

 

[Doctor Bagel]

I tried reading that ACGME FAQ - it reminded me of talmudic scholars interpreting the finer points of religious law. The idea that different RRCs can interpret the rules in a different way is just plain silly. Fewer hours is going to have to mean either more resident slots or (more likely) more years in residency at some point.

You know, I agree. Letting different RRCs determine this stuff is just plain wrong. However, I'm not with you on the possibility of extending residencies because I"m no seeing how anyone can make an argument that we'd have to train longer to be well trained psychiatrists. There are plenty of psychiatry programs out there that don't have much overnight call and that don't work their residents anywhere closet 80 hours a week. And yet, they still train pretty competent, board certified psychiatrists. I just can't see how any psychiatry program out there can claim we should stick around for another year because interns can't work more than 16 hours in a call. The call requirements at my program are largely about service, not about education, and I'm guessing that's pretty typical nationwide. It would be a total lie to extend training on the guise that it's needed to make us competent psychiatrists.

 

[Doctor Bagel]

I agree with you. I think that's pretty unfair and poorly thought out. At my program, I know there would be a lot of outcry if they dumped a bunch of call on one particular class. I definitely think that an effort should be made to distribute call fairly. What is the rationale for excluding the seniors? Is it really not feasible because of the rotation structure for them or just another case of the medical world's fondness for hazing and mistreating the people low on the totem pole? 🙄

The justification for that is the theory that call would disrupt clinical training for third and fourth years. You know, I honestly agree with that. However, lots of our third and fourth years work every other weekend moonlighting. Making 2nd years cover all these weekends (and again, maybe violating ACGME rules), so upper class residents can moonlight freely doesn't seem like a good justification. I'm certainly a fan of 3rd years having less call than 2nd years, but yeah, excluding them from a call pool, and pushing us beyond 2 out of 4 weekends, is not OK.

I am curious about how much burden other programs are placing on 2nd years. And, again, how much support are you getting from other people in your program. We're getting pretty much none, because, of course, we're the only ones who care.

 

[futurepsychdoc]

The justification for that is the theory that call would disrupt clinical training for third and fourth years. You know, I honestly agree with that. However, lots of our third and fourth years work every other weekend moonlighting. Making 2nd years cover all these weekends (and again, maybe violating ACGME rules), so upper class residents can moonlight freely doesn't seem like a good justification. I'm certainly a fan of 3rd years having less call than 2nd years, but yeah, excluding them from a call pool, and pushing us beyond 2 out of 4 weekends, is not OK.

I am curious about how much burden other programs are placing on 2nd years. And, again, how much support are you getting from other people in your program. We're getting pretty much none, because, of course, we're the only ones who care.

Have you talked to the administration and your fellow residents about this? I'd guess that other 1st years feel similarly and you might be able to advocate together for your class. Now's probably the time to speak up---and secondly, I wonder, with a new PD coming on board, if your program will revisit the issue later this summer.

 

[Doctor Bagel]

Have you talked to the administration and your fellow residents about this? I'd guess that other 1st years feel similarly and you might be able to advocate together for your class. Now's probably the time to speak up---and secondly, I wonder, with a new PD coming on board, if your program will revisit the issue later this summer.

So far, I've sent an email to the PDs and to the chiefs about the call schedule. I've gotten one brief reply back from the chiefs and nothing from the PDs. Notably, they're at that PD conference this week, which kind of explains not replying, but it also annoys me that we got sent two big announcements (one that one of the interns isn't coming back this year, and two this call schedule that's just plain wrong) while they were gone.

Getting a new PD is probably part of the issues because who really is our leadership right now? I'm assuming the new PD will get be good and that things will be better once that is formalized. Of course, we haven't gotten a whole lot of communication about that process either. See below --

But all this is really highlighting how communication is really not a strength at our program. Notably, we have zero contact with the chair -- I know what he looks like, but that's it. Everyone says it's a good thing that he's there, but I don't personally know that. I don't know how it works at other programs, but I know that the residents had plenty of contact with the chair at my medical school program. In fact, as a medical student, she was my adviser. Much smaller program, but still I know I would have taken a great deal of comfort knowing she was the chair if the program was losing their PD. Since we had contact with her, I know that she would fix it.

And thinking about it, again, has convinced me that maybe exempting 3rd years from the call pool isn't such a great idea. I think it's pretty reasonable to ask them to cover say one weekend call a month, so we aren't stretched incredibly thin. It also really highlights to me that people really aren't being fair to the lower levels in my program right now.

And adding, my irritation about this is probably compounded by the fact that I've been working too damn much recently and that today's my first day off in 12 days. I just can't see being a reasonably happy person without getting my average of 1 (not post call) in 7 days off.

 

[Cinnameg]

I tried reading that ACGME FAQ - it reminded me of talmudic scholars interpreting the finer points of religious law. The idea that different RRCs can interpret the rules in a different way is just plain silly. Fewer hours is going to have to mean either more resident slots or (more likely) more years in residency at some point.

