Losing co-residents, options

[Coop11]

Looking for advice from those who may have experienced something similar or know about legal rights of residents:

I belong to a very small residency program in a surgical field. We have lost one resident this year, have one resident who is unexpectedly unable to work for an undefined amount of time, and a third resident who will be going on maternity leave shortly. A larger program might be able to absorb this loss, but for us, it results in a dramatic change in work load. So far, our program has tried some stop gap measures, but none have resulted in an increase in the number of people taking primary call. The end result is, the remaining few residents are having to take the extra primary call of those who are gone. Seniors are taking the amount of call a typical PGY2 or 3 would be taking, our PGY2 has likely been breaking work hour restrictions for the past few months, and all of use are losing out on education/research because we are taking so much primary call. We are several months into this "temporary" situation, which is only getting worse.

My hope is that we can find a solution through hiring additional residents, but our program has been slow to find replacements. It's also the holidays, so all the pending paperwork is only prolonging things. With the upcoming (and also unpredictable) maternity leave, we are all losing a lot of sleep over our situation and some of the existing residents are actively looking for other residency spots.

Who can help us in this situation?

If our program really cannot find a solution, like ASAP, I'm not even sure which organization to go to for help (ACGME, my hospital's GME, the governing body for my specialty?). I'm not interested in leaving my program out to dry, and turning it into a malignant relationship, because I do think they've been trying. They've also been reaching out to us for possible solutions, but... we are still being asked to take more and more primary call as residents are dropping by the wayside, with no backup plan or room for anyone to even get the flu at this point. Suggestions?

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[gutonc]

Your attendings need to step the f*** up. They won't of course. But that's the only real answer to the question.

 

[Law2Doc]

Looking for advice from those who may have experienced something similar or know about legal rights of residents:

I belong to a very small residency program in a surgical field. We have lost one resident this year, have one resident who is unexpectedly unable to work for an undefined amount of time, and a third resident who will be going on maternity leave shortly. A larger program might be able to absorb this loss, but for us, it results in a dramatic change in work load. So far, our program has tried some stop gap measures, but none have resulted in an increase in the number of people taking primary call. The end result is, the remaining few residents are having to take the extra primary call of those who are gone. Seniors are taking the amount of call a typical PGY2 or 3 would be taking, our PGY2 has likely been breaking work hour restrictions for the past few months, and all of use are losing out on education/research because we are taking so much primary call. We are several months into this "temporary" situation, which is only getting worse.

My hope is that we can find a solution through hiring additional residents, but our program has been slow to find replacements. It's also the holidays, so all the pending paperwork is only prolonging things. With the upcoming (and also unpredictable) maternity leave, we are all losing a lot of sleep over our situation and some of the existing residents are actively looking for other residency spots.

Who can help us in this situation?

If our program really cannot find a solution, like ASAP, I'm not even sure which organization to go to for help (ACGME, my hospital's GME, the governing body for my specialty?). I'm not interested in leaving my program out to dry, and turning it into a malignant relationship, because I do think they've been trying. They've also been reaching out to us for possible solutions, but... we are still being asked to take more and more primary call as residents are dropping by the wayside, with no backup plan or room for anyone to even get the flu at this point. Suggestions?

You have no legal recourse as long as everything is kosher in terms of duty hours. If there's a provable violation of duty hours, it could be reported, but getting your program into trouble/probation doesn't really help you in the near term, and as you mentioned, could create a malignancy/hostility that doesn't presently exist with administration and maybe co-residents.

The only suggestion, which I've seen work out a few times, is for the residents to use their own network of friends to find residents at other programs who are unhappy with their residency/geography and would love to be in yours, and then pass the CV on to your PD. It's a bit tricky because the program can't formally try to poach people. But sometimes these informal communications can lead to a program finding the right person faster than running an ad.

 

[Doctor Bagel]

It might be useful to at least talk to your hospital's GME because sometimes they can do things. We had some extra shortages and GME was able to come up with extra money to pay upper levels to moonlight to provide additional coverage. If the program is going to actually lose more residents over this, it's something they should be concerned about and should on their own be pushing GME for help.

 

[doc05]

hire a few PAs. or perhaps convince your attendings to step up.

 

[Crayola227]

Be so careful as they are saying above.

Proving hours violations is really the only way to hold the program accountable to whoever (the ACGME I believe), but as pointed out, getting your program into trouble is like spiting your nose by biting your face. (yes that's how I meant that).

However, if the hour violations are so bad as to lead to some serious patient danger badness, that never did a program any favors either. Or if someone quits over this making things worse.

ACGME pretty much always expects you to try to resolve these things at the local level first (if I remember what I read right, doublecheck their website on grievance procedures) and proof of that before they intervene, although hour violations whistle-blowing may be in a different category as far as what they expect you to have done before bringing it to them.

I suggest the following:
1) Read the ACGME website closely about these topics, grievances, hour violations
2) Your specialty board has residency rules that are much more specific than ACGME, like about supervision, vacation, breakdown of hour rules, grievance procedures (I think), read this
3) Read your contract carefully, especially sections about hours and how to bring grievances to GME, HR
4) Let all of that reading sink in
5) The more anonymous you can make noise to address this, the better, if you have to come out of the shadows to make these waves, DON'T
6) Always get set up at least with a lawyer to call if not actually on retainer that can help you with the following: employment law, and medical licensing board. They exist you just have to find them. An anonymous call to the local bar association or even a google search can yield help. If a lawyer says it's outside their expertise, you can always ask if they know someone who can for referral. I say this if after reading the above you're about to start taking those sort of steps
7) Document document document
8) You might consider going to your Chief or PD with your concerns, but if you take any stronger action along the lines of the above, you will have outed yourself, which might lead to actually outing yourself, although with the schedule this tight you may not be fired, but they can always make you wish you were, and there are so many ways they can hurt your career you have no idea the world of hurt they can unleash upon you

Aside from the above official pathways, there is jack you can really do to twist the program's arm on this, and any attempt to twist a program's arm usually not only fails but can pile drive your head straight into the mat leaving you a quadriplegic.

Oh, and like Law2Doc suggested, while poaching from programs is frowned on, troll these threads for the people desperately seeking a residency slot. PM them and try to recruit for your program. You never know it might work.

