Hi guys, new IM intern here about to start. Got my schedule yesterday. Is it normal to work for 15 days straight with no day off? I did get 4 days off for the first month but they are unevenly distributed. This arrangment seems far worse than q4 call. Any thoughts/experiences with this type of schedule?
New intern schedule
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I haven't gotten my day to day schedule yet, but I saw a lot of the interns do similar things during medical school (usually because they started grousing towards the end of the stretch).
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45408
Welcome to residency. It sucks. I worked 19 days straight in my first month as an intern.
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cowme
Q4 was way better than the current system. As long as you get 4 days off per month, they can do whatever they want.
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Pretty typical, especially since interns now have ACGME mandated naps every 45 minutes. I started internship with 13 straight days in the MICU. It sucks. You deal with it or you quit.
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Intern schedules were not much better before all these work hours mandates. I remember starting in the ER as an intern (I was an obgyn), and felt like I had a worse schedule than the ER interns. That's how you are going to feel. Life sucks as a resident, but that's how it is.
QofQuimica
Seriously, dude, I think you're overreacting....
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Totally normal if you're doing a ward or ICU month. It sucks, you'll be tired, but you'll survive.
It's 4 days off averaged over 4 weeks. So it can be where they want. I had a 21 days straight schedule just a few months ago. You learn to live with it.
It's also 80hrs/week averaged over 4 weeks. So you can have a 90+ hr week.
It's worthwhile to read the ACGME guidelines and really understand them.
I hope you have fun!
It's also 80hrs/week averaged over 4 weeks. So you can have a 90+ hr week.
It's worthwhile to read the ACGME guidelines and really understand them.
I hope you have fun!
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That's basically just a weekend off every other weekend.
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Generally Q4 and sometimes Q3 (or worse).
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One thing about the 4 days off -- I believe it's averaged going both backwards and forwards in time, so you need to meet it in every discrete 4 week block. Of course that doesn't mean your schedule isn't compliant. The most I've worked in a row is 21 days (two weekend calls back to back), which sucks but is legit.
How normal it is depends on where you work. The IM folks here generally get one day off every 7 days, but the downside of that is that they hardly ever get 2 days off in a row in a week, so no weekends for long stretches of time. I'm assuming they've decided that people like it better that way. We work full weekends in exchange for other full weekends off. I think the peds folks here work 12 days in a row and then get 2 days off, which apparently is pretty painful.
How normal it is depends on where you work. The IM folks here generally get one day off every 7 days, but the downside of that is that they hardly ever get 2 days off in a row in a week, so no weekends for long stretches of time. I'm assuming they've decided that people like it better that way. We work full weekends in exchange for other full weekends off. I think the peds folks here work 12 days in a row and then get 2 days off, which apparently is pretty painful.
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The only people who say this are people who have never taken Q4 call or people who have taken cush Q4 call. Intern calls at my institution were brutal. Huge cross-coverage, a page every 5 minutes or so until the middle of the night, then maybe every 30 minutes or so. Way more admissions than the interns take now. I frequently stayed at work several hours past rounds to finish my admission notes and progress notes (because it's very hard to write an admission note in EMR when you are being paged about other patients q5 minutes and need to be able to access other patients in EMR for those pages). It's not like I ever had the energy to enjoy my post-call day. I walked home and more than once I almost walked into traffic because I was practically sleep-walking. Senior call was significantly easier for me than intern call, although that may not hold true for seniors who have never taken call before.
Interestingly enough, I've taken Q3 call and it wasn't so bad - the schedule was designed to be work hour compliant, so call days were long, but rounding post-call wasn't too bad, and on your inter-call day you were home for lunch!
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cowme
We had it just as rough on night float. The difference is would you rather lump it together and not see anyone for weeks to a month at a time, or spread it out one in four days, and have post call days where you can actually run errands/have a life if need be
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Usually you get 1 day off/week, or you can work whole weekend and get the next weekend off. I would not say it's normal per se, but many of us did i if we wanted to have the whole day off and stuff, and even change calls to have Thurs. call and be off from noonish on Friday until Monday am. But I guess it's program/team dependent.
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I just got my call schedule for the first 3 months. I have 1 weekend day off every week, a golden weekend each month, 5-6 days off each month. Not too bad. 