Wow, that's the first time I've heard a non-surgeon worry about more years in residency due to limited duty hours. I have heard this a lot from surgeons in the past few weeks. I do wonder about the validity of associating hours on call with learning, though. I was just on surgery, which has crazy hours, but I don't think a lot of learning was happening for the overworked (and very bitter) intern during a large chunk of her 4am-10pm days. For one thing, she spent a lot of this time doing scutwork that nobody above her had time to do -- marking sites on patients she hadn't met before for surgeries she wouldn't participate in, for example. Also, it seemed that since these residents never left the hospital to relax and chill out, they ended up doing that at the hospital. The surgeons' evening sign-out took forever because there was lots of gossip, watching youtube videos, and generally hanging out because nobody wanted to be the one who looked like s/he was in a rush to get home. It's better to be social in the hospital and be there an extra hour or two, it seems, than to push through to get home. In other words, more hours at the hospital doesn't necessarily mean more work done or more learning.

 

[peppy]

At least at my program there aren't that many options for how to comply. Even program directors can't do much--the issue is resources. Add a lot of 3rd year call and you will have post call residents who can't work in clinics which need to be staffed, for example.

The irony is it will probably harm patient care by overworking the upper levels who will be doing everything now while the interns "nap" or whatever their new job is. In the end nothing will change and it will still be a system without the money to make the improvements it says it is promoting.

Yeah, it's a difficult situation since every program is different and what is feasible at one program may not work at another. I definitely think that in psychiatry it's important for us to not be spread too thin since when you're stressed out and tired it can affect your ability to be patient and empathetic with patients, and that's something that is so important to our work.

 

[peppy]

But all this is really highlighting how communication is really not a strength at our program. Notably, we have zero contact with the chair -- I know what he looks like, but that's it. Everyone says it's a good thing that he's there, but I don't personally know that. I don't know how it works at other programs, but I know that the residents had plenty of contact with the chair at my medical school program. In fact, as a medical student, she was my adviser. Much smaller program, but still I know I would have taken a great deal of comfort knowing she was the chair if the program was losing their PD. Since we had contact with her, I know that she would fix it.

I'm wondering, how is the communication within your residency class? It might be more effective if your class approached the leadership as a united front with ideas about how to improve the planned changes rather than if you try to express your grievances on your own.
As for how it works at other programs, the chair of our dept has been pretty approachable and did make the time to meet with us when there were some program changes even though we weren't facing anything as major as the issue of a PD leaving. I definitely agree with you that it helps to have a chair who is resident-friendly, but I get the impression it isn't that uncommon for the chair to be hands-off and not really deal with the residents much.

 

[Doctor Bagel]

Yeah, it's a difficult situation since every program is different and what is feasible at one program may not work at another. I definitely think that in psychiatry it's important for us to not be spread too thin since when you're stressed out and tired it can affect your ability to be patient and empathetic with patients, and that's something that is so important to our work.

Definitely a good point. Even without these changes, our program is a little heavier on the call schedule, and I really struggle when sleep deprived and overworked (getting paged excessively, etc.) to be good practitioner. I honestly feel like I've been pretty cold on my inpatient psych rotations with the combo of sleep deprivation and dealing with a few malingerers/users.

 

[Doctor Bagel]

I'm wondering, how is the communication within your residency class? It might be more effective if your class approached the leadership as a united front with ideas about how to improve the planned changes rather than if you try to express your grievances on your own.
As for how it works at other programs, the chair of our dept has been pretty approachable and did make the time to meet with us when there were some program changes even though we weren't facing anything as major as the issue of a PD leaving. I definitely agree with you that it helps to have a chair who is resident-friendly, but I get the impression it isn't that uncommon for the chair to be hands-off and not really deal with the residents much.

So I contacted my class, and we'll be meeting to talk about this stuff. We've had a lot of one on one conversations expressing dissatisfaction but have yet to come together in an organized manner. I also just contacted the class above, since they too are affected by lots of this stuff.

Thanks for the info about chairs. Of course, I knew our chair was pretty hands off when we didn't meet him or hear anything about him when we interviewed. Unfortunately, our program has been hit with multiple changes, so we're looking to the chair as a source of stability.

 

[kcrd]

Bagel, has anyone looked into proposing paid moonlighting shifts for the 3's or 4's to take to relieve the weekend call burden off your class? You might find that the upper years would willingly help out for a little extra cash.

 

[Doctor Bagel]

Bagel, has anyone looked into proposing paid moonlighting shifts for the 3's or 4's to take to relieve the weekend call burden off your class? You might find that the upper years would willingly help out for a little extra cash.

For next year, I'm pretty sure this is a no go because our department is ridiculously broke. For the same reason, it probably won't work for this year's intern loss either.

From my understanding, our schedule for next year has to be cost neutral. It would be a good idea, though.