TLDR
do your homework reading the ACGME, specialty, and hospital paperwork
always have a lawyer secretly in your back pocket
tread carefully, if you can't safely stay in the shadows or address this without making enemies, your safest bet is to suck it up
sorry
you can try recruiting from SDN, residentswap website (hopefully your program has that one covered, I'm willing to be they're already on Frieda)

 

[j4pac]

Sounds like a crap situation for everyone involved.

As in most things in life, it isn't always what you do but how you do it. Reporting work hour violations without exhausting all other options is BAD. If your PD is reasonable, which it sounds like they may, express your concerns through your chief resident. You absolutely have to give your PD an opportunity to fix the problem. Maybe the PD isn't aware of the strain.

My wife's program suffered a similar situation. They eventually told the PD...who then told the higher ups at the hospital. They then hired a few hospitalists...after the hospital CEO attended with the on-call residents overnight...and he saw that there were patient safety concerns because of the load. Reasonable people will want their residents to be more than slaves. They will want good learning environments and high quality of care for their patients.

 

[Coop11]

Thanks for the advice team SDN!

 

[Law2Doc]

Sounds like a crap situation for everyone involved.

As in most things in life, it isn't always what you do but how you do it. Reporting work hour violations without exhausting all other options is BAD. If your PD is reasonable, which it sounds like they may, express your concerns through your chief resident. You absolutely have to give your PD an opportunity to fix the problem. Maybe the PD isn't aware of the strain.

My wife's program suffered a similar situation. They eventually told the PD...who then told the higher ups at the hospital. They then hired a few hospitalists...after the hospital CEO attended with the on-call residents overnight...and he saw that there were patient safety concerns because of the load. Reasonable people will want their residents to be more than slaves. They will want good learning environments and high quality of care for their patients.

The snag though is that for OPs surgical program it's going to be trickier to find stop gaps like you perhaps might with Hospitalists in IM. I don't see that many surgeons out there looking for overnight call jobs where they get to relive the thrill of being a surgical resident on the floor. (And if you are going to hire attending level people you are going to deal with a many month interview and credentialing process, so it won't help OP in the near term.) But I guess with the right mix of hours and pay anything is theoretically possible. I still think recruiting more residents is going to be the more realistic and faster option.

 

[FutureInternist]

Make sure you get a print out of all of your evaluations up until this point & any formal emails regarding how you performed in rotations before doing any of the above, since they can suddenly have a computer 'malfunction" & lose all your evals

 

[Raryn]

The snag though is that for OPs surgical program it's going to be trickier to find stop gaps like you perhaps might with Hospitalists in IM. I don't see that many surgeons out there looking for overnight call jobs where they get to relive the thrill of being a surgical resident on the floor. (And if you are going to hire attending level people you are going to deal with a many month interview and credentialing process, so it won't help OP in the near term.) But I guess with the right mix of hours and pay anything is theoretically possible. I still think recruiting more residents is going to be the more realistic and faster option.

There's always the possibility of midlevels that can handle most of the floor call/consults with attending backup. That's what my institutions surgery program did when they realized they just had too much floor work and didn't have the money (or maybe the volume of some specific procedures) to expand the residency program.

 

[Law2Doc]

There's always the possibility of midlevels that can handle most of the floor call/consults with attending backup. That's what my institutions surgery program did when they realized they just had too much floor work and didn't have the money (or maybe the volume of some specific procedures) to expand the residency program.

Sure That's possible to an extent, but that's still mostly a stopgap for replacing juniors, not seniors. I'd be worried if the only person on the floor overnight was a PA without someone in house (i.e. a senior) to call. It's not clear from OPs post what level people are out, but unless it's just interns I don't know if PAs and NPs fix the overnight problem. Of course you could have midlevels working with attendings during the day, and residents working primarilly at night but I expect this would eliminate much of the didactics and training, so this is only good as a very short term solution. But yeah the OPs program probably needs to get a bit more creative.

 

[22031 Alum]

The issue I see is that two of the three absences that OP describes are temporary. The program could get one resident as a replacement, but any more than that would be enlarging the size of the program - getting the okay to do that can take a while. And in my experience, these programs tend to have plenty of service-type work to go around, but lack the true educational volume to support additional residents. Then there's the question of whether any appropriate candidates would even want to come. Basically, it's not as simple as "Just get some more residents!" That's why I agree with the comment about the attendings needing to step up.

 

[Law2Doc]

The issue I see is that two of the three absences that OP describes are temporary. The program could get one resident as a replacement, but any more than that would be enlarging the size of the program - getting the okay to do that can take a while. And in my experience, these programs tend to have plenty of service-type work to go around, but lack the true educational volume to support additional residents. Then there's the question of whether any appropriate candidates would even want to come. Basically, it's not as simple as "Just get some more residents!" That's why I agree with the comment about the attendings needing to step up.

Attendings "needing to step up" never works-- for one thing it's a pyramidal structure so you have fewer attendings overseeing residents, not a lot of man-hours to work with. Who is going to teach and supervise residents if you have your attendings working alone in the wards at night to fill gaps in residency coverage? And attendings at surgical programs often already work pretty absurd hours -- if you've got a guy already working 100+ hours a week (as he typically doesn't get post call days on nights he has to come in, or duty hour protections), you can't exactly ask him to "step it up." Your comment perhaps reflects some specialty where attending call obligations are less and average hours are less to start with. The IM attending working 55 hours a week, sure, he should step it up. The surgical junior faculty already logging 90-110 hours a week, not such a reasonable request.

When surgical attendings do overnight shifts, they typically don't get to go home and sleep the next day, and frankly they generate a lot more money for the hospital during the day so no hospital would really want them to give that up. Finally, these programs don't often have the kind of leverage over attendings they do for residents. Attendings who work at teaching hospitals are already taking certain financial hits because (a) they like to teach, (2) they like research and (3) the hours at a teaching hospital are generally better. But if you eliminate #3 and the change in hours starts to impact #1 and #2, then you'll lose all your best faculty in droves. Why would you earn less for the same hours when you can go across the street. You want to eliminate the one hook teaching hospitals have to attract good people. And without good faculty the training and reputation at the program suffers.

