Leaving way after sign-out: program red flag or normal?

[boromirmycaptain]

Applying to residency this year and making up my rank list now and am in need of some advice. At interview dinners, residents from 2 of my programs mentioned that they tended to leave hours after sign-out. For instance, at one program they sign out at 7PM on late call but the resident said he usually left at 10PM. He seemed like a really nice guy and was happy as a clam at his program, but these comments alarmed me. Not sure if they should though and so I was hoping for some advice about if this info should shape my opinion of these programs.

I happen to go to a home institution where the residents hours are respected very well. Sign-out is at 8PM here and we stop admitting a little in advance - I forget when - so that you don't end up with 3 new admits right as you're ready to leave. Because of that, all I've ever seen in med school is a system where residents leave usually within the hour after sign-out, unless there is an emergency with a pt of course. But is this normal? My home med school is known as a pretty kind place overall so I'm not sure if it's common for programs to behave the way mine does.

Basically: just wondering if I should be alarmed at how late residents stay at these 2 programs that I'm applying to. I wasn't always able to get this information at every interview so I don't know if routinely staying that late is common everywhere I'm applying.

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[Crayola227]

it's not so much a question of when you sign out - if you are not on an admitting day, or are capped, leaving immediately or ~1 hr of sign out (depending what you're tying up) would be totally normal, or places might let you sign out earlier to the long call team rather than wait until night float gets in, which would let you out earlier

however, if it's a long call admit day, you can take up to 5 patients, and the program has you admit right up until sign out - 6:59 pm - then it wouldn't be unusual or abusive at all that you might be there until 10 pm on your long call day (if that resident is happy, I'm betting the time is being made up elsewhere and guessing it's not a consistently ~120 hr / wk type program)

so, the question of when you leave is somewhat related to when sign out is (7pm is pretty common), but is really more related to the call structure

for long call teams, often they can sign out their pager to nightfloat at 7 pm (so they don't have *that* work to do on the current census) and continue to work on admit orders & H&Ps undisturbed, but yeah, that often means long call days can be anywhere from 7-10 pm in terms of when you get to step out of the hospital, usually ones structured this way have short call days, nightfloat accept, other days you get out much earlier

what you mention isn't what I would prioritize in ranking programs - #1 is how well you fit there (elusive, I know) and how supportive you think everyone above you (seniors, faculty, PD, APD, Chair, GME, etc etc)

People people people people.

I know a resident that thought a program was really cush and educationally strong (don't tell me this is an oxymoron), and in every way it was, everything about the hospital, structure, patient population, faculty, ancillary staff, parking, right down to the cafeteria - but they had a bad gut feeling about the people, especially the Chiefs. They did not follow the advice of using your gut in making their rank list. Story did not end well.

A lot of attention is given to PDs in making your choice, and that's fair. Except in some programs it's really the APD and the Chiefs that are running things and setting the tone.

The Chiefs do a lot of the "dirty" work of managing the residents, so their attitude is a big reflection on the spirit of the program IMHO - even if the PDs seem so nice. Soft voice, big stick. You have to look at the people that leaders put in charge to carry out their policies and structures. Do they genuinely seem to care for residents on a personal level, or do they seem like uptight dickwads, moving chess pieces on a board in their quest for greater academic glory and gain? They reflect not only the PD's selection, but also the residents there as a whole - they are selected for being the most "___" of the residents there, typically, and the ones that are felt to continue the culture the program wants to have.

No joke, some people become Chiefs because of how much they love working in the program and the people there - they just don't want to leave, and continuing the culture of the program is a job they enjoy and comes naturally to them. Some do it with a frown on their face because they feel they must walk over the fire that is being in the program for yet another year, the bitter price of career advancement. Which program do you want to be in?

TLDR:
It is a given that you will work very long hours in residency.
The most important thing for how those hours pass is how well you get along with the people around you.
Focus on the latter, less of the details of the former.

 

[Raryn]

It honestly depends on the time of year how normal that is.

August of my intern year, during my first ward month, I might leave three or four hours after signout. Both on call days (signout at 8pm) and noncall days (signout at 5p). Pushed the duty hour cap a number of times, may have actually come close to breaking it that month. But over time, I became more efficient at triaging work, writing notes, and just overall doctoring. I also grew somewhat more comfortable with the fact I didn't have to do every little thing myself (i.e. Leaving some simple things for the night team was OK as long as you weren't a dick about it when it was your turn).

Come the following May, I (and all my cointerns) were routinely done well before signout, and if we weren't on call could commonly sign out a few hours early to the on call team and enjoy many of our afternoons. On call days, we could leave within 30 minutes or so after signout as long as we hadn't been slammed with late admissions.

Basically, I think it's a pretty universal truth that a brand new intern is inefficient. This can lead to longer work hours. But it should get better.