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Yeah that was me last week... 14 days on then a day off on tuesday. Wasn't as brutal as I thought because the service I transferred on to I was carrying like 3 patients. Also that contained two weekends of working and since I was at the VA they let us leave once work is done on weekends which can be as early as 11am if you just have a bunch of patients that are placement issues you are essentially babysitting. I haven't had two consecutive days off all year save for conslt months where we didn't come in on weekends (cards, renal, pulm). The big scheduling issue has been getting days off worked in on days no one has clinic or is post call, since those can be few and far between.
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deleted103644
I believe the rules in NY are stricter and prevent this. Rule 405 or something like that. I'm sure there's some flexibility, but believe we're guaranteed 1/7, not just 4/month.
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This still allows for a long time between days off. Say week 1 you have day 1 of 7 off, then week 2 you have day 7 of 7 off. That's 12 days between days off.
Anyway, my longest stretch was 28 days, sucked..
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I think q4 call with post call days Is a lot better than endless strings of night float, actually.
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Agreed. Our prior schedule for junior residents wasn't a strict q4 or q anything schedule, but typically it amounted to 1 (rarely 2) weekday calls and 2 weekends a month (one Friday/Sunday and one Saturday). Postcall days off were when I got my grocery shopping done, ran errands, went to the dentist, etc. I have no problem going with little or no sleep for one night when I can catch up the next day. Additionally, the typical arrangement was that if you were precall, if you had your service tidied up and everything tucked in, the oncall person would take the pager for you starting at around 4. Everyone did this for everyone, so it all evened out.
Now, with night float, I find that I am much more tired. I'm sometimes at the hospital a few hours less during the month but I'm there M-F 5a-6:30/7p. This leaves very little time for the rest of life. By the time I've tried to go to the gym/eat dinner/read a few pages/shower, its past my bedtime again and I feel more perpetually short on time and sleep than I ever did under the previous system. Still taking call two weekends a month, though now its either working straight through on days (but covering multiple services), working nights, or, in the case of our 2nd/3rd years, taking a 30-hour call on Saturday so the interns can work Friday night/Sunday morning. Its complicated, there are more handoffs, and you're typically taking call for services you are not otherwise seeing during the week (so you only see them every other weekend on call) which makes it MUCH harder to know the patients on those cross-cover services than it was when you took call at least one weekday every week.
Nightfloat is miserable IMHO because you are not really involved in the real care of the patients. You're the guy who puts out fires in the middle of the night, cleans up the crap that didn't get taken care of during the day, and you're always worried that any significant decision you make, if not specifically instructed on the possibility at signout, will interfere with the day team's overarching plan of care. I'm in Surgery and on nightfloat there are even fewer opportunities to be in the OR than usual for a junior resident. At my program nightfloat is Sunday-Thursday; you have every Friday & Saturday off, but I wasn't able to switch back to days for just 2 days and thus was wide awake when everyone else was ready for bed. Sure, I had "off" but it was a miserable lonely time.
I have done both overnight call and the system currently in place and I suppose everyone who has done both can have their personal preference - but IMHO the current system is far worse for junior resident fatigue and morale than "traditional" overnight call with postcall days off. We'll suck it up and make it work because that's what we do, but I would jump at the chance to go back to the old system and I suspect the majority of residents who have worked under conditions similar to my program's previous schedule would agree.
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At many places night float is 6 days in a row, not 5, only having off Saturday night, working 13 hours a night for a grand total of 78 hours on paper (assuming no end of shift Codes, etc) so what you describe isn't even the worst case scenario.
I agree with you, having worked under both systems, a few 30 hour shifts with post call days was a much better deal for residents.
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As everyone else has said, completely normal.
As far as 30 hour calls vs night float. I'm split. My program has strings of mole shifts in the ICU's, and then night float on the wards. Before the 2011 work hour rules, you just grouped your nights together - if there were 3 of you in the NICU, you did your 10 nights in a row, and you were done. Having to split those strings up and flip back forth between days and nights, much, much, much worse. For the wards, the night float month was not the best (and also got worse with the new work hour rules) but it made for a better year overall - as an intern when it meant you had 4 wards months without any overnights. As an upper level however, fewer wards months totally tips the cost/benefit ratio to crap. I'm ready to be a fellow and take overnight calls instead.