What you are suggesting sounds on first blush reasonable as a knee jerk reaction but is often the kind of thinking that makes a bad situation much much worse. OP doesn't want to create a situation where the training goes away in an effort to make residents lives more manageable. OP is there for the training, not to bide his time and then figure it out as an attending. There may be fields where you learn most of what you need early on and the latter years are more independent practice but I doubt surgery is one of these. I'm betting OP wouldn't mind more one on one time with attendings during the day instead of attendings MIA because they are doing floor work overnight while he's home asleep. Or at least as he nears the end of his training he would wish he had had more of this.

Frankly there's always a balance that needs to be found between good training and oppressive hours, and your suggestion focuses mostly on the latter at huge expense of the former. Many of us think the former is much more important.

 

[22031 Alum]

Attendings "needing to step up" never works-- for one thing it's a pyramidal structure so you have fewer attendings overseeing residents, not a lot of man-hours to work with. Who is going to teach and supervise residents if you have your attendings working alone in the wards at night to fill gaps in residency coverage? And attendings at surgical programs often already work pretty absurd hours -- if you've got a guy already working 100+ hours a week (as he typically doesn't get post call days on nights he has to come in, or duty hour protections), you can't exactly ask him to "step it up." Your comment likely reflects some specialty where attending call obligations are less and average hours are less to start with.

Allow me to clarify what I have seen in similar situations to OP's. I won't presume to say this would work at every program everywhere. Nor will I presume to tell everyone else what will never or always work.

I'm an OB/Gyn. I have done stretches of taking call with one resident on at night, as opposed to our usual three, because we literally didn't have the bodies, resident-wise, to cover everything that needed it. That meant instead of being immediately available in a call room as usual, I was up running around like an intern all night taking care of the antepartum, L&D, postpartum, and Gyn services. This was followed by my regular full clinic day, followed by a full OR day, after which I did it all again. There was a different stretch of time when my partners and I all gave up our academic time to provide necessary clinic coverage when residents were out. It sucked, and I really didn't need the explanation that attendings don't get post call days or duty hour protections. But the alternative was subpar patient care (or canceled clinics --> empty OR days --> residents failing to meet minimum numbers). So we, the attendings, "stepped up" and did what we had to do. There was no way on earth we would have gotten approval to recruit an additional resident in either of those circumstances. I imagine @gutonc has seen similar things, hence the original comment.

 

[Law2Doc]

Allow me to clarify what I have seen in similar situations to OP's. I won't presume to say this would work at every program everywhere. Nor will I presume to tell everyone else what will never or always work.

I'm an OB/Gyn. I have done stretches of taking call with one resident on at night, as opposed to our usual three, because we literally didn't have the bodies, resident-wise, to cover everything that needed it. That meant instead of being immediately available in a call room as usual, I was up running around like an intern all night taking care of the antepartum, L&D, postpartum, and Gyn services. This was followed by my regular full clinic day, followed by a full OR day, after which I did it all again. There was a different stretch of time when my partners and I all gave up our academic time to provide necessary clinic coverage when residents were out. It sucked, and I really didn't need the explanation that attendings don't get post call days or duty hour protections. But the alternative was subpar patient care (or canceled clinics --> empty OR days --> residents failing to meet minimum numbers). So we, the attendings, "stepped up" and did what we had to do. There was no way on earth we would have gotten approval to recruit an additional resident in either of those circumstances. I imagine @gutonc has seen similar things, hence the original comment.

OP has described his program as very small and his attendings as reasonable people. I suspect they are already running pretty lean and that your suggestion assumes a level of man-power or redundancy that doesn't exist there. Your hours weren't maxed out so you had room to increase them. Some of the small programs I've seen often work at the other end of the spectrum, and if someone gets sick or leaves, they really don't have such good contingencies in place. Without knowing the staffing either of us could theoretically be right but from what OP has written I think your post came off as a bit knee jerk "just let the attendings pull their weight". Most of the time, if that was actually an option, it will have already happened (like it did in your program). I promise you surgeons aren't gun-shy about a few more hours-- they didn't pick the field for the lifestyle. But you can only get so much blood from a stone.

 

[22031 Alum]

OP has described his program as very small and his attendings as reasonable people. I suspect they are already running pretty lean and that your suggestion assumes a level of man-power or redundancy that doesn't exist there. Your hours weren't maxed out so you had room to increase them. Some of the small programs I've seen often work at the other end of the spectrum, and if someone gets sick or leaves, they really don't have such good contingencies in place. Without knowing the staffing either of us could theoretically be right but from what OP has written I think your post came off as a bit knee jerk "just let the attendings pull their weight". Most of the time, if that was actually an option, it will have already happened (like it did in your program). I promise you surgeons aren't gun-shy about a few more hours-- they didn't pick the field for the lifestyle. But you can only get so much blood from a stone.

Knee jerk?? I didn't say "attendings should step up" without further comment. I explained why hiring more residents isn't as simple as just deciding to do so. And to say "just hire more residents" or "just use mid levels" is equally knee-jerk, by the way.

The truth is none of us know OP's exact situation, and none of us can say "just do this" or "that never works." All we can do is talk about our own experiences, and what we have seen work (or fail horribly).

My comments are from the point of view of someone who has worked for a program that seemed like it was always teetering on the edge of probation. The issue there is that giving the brunt of the extra workload to attendings leads to exhausted, unhappy attendings. Giving the extra workload to the remaining residents leads to exhausted residents and attention from the ACGME. You're right, though, there are limits to what can be done.

In any case, nobody saying "recruit more residents!" has addressed what happens when the temporary absences that OP mentioned are over. Presumably OP's program is the size it is because of the volume it can generally support. So they hire residents to cover the one that left, and maternity leave, and absence of undetermined length. When those residents come back, they have more than their full complement. Now the floor work and clinic is a little easier, but they're triple scrubbing the tiniest cases in an attempt to get OR time- forget meaningful OR time. I've seen that happen. Now the program is getting the attention of the ACGME for a different reason. I suppose they could turn into Crayola's program and start finding excuses to dump people.

All that ignores the fact that if they are a program that tends to lose people, outside of the desirable locales, it can be really hard to get replacement residents- even from the IMG/desperate to go somewhere crowd. Another thing I have experienced firsthand.

Basically, none of the solutions is simple.