 

[FlowLimited]

I wouldn't consider this a red flag. At my residency program we had interns assigned to stay late to help with evening admissions. They could be assigned admissions between 5pm and 9pm. After 9pm they would not be assigned a new admission, but were allowed to stay until 11pm to finish up work. Whether you needed this extra time depended on the complexity of the admissions you were assigned. As you became more efficient, you would need this extra time less and less.

This doesn't mean that "resident time isn't respected." All of these interns were still well within their duty hour restrictions

 

[kchan99]

Applying to residency this year and making up my rank list now and am in need of some advice. At interview dinners, residents from 2 of my programs mentioned that they tended to leave hours after sign-out. For instance, at one program they sign out at 7PM on late call but the resident said he usually left at 10PM. He seemed like a really nice guy and was happy as a clam at his program, but these comments alarmed me. Not sure if they should though and so I was hoping for some advice about if this info should shape my opinion of these programs.

Your follow-up should have been what the residents were doing between sign out and leaving. So it's usually tidying up admissions, finishing up a complicated H&P for an admission if it was a busy day, D/C summaries, preparing D/C instructions, etc. I remember I had days in which I left soon after sign out if everything for my admissions was done, but I wrote D/C summaries at home.

 

[caffeinemia]

Applying to residency this year and making up my rank list now and am in need of some advice. At interview dinners, residents from 2 of my programs mentioned that they tended to leave hours after sign-out. For instance, at one program they sign out at 7PM on late call but the resident said he usually left at 10PM. He seemed like a really nice guy and was happy as a clam at his program, but these comments alarmed me. Not sure if they should though and so I was hoping for some advice about if this info should shape my opinion of these programs.

I happen to go to a home institution where the residents hours are respected very well. Sign-out is at 8PM here and we stop admitting a little in advance - I forget when - so that you don't end up with 3 new admits right as you're ready to leave. Because of that, all I've ever seen in med school is a system where residents leave usually within the hour after sign-out, unless there is an emergency with a pt of course. But is this normal? My home med school is known as a pretty kind place overall so I'm not sure if it's common for programs to behave the way mine does.

Basically: just wondering if I should be alarmed at how late residents stay at these 2 programs that I'm applying to. I wasn't always able to get this information at every interview so I don't know if routinely staying that late is common everywhere I'm applying.

What kind of programs are you applying for? Sounds like internal medicine.

I remember intern year on the surgical service -- signout was say 6:30pm or whatever, but sometimes stuff gets left over from the day and you had to go help place a line or dress a wound or wheel someone on a vent down to MRI etc. It was considered bad form to leave things over for the night guy. However, this was not the case every day -- in fact it was relatively infrequent to stay 1 or 1.5 hours past sign out. So either the guy was not very efficient or the culture of the program is not great at releasing people on time. So coming from a hardass surgery type -- yeah. I'd be concerned, but I'd take the time to inquire further and speak to other residents and not just that one individual at that program.

 

[girlofgrace7]

Agree with the above.
I'm in a program that doesn't do 24 or 30 hour calls (we have a night float system that we all spend a month per year on); so, it's not that big of a deal when we have to stay late to tie things up. We have one person on call for each team; so, the rest of the team leaves around 4 pm and the late person signs out at 7 pm. Admissions bump over to the night team at 6:45. That being said, there were absolutely nights during intern year that I was at the hospital until 11 pm writing H&Ps and such after checkout because I had been so slammed with admissions late in the day. We always caution our interns to do their check out lists before anything else so they can at least check out patients to the night team, turn off their pagers, and go find a quiet room or go home to finish up whatever notes they still had. I definitely have become more efficient over time; so, the end of intern year as well as my upper level years, I routinely am out by 7:15 even on a crazy day (there has been one or two hellacious days with a billion admissions and patients crashing along the way since then... but even then I'd say I've been out by 9). Overall, it's a good system and a lot of the residents help each other out with admissions or tying things up if they can, and I honestly have no idea how many hours a week I work because we never get close to going over on wards. Pay more attention to the structure of the program and to how happy overall residents are... and definitely go with your gut feeling because it's there for a reason.

 

[Psai]

To me it seems like those guys are invested in the care of their patient. It really sucks people are trying to leave even though major things are still going on with their patients just because they wrote all the notes and want to go home because when you're the night person you don't really know the patients that well because you have 50 of them.

 

[Dr.Acula99]

To me it seems like those guys are invested in the care of their patient. It really sucks people are trying to leave even though major things are still going on with their patients just because they wrote all the notes and want to go home because when you're the night person you don't really know the patients that well because you have 50 of them.

I agree, but staying more than one hour or so over is excessive, unless it's from late admissions. You should be able to assess a sick patient and make a plan, and tell the night team what to follow up on. You need to leave some time, and things never happen quickly in the hospital.