 

[RadOncDoc21]

Basically, none of the solutions is simple

Are simple... sorry just felt like being an ass for no good reason .

 

[22031 Alum]

Are simple... sorry just felt like being an ass for no good reason.

Dammit! I debated which one it was for five solid minutes!! Should've googled. Don't tell my high school English teacher on me.

 

[RadOncDoc21]

Sadly, I'm only 50% sure, so you def could still be right! I'm gambling here.

 

[j4pac]

Sadly, I'm only 50% sure, so you def could still be right! I'm gambling here.

The snag though is that for OPs surgical program it's going to be trickier to find stop gaps like you perhaps might with Hospitalists in IM. I don't see that many surgeons out there looking for overnight call jobs where they get to relive the thrill of being a surgical resident on the floor. (And if you are going to hire attending level people you are going to deal with a many month interview and credentialing process, so it won't help OP in the near term.) But I guess with the right mix of hours and pay anything is theoretically possible. I still think recruiting more residents is going to be the more realistic and faster option.

That is a good point. But at the very least the attendings could pick up their hours, and PAs could be hired to do some of the day-time scut. Wouldn't getting a new resident also take quite a bit of time.

 

[gutonc]

Attendings "needing to step up" never works-- for one thing it's a pyramidal structure so you have fewer attendings overseeing residents, not a lot of man-hours to work with. Who is going to teach and supervise residents if you have your attendings working alone in the wards at night to fill gaps in residency coverage? And attendings at surgical programs often already work pretty absurd hours -- if you've got a guy already working 100+ hours a week (as he typically doesn't get post call days on nights he has to come in, or duty hour protections), you can't exactly ask him to "step it up." Your comment perhaps reflects some specialty where attending call obligations are less and average hours are less to start with.

I used to think like this. But then a colleague of mine (on the research side) who is in his 60s, is an HPB surgeon who does 4 or 5 Whipples a week (plus a bunch of other stuff) and holds an endowed chair at the University, picked up Q4 Trauma call when the trauma team was down 2 attendings (injury and pregnancy) and 3 Chiefs for a 6 month period a few years ago. He did slack off for a week to climb Mt Kilimanjaro during that period (and if you saw him across the room, you'd think he was only interested in climbing Mt. Krispy Kreme).

Bottom line...this sucks for everybody. It's also time limited. We don't know the complete details, and never will, but to say that there's no room for the attendings to step up and take a little pressure off the residents is just ridiculous.

 

[Law2Doc]

I used to think like this. But then a colleague of mine (on the research side) who is in his 60s, is an HPB surgeon who does 4 or 5 Whipples a week (plus a bunch of other stuff) and holds an endowed chair at the University, picked up Q4 Trauma call when the trauma team was down 2 attendings (injury and pregnancy) and 3 Chiefs for a 6 month period a few years ago. He did slack off for a week to climb Mt Kilimanjaro during that period (and if you saw him across the room, you'd think he was only interested in climbing Mt. Krispy Kreme).

Bottom line...this sucks for everybody. It's also time limited. We don't know the complete details, and never will, but to say that there's no room for the attendings to step up and take a little pressure off the residents is just ridiculous.

You know ONE guy who wasn't exactly pushing the envelope at one place so nobody anywhere must be. OP already described this as a pretty lean program. You are more likely extrapolating an atypical situation to OPs.

 

[rokshana]

You know ONE guy who wasn't exactly pushing the envelope at one place so nobody anywhere must be. OP already described this as a pretty lean program. You are more likely extrapolating an atypical situation to OPs.

as are you...you are assuming that this program is willing to call upon those endowed chairs and faculty that are only part time to work extra during a time of crisis...there are plenty of places that won't even "Disturb" the attending listed as call for a consult after 4pm...i would imagine these places would be less likely to call upon them to be in house...having A PGY2...strikes me as a crisis situation.

and the program could always use locums (which yes, exist in the surgical world) to fill the spot(s) to ease the burden on the residents...

 

[gutonc]

You know ONE guy who wasn't exactly pushing the envelope at one place so nobody anywhere must be. OP already described this as a pretty lean program. You are more likely extrapolating an atypical situation to OPs.

Unsurprisingly, you missed my point. Which was simply that you may find help where you least expect it.

And if you don't think that 50+ hours in the OR each week, plus clinic and rounding time, and call for your primary group (before adding on extra call) isn't pushing the envelope, then I'm not sure I can reason with you.

 

[Law2Doc]

...
And if you don't think that 50+ hours in the OR each week, plus clinic and rounding time, and call for your primary group (before adding on extra call) isn't pushing the envelope, then I'm not sure I can reason with you.

I know young attendings at small places who regularly still hit 90-100 hours a week post residency, so no, your description isn't of someone already pushing the envelope. At big universities and groups where they have lots of underlings taking the lions share of the call, perhaps. At the small lean programs I have seen (and which I'm gathering OP is describing) we aren't talking about "endowed chairs" or "part time faculty" or people who have research labs/days, or guys who have three scheduled OR days a week. Maybe you could pull someone old and shaky back out of retirement and re-credential them (doubtful), maybe you could find a locums (although despite what rokshana wrote above this is not so easy as finding a hospitalist in IM). Maybe you could move some of the scut onto midlevels and free up the junior residents (again this doesn't work well at night, and it's unclear to me if the OPs program is missing Juniors, seniors or both). But I still think replacing those residents that aren't coming back with residents geographically unhappy at other programs, if you can find any, is the biggest bang for the buck.

 

[deleted480308]

I know young attendings at small places who regularly still hit 90-100 hours a week post residency

Are these people chasing money/promotions or are there actually jobs that "require" this...please elaborate because I'd like to avoid that mess. I still like my family

 

[Law2Doc]

Are these people chasing money/promotions or are there actually jobs that "require" this...please elaborate because I'd like to avoid that mess. I still like my family

All of the above. There are jobs out there where they expect the new attendings to pay their dues and take the lions share of the call, and thus see their hours jump after residency. There are places where you want to work hard to get ahead. There are subspecialties where the hours are simply more intense and the jobs require this. And there are lean hospital systems where too few people are covering too many patients to have a cushier schedule. These jobs don't happen accidentally and so aren't something you need to work to avoid. We aren't talking malignant here (unless a place opts to do what some on this thread are describing and ask them to take the residents call on top of this).
Most people see it as an opportunity to achieve some goal, career path, nest egg, title, whatever and so do so willingly-- the mantra of those who take them as they get awoken so often at 3 am is "well, this is what I signed on for..." So you won't fall into this accidentally and need to watch out for it, but if you have certain career goals you might seek such a job out for non-lifestyle reasons.

 

[Perrotfish]

Are these people chasing money/promotions or are there actually jobs that "require" this...please elaborate because I'd like to avoid that mess. I still like my family

L2D has posted many times about how new attendings, particularly surgical attendings, routinely work more than is legally allowed for residents, week in and week out. Everyone else always say that they never, ever see attendings work nearly that hard. Personally the only attending I have ever seen work 100 hours a week was a pulmonologist who actually took two separate full time jobs with two different employers. I have occasionally heard rumors of groups with a particularly brutal one year partnership tracks that are that bad, but that's for a single year and even then the compensation for the group would need to be WAY above average for that to make sense.

If there is a surgeon out there working 100 hours/week for a single salary's worth of compensation, he has to be an idiot. Its not like there aren't hospital systems recruiting for 45 hours/week of surgery coverage for 300K/year, or alternatively 20 hours/week for 120K/year. How much better could the job possibly be for it to make sense to sacrifice all of your waking hours and half of your sleep?

 

[Raryn]

L2D has posted many times about how new attendings, particularly surgical attendings, routinely work more than is legally allowed for residents, week in and week out. Everyone else always say that they never, ever see attendings work nearly that hard. Personally the only attending I have ever seen work 100 hours a week was a pulmonologist who actually took two separate full time jobs with two different employers. I have occasionally heard rumors of groups with a particularly brutal one year partnership tracks that are that bad, but that's for a single year and even then the compensation for the group would need to be WAY above average for that to make sense.

If there is a surgeon out there working 100 hours/week for a single salary's worth of compensation, he has to be an idiot. Its not like there aren't hospital systems recruiting for 45 hours/week of surgery coverage for 300K/year, or alternatively 20 hours/week for 120K/year. How much better could the job possibly be for it to make sense to sacrifice all of your waking hours and half of your sleep?

In all the departments that I've been familiar with either rotating with or consulting, I can think of only one example. What that comes to mind is that at my old medical school, only two of the CT surgery attendings routinely did cardiac (as opposed to thoracic) work, so they basically did q2 call forever. If there were a couple late night type A dissections or a heart transplant in a week, they could easily crack 100 hours. That said, they had NPs and residents that did all of their floor work, and their rounding took all of 5 minutes BID. From the perspective of a surgeon who basically just wanted to operate, they had great gigs.

In pretty much every other environment I'm familiar with, attendings put up with the academic pay cut primarily because it gives them significant flexibility in the schedule. Compared to anyone in private practice, most attendings do significantly less clinical work with much more time for research or flex time for academic committees and such. If it's a temporary circumstance, they can easily spend more time on service. We've had that before at my program when we've lost attendings before, and the remainder easily covered the difference. We could get rid of all the residents on all of our consult services, and our staff would be fully capable of covering the services, it would just be a pain in their asses.

 

[Law2Doc]

L2D has posted many times about how new attendings, particularly surgical attendings, routinely work more than is legally allowed for residents, week in and week out. Everyone else always say that they never, ever see attendings work nearly that hard. Personally the only attending I have ever seen work 100 hours a week was a pulmonologist who actually took two separate full time jobs with two different employers. I have occasionally heard rumors of groups with a particularly brutal one year partnership tracks that are that bad, but that's for a single year and even then the compensation for the group would need to be WAY above average for that to make sense.

If there is a surgeon out there working 100 hours/week for a single salary's worth of compensation, he has to be an idiot. Its not like there aren't hospital systems recruiting for 45 hours/week of surgery coverage for 300K/year, or alternatively 20 hours/week for 120K/year. How much better could the job possibly be for it to make sense to sacrifice all of your waking hours and half of your sleep?

That you haven't personally seen it doesn't mean others haven't. It doesn't even mean the people you know aren't doing career related things when they are out of your sight. I have previously posted about the guy I know who seemed to have a very cushy appearing 45 hour a week job until I rotated at another hospital and saw he was working 45 hours a week there as well.

In my above post I listed a variety of reasons people hit high hours post-residency. If you want a specific situation/group/practice/subspecialty/opportunity, you do what is required to get it. And no, the only "idiot" is the person who would rather choose better hours for a few years over ones dream career. If you want something you trade a few hours of sleep here and there to make it happen. I'm not sure why that's so controversial, other than some people on here have this notion that they'll get to a point where the race is over and they can just settle in and coast. But that's a bit false, and not even everyone's goal and certain jobs and (sub)specialties absolutely reward those who don't have that mindset. It's naive to label them idiots because they have a different goal than you.

 

[hamstergang]

the only "idiot" is the person who would rather choose better hours for a few years over ones dream career.
...
It's naive to label them idiots because they have a different goal than you.

I mean, I guess "idiot" and idiot aren't exactly the same.

 

[Law2Doc]

I mean, I guess "idiot" and idiot aren't exactly the same.

The quotes are to show it was another's prior use of the word idiot rather than my word choice.

 

[MediCane2006]

L2D has posted many times about how new attendings, particularly surgical attendings, routinely work more than is legally allowed for residents, week in and week out. Everyone else always say that they never, ever see attendings work nearly that hard. Personally the only attending I have ever seen work 100 hours a week was a pulmonologist who actually took two separate full time jobs with two different employers. I have occasionally heard rumors of groups with a particularly brutal one year partnership tracks that are that bad, but that's for a single year and even then the compensation for the group would need to be WAY above average for that to make sense.

If there is a surgeon out there working 100 hours/week for a single salary's worth of compensation, he has to be an idiot. Its not like there aren't hospital systems recruiting for 45 hours/week of surgery coverage for 300K/year, or alternatively 20 hours/week for 120K/year. How much better could the job possibly be for it to make sense to sacrifice all of your waking hours and half of your sleep?

Just FYI, there are LOTS of surgeons in this situation. Particularly young attendings, covering multiple hospitals, with expectations for research productivity. You are fighting for block time, taking call (and then have to figure out when to operate on the cases which come in when you're on call, and you may not have block time, so...) and trying to build up a practice which means operating on whatever comes in the door.

I'm not saying all of academic surgery is like this, but it absolutely does happen. And there is no such thing as a "post-call" day when you're an attending.

 

[Perrotfish]

Just FYI, there are LOTS of surgeons in this situation. Particularly young attendings, covering multiple hospitals, with expectations for research productivity. You are fighting for block time, taking call (and then have to figure out when to operate on the cases which come in when you're on call, and you may not have block time, so...) and trying to build up a practice which means operating on whatever comes in the door.

I'm not saying all of academic surgery is like this, but it absolutely does happen. .

Even if it were true (I still disagree that it's common) it still begs the question of why anyone would agree to put up with that kind of schedule. Attending surgeons are professionals in their mid-30s. They can generally command a 250K+ salary, in a desirable location, doing exactly what they want to do for no more than 50 hours a week. If they're willing to go rural they can command 500K+ for the same hours. What exactly are these surgeons chasing, for 100 hours/week, that is so much more of a dream than what they already have available to them? How good could it possibly be to be worth all of your waking hours for the handful of healthy, relatively youthful years you have left at the end of an already extremely long residency?

The comes a point where delayed gratification stops being a strategy and starts being a pathology. You can chase the perfect life for so long that you run out of time to live one that is merely great. At some point, you need to let yourself be done with the hard part, and waiting until the end of a Surgical Residency is more than long enough.

 

[Wordead]

Even if it were true (I still disagree that it's common) it still begs the question of why anyone would agree to put up with that kind of schedule. Attending surgeons are professionals in their mid-30s. They can generally command a 250K+ salary, in a desirable location, doing exactly what they want to do for no more than 50 hours a week. If they're willing to go rural they can command 500K+ for the same hours. What exactly are these surgeons chasing, for 100 hours/week, that is so much more of a dream than what they already have available to them? How good could it possibly be to be worth all of your waking hours for the handful of healthy, relatively youthful years you have left at the end of an already extremely long residency?

The comes a point where delayed gratification stops being a strategy and starts being a pathology. You can chase the perfect life for so long that you run out of time to live one that is merely great. At some point, you need to let yourself be done with the hard part, and waiting until the end of a Surgical Residency is more than long enough.

I think you're confusing your desires with theirs. Some people are just workaholics. They're not "chasing" anything. Some attendings will come in and operate any time anywhere if they can get a room and anesthesia. Is it pathological? Arguably so.

 

[joker2400]

I think you're confusing your desires with theirs. Some people are just workaholics. They're not "chasing" anything. Some attendings will come in and operate any time anywhere if they can get a room and anesthesia. Is it pathological? Arguably so.

We have a chairman like this. I swear he probably puts in as many hours as his residents more frequently than he should.

 

[Perrotfish]

I think you're confusing your desires with theirs. Some people are just workaholics. They're not "chasing" anything. Some attendings will come in and operate any time anywhere if they can get a room and anesthesia. Is it pathological? Arguably so.

That's not what L2D was talking about, though. He was talking about groups that expect attending surgeons to start at the bottom and work their way up, and how attendings should expect to work 100 hour weeks for multiple years to get their dream job. The long hours are being described as a means to an end, not an end to themselves.

What I hate to see is someone who has a life they want to live, and who is then undermining their own goal. An attending (like the pulmonologist I mentioned) who is working 100 hours/week because he feels the work is worth every waking moment of his life is heroic. An attending physician who is working 100 hours/week because he want to 'someday' have a high paying job with good hours is both tragic and idiotic. He's sacrificing years of his life to abuse and dreaming of a goal he could achieve just by applying to a different job. Its like watching a man who has lived for years as though he was blind, weeping nightly for the memory of sunlight, because he refuses to take off an oversized hat.

 

[Law2Doc]

Even if it were true (I still disagree that it's common) it still begs the question of why anyone would agree to put up with that kind of schedule. Attending surgeons are professionals in their mid-30s. They can generally command a 250K+ salary, in a desirable location, doing exactly what they want to do for no more than 50 hours a week. If they're willing to go rural they can command 500K+ for the same hours. What exactly are these surgeons chasing, for 100 hours/week, that is so much more of a dream than what they already have available to them? How good could it possibly be to be worth all of your waking hours for the handful of healthy, relatively youthful years you have left at the end of an already extremely long residency?

The comes a point where delayed gratification stops being a strategy and starts being a pathology. You can chase the perfect life for so long that you run out of time to live one that is merely great. At some point, you need to let yourself be done with the hard part, and waiting until the end of a Surgical Residency is more than long enough.

Your clause "if they're willing to go rural..." Pretty much sums up where you aren't getting it. Most doctors aren't. That's exactly why rural places have to pay big premiums and still have difficulty filling spots. If your goals are the job you want where you want you'll do what's expected.

 

[surg]

A few thoughts:
1) This highlights an issue with smaller programs in that there is very little slack in the system both on the resident and the attending side. Larger programs and big academic programs that often have people in lab years or research rotations too, have a lot more flexibility to plug the gaps from attrition (either temporary or permanent).
2) For adding residents, as other posters have noted, it is highly unlikely that you will find new residents to hire that you would want in your program permanently most years, especially mid-year that would actually improve your situation. Even if you could magically make them appear ready to go from a paperwork standpoint (which could take days to months depending on your state licensing laws for trainees and whether they are an AMG or IMG), remember these are people who need to move, etc. and there is generally a reason they are available mid-year, it is because they were not able to find a position that started July 1st (barring some who have sudden life-change situations, or program closures). If they are not unemployed/underemployed, then it means they are willing to ditch their current program on very short notice, so perhaps not the person you are looking for to step up and take a bunch of call. Also, even if they are the world's greatest resident, they have no idea how your system works. It may actually create even more work to get them integrated than to just "suck it up" for a few months more, although I think looking for someone to fill the permanently lost resident makes sense.

That leaves you with a few options I can think of
0) Use senior residents to cover junior resident call even more.... (what it seems your current plan is)
1) If you have lab residents, pull them out of the lab until you can get the program back to fuller strength then send them back. Bad for them and their career, but probably the easiest thing to do.
2) Entice some people from other specialty programs to moonlight to cover call or join your program (as there are always people who may have chosen another specialty than realized later that they would prefer yours).
3) If there is a larger program close by that has lab years that could reasonably cover some of the call (e.g. general surgery residents covering overnight urology call with back-up for consults), consider calling their chief resident and letting it be known that your program is hiring for night call coverage moonlighting
4) Check to see if there are any community surgeons in town (especially relatively young and new to practice) who might be interested in taking a call night for money. When I ran a program that had call schedule holes, we had a number of community surgeons who loved to take the call because it paid reasonably ok, and it was a very easy call, so they slept in the hospital and got a check. The attendings came in and did the operations anyway, so there was no one for them to follow afterwards, and they usually even got to bill an assist fee if they actually went to the OR. This can be a little tricky with credentialing since they are credentialing as attendings usually, so may not be easy at purely academic hospitals with no private practice surgeons.
5) Use current institutional attendings to cover primary call. This is less than ideal as it takes away the attending from their usual schedule as well (don't forget, with the exception of trauma services that choose to be shift-based, most surgeons cover their own patients every night as well, so are on back-up call pretty much every night they are in town and thus may cause legal issues if they have patients at more than one hospital, but are taking primary in-house call and can't leave a hospital)
6) Hire midlevels to take call. If you pay enough you can even find some to take night call, but those are quite difficult to find.
7) Convert some easier services to home call with an emergency cross-cover in house for life-threatening issues that the home call person can call on to run to the bedside until someone can come in from home. I did this once for a cardiac surgery rotation as I was on call 6 nights/week for 3 weeks when my call coverage went out with a family emergency (back in the days when q2 was still allowed). It wasn't fun, but at least getting to go home each night after I thought I had all the patients tucked in made it more tolerable and I was willing to actually take it from home knowing that I had some back-up in house if someone tried to tamponade while I was in the car.

As to what attendings do when you don't see them, believe me they are all busy. Attending productivity is closely monitored these days, both in terms of clinical productivity but also non-clinical productivity. There are millions of things to do when you see us leave the floor, clinic, or OR. For those with research efforts, it tends to be an up or out situation. If you don't get your research off the ground in your first few years, you are destined to be bumped off the tenure track at best, and potentially lose your job at worst depending on your institution's policies. Even for those on "teaching" tracks, there are typically numerous committee meetings both hospital and medical school based, as well as preparing teaching materials, teaching students, community outreach etc. I would say that absent the people who were intent on coasting through life, it is rare to see a surgical academic attending put in less than 60-70 hrs on site a week, not counting overnight call duties, which while more numerous in terms of actual nights, is definitely less strenuous than intern/junior resident call. For those trying to have a career that progresses (assistant to associate to full professor with or without chief duties), they almost certainly put residency level hours, the difference is they have more control over their schedule. Most of us could push ourselves to take another call here and there as needed (and some people did when option #4 above was being done). Ironically, most of us are so far out from doing orders, etc. that I think we frustrated the residents more when they came in and saw what hash we made of writing orders, keeping up the list, etc. On top of that, I think the residents also ended up working even harder to try to get everything so tucked in before they left as they didn't want to look bad handing off a bunch of work to the attending taking call that it ended up being somewhat counterproductive overall when we took call!.

 

[22031 Alum]

Excellent post, @surg. Without knowing the details of what OPs program has tried, it's a good breakdown of the possible options that are out there. It's nice to see someone else acknowledge that there's not a magical source of other residents a program can just hire to instantly fill in gaps- especially temporary gaps. The thought of having residents from a different specialty (or a different institution) do some coverage hadn't occurred to me, but I can definitely see how that might work in specialties that "cross over" with each other a little better.

 

[Law2Doc]

A few thoughts:
1) This highlights an issue with smaller programs in that there is very little slack in the system both on the resident and the attending side. Larger programs and big academic programs that often have people in lab years or research rotations too, have a lot more flexibility to plug the gaps from attrition (either temporary or permanent).
2) For adding residents, as other posters have noted, it is highly unlikely that you will find new residents to hire that you would want in your program permanently most years, especially mid-year that would actually improve your situation. Even if you could magically make them appear ready to go from a paperwork standpoint (which could take days to months depending on your state licensing laws for trainees and whether they are an AMG or IMG), remember these are people who need to move, etc. and there is generally a reason they are available mid-year, it is because they were not able to find a position that started July 1st (barring some who have sudden life-change situations, or program closures). If they are not unemployed/underemployed, then it means they are willing to ditch their current program on very short notice, so perhaps not the person you are looking for to step up and take a bunch of call. Also, even if they are the world's greatest resident, they have no idea how your system works. It may actually create even more work to get them integrated than to just "suck it up" for a few months more, although I think looking for someone to fill the permanently lost resident makes sense.

That leaves you with a few options I can think of
0) Use senior residents to cover junior resident call even more.... (what it seems your current plan is)
1) If you have lab residents, pull them out of the lab until you can get the program back to fuller strength then send them back. Bad for them and their career, but probably the easiest thing to do.
2) Entice some people from other specialty programs to moonlight to cover call or join your program (as there are always people who may have chosen another specialty than realized later that they would prefer yours).
3) If there is a larger program close by that has lab years that could reasonably cover some of the call (e.g. general surgery residents covering overnight urology call with back-up for consults), consider calling their chief resident and letting it be known that your program is hiring for night call coverage moonlighting
4) Check to see if there are any community surgeons in town (especially relatively young and new to practice) who might be interested in taking a call night for money. When I ran a program that had call schedule holes, we had a number of community surgeons who loved to take the call because it paid reasonably ok, and it was a very easy call, so they slept in the hospital and got a check. The attendings came in and did the operations anyway, so there was no one for them to follow afterwards, and they usually even got to bill an assist fee if they actually went to the OR. This can be a little tricky with credentialing since they are credentialing as attendings usually, so may not be easy at purely academic hospitals with no private practice surgeons.
5) Use current institutional attendings to cover primary call. This is less than ideal as it takes away the attending from their usual schedule as well (don't forget, with the exception of trauma services that choose to be shift-based, most surgeons cover their own patients every night as well, so are on back-up call pretty much every night they are in town and thus may cause legal issues if they have patients at more than one hospital, but are taking primary in-house call and can't leave a hospital)
6) Hire midlevels to take call. If you pay enough you can even find some to take night call, but those are quite difficult to find.
7) Convert some easier services to home call with an emergency cross-cover in house for life-threatening issues that the home call person can call on to run to the bedside until someone can come in from home. I did this once for a cardiac surgery rotation as I was on call 6 nights/week for 3 weeks when my call coverage went out with a family emergency (back in the days when q2 was still allowed). It wasn't fun, but at least getting to go home each night after I thought I had all the patients tucked in made it more tolerable and I was willing to actually take it from home knowing that I had some back-up in house if someone tried to tamponade while I was in the car.

As to what attendings do when you don't see them, believe me they are all busy. Attending productivity is closely monitored these days, both in terms of clinical productivity but also non-clinical productivity. There are millions of things to do when you see us leave the floor, clinic, or OR. For those with research efforts, it tends to be an up or out situation. If you don't get your research off the ground in your first few years, you are destined to be bumped off the tenure track at best, and potentially lose your job at worst depending on your institution's policies. Even for those on "teaching" tracks, there are typically numerous committee meetings both hospital and medical school based, as well as preparing teaching materials, teaching students, community outreach etc. I would say that absent the people who were intent on coasting through life, it is rare to see a surgical academic attending put in less than 60-70 hrs on site a week, not counting overnight call duties, which while more numerous in terms of actual nights, is definitely less strenuous than intern/junior resident call. For those trying to have a career that progresses (assistant to associate to full professor with or without chief duties), they almost certainly put residency level hours, the difference is they have more control over their schedule. Most of us could push ourselves to take another call here and there as needed (and some people did when option #4 above was being done). Ironically, most of us are so far out from doing orders, etc. that I think we frustrated the residents more when they came in and saw what hash we made of writing orders, keeping up the list, etc. On top of that, I think the residents also ended up working even harder to try to get everything so tucked in before they left as they didn't want to look bad handing off a bunch of work to the attending taking call that it ended up being somewhat counterproductive overall when we took call!.

I agree with most of this but would suggest that when you find residents willing to move to your program mid cycle, it's not always because they need to move, are screw ups, etc. Where I did residency we filled a gap or two along the way with people already in pretty good situations but wanted to be closer to family/home. Often these are people that always wanted your program, but didn't quite strike gold during the match, went to their next best but still decent option, and were smart enough to ask their friends who did match at your program to let them know if something unexpected opened up. It happens and they usually are grateful for the opportunity and pull their weight.

As mentioned, a lot of these options work better at larger places with research and more electives and redundancy, which wasn't the picture I was getting from OP. When you are lean and already butting the duty hour limits, the options are limited.

One last thought is that at some places family med and ER residents are required to rotate through surgery -- maybe you bully those specialties to get more people for more time, to get the (junior level) overnight man hours you need -- these fields are less likely to be running afoul of duty hours so you their programs can ask more of them. Make up some certificate/award to give them so they get some CV value, and/or throw some moonlighting money their way. The nice part of this plan is their paperwork is already done if they are part of the same institution, and you can send them back as soon as someone on temporary leave comes back. The disadvantage is it might be a tough sell to get someone to rank a FM or ED program highly if in a previous year someone was asked to take surgery call for a few more months. But if the money is right, maybe you could sell it.

 

[Coop11]

Thanks for all the replies. Let this be a cautionary tale for people looking at small surgical subspecialty programs. (We're not talking 1-a-year Rad-onc programs here, but programs where there is an in house service that needs 24/7 coverage.)

Follow-up: We have 'solved' the problem by pulling interns from other services to run a night float service. Seniors are still in house running the show, but with an intern to help out. Also... prayer that the temporary situations will be resolved by the end of the month and no one goes into preterm labor! As many mentioned above, though our initial knee jerk reaction was that the attendings needed to help out, at the end of the day, we all agreed that the reality of our attendings taking primary call would not be good for anyone!

 

[Psai]

Thanks for all the replies. Let this be a cautionary tale for people looking at small surgical subspecialty programs. (We're not talking 1-a-year Rad-onc programs here, but programs where there is an in house service that needs 24/7 coverage.)

Follow-up: We have 'solved' the problem by pulling interns from other services to run a night float service. Seniors are still in house running the show, but with an intern to help out. Also... prayer that the temporary situations will be resolved by the end of the month and no one goes into preterm labor! As many mentioned above, though our initial knee jerk reaction was that the attendings needed to help out, at the end of the day, we all agreed that the reality of our attendings taking primary call would not be good for anyone!

Buy those interns some dinner while they're there

 

[asdf123g]

sorry for the ignornace..but what do you mean you lost a resident? They just got up and decided to quit their entire med career and be insanely indebt after all of that hard work???...

 

[Perrotfish]

sorry for the ignornace..but what do you mean you lost a resident? They just got up and decided to quit their entire med career and be insanely indebt after all of that hard workout

Fired, switched programs, switched specialties, got sick for a long period of time, quit the residency to practice as a GP, or just flat out quit medicine.

 

[VA Hopeful Dr]

One last thought is that at some places family med and ER residents are required to rotate through surgery -- maybe you bully those specialties to get more people for more time, to get the (junior level) overnight man hours you need -- these fields are less likely to be running afoul of duty hours so you their programs can ask more of them. Make up some certificate/award to give them so they get some CV value, and/or throw some moonlighting money their way. The nice part of this plan is their paperwork is already done if they are part of the same institution, and you can send them back as soon as someone on temporary leave comes back. The disadvantage is it might be a tough sell to get someone to rank a FM or ED program highly if in a previous year someone was asked to take surgery call for a few more months. But if the money is right, maybe you could sell it.

That's pretty devious... I like it.

 

[Bacchus]

Your attendings need to step the f*** up. They won't of course. But that's the only real answer to the question.

Amen. Or, risk getting the program into a huge ****storm with the ACGME.

 

[Doctor4Life1769]

Amen. Or, risk getting the program into a huge ****storm with the ACGME.

Too bad the program would retaliate against the resident big time

 

[Bacchus]

That's pretty devious... I like it.

I simply would find another program, haha. ACGME requires now only 1 month of general surgery for FM so I doubt you'd find residents, even if paid, covering. **** that.