As far as 30 hour calls vs night float. I'm split. My program has strings of mole shifts in the ICU's, and then night float on the wards. Before the 2011 work hour rules, you just grouped your nights together - if there were 3 of you in the NICU, you did your 10 nights in a row, and you were done. Having to split those strings up and flip back forth between days and nights, much, much, much worse. For the wards, the night float month was not the best (and also got worse with the new work hour rules) but it made for a better year overall - as an intern when it meant you had 4 wards months without any overnights. As an upper level however, fewer wards months totally tips the cost/benefit ratio to crap. I'm ready to be a fellow and take overnight calls instead.
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All I know is I would MUCH rather have done things the way my program used to do it before the brainiacs at ACGME decided to screw up the whole system.
The 5 and 6 16 hour shifts back to back to back this year have been BRUTAL.
Really, inpatient medicine just blows no matter how you cut it, so it really doesn't matter in the end.
That said, I'd have rather done the old system. Q4 (or so) calls that were from 4:30pm to after rounds (noon).
Even 30 hour calls would have been better than this crap.
The 5 and 6 16 hour shifts back to back to back this year have been BRUTAL.
Really, inpatient medicine just blows no matter how you cut it, so it really doesn't matter in the end.
That said, I'd have rather done the old system. Q4 (or so) calls that were from 4:30pm to after rounds (noon).
Even 30 hour calls would have been better than this crap.
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deleted103644
I know there is evidence that doctors are more likely to make mistakes at the end of long shifts, but are there studies that take into account errors due to increased handoffs?
That's probably a more difficult cause of errors to pin down, but it seems like medicine is turning into a very dangerous game of telephone with the 16 hr restriction.
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There are a great many of us who HATE being in clinic and would pick being on inpatient wards any day of the week. In my mind clinic "just blows no matter how you cut it" and if forced to do that for the rest of my career, I'd have quit altogether. In the end, your viewpoint is irrelevant because the backbone of residency is always going to be inpatient wards and the ICU's. But that's one of the best things about medicine, those of us who want it can be hospitalists or critical care physicians and others can manage patients over the course of months and both groups will be happy with their choice.
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There are actually quite a few ongoing studies showing the opposite, as johnnydrama suggests. It's anything but "reasonably consistent". This is what is frustrating about ACGME continuing to talk about adjustments to duty hours. After the initial change (to 80 hours), the data didn't show appreciable decrease in errors, and after this more recent change, which is far far too early to evaluate scientifically, the results are very mixed, yet I'd bet ACGME isn't done tinkering. It's an "emperors new clothes" story -- the ACGME says reducing hours decreases errors and since it sounds reasonable folks go along, ignoring the naked guy, ie the fact that we have increased handoffs, decreased days off, increased the number of total switches in sleep cycle, and decreased the amount of didactics, attending interaction, and other educational opportunities folks get during intern year, all potential sources of errors. I think " reasonably consistent" is a very boldly questionable statement, at best you could be guardedly optimistic about some of the data, but absolutely do not swallow this thing hook line and sinker at this juncture like you seem to have done.
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And I'm thankful every day that there are folks out there that get a kick out of inpatient medicine, ER, etc...where the non-compliant frequent fliers dwell.
While some of the medicine subspecialties were interesting to me, there's no way in hell I would have subjected myself to 3 years of IM hell.
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I'm gonna go on a limb and say the evidence will show that the increased hand-offs, increased schedule flipping, and inconsistencies in continuity of care will be worse for patient care than any 30 hour call ever was.
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Maybe my intern year schedule was benign compared to most of y'all.
Had a transitional year (categorical resident).
I'm pretty sure I never worked more than 7 days consecutively. Always had 1 weekend day/week off on medicine. Worked 6 out of 7 days/week. Schedule was from 7am-4pm (I usually finished around 4 unless I was on q4 short call, which would put me in the hosp till 10-11p).
Surg... worked 6 out of 7 days with 1 golden weekend per month. hrs were around 14-16 hrs/day
Consults: M-F
ER: worked 3-4 consecutive shifts then had a few days off before another 3-4 consec shifts. Worked overall like 18-20 shifts?
Pain service: M-F
ICU: same schedule as medicine wards except no short call. 7-4p, work 6 out of 7 days, 1 wkend day off/wk
NF: work every other night from 4p-8a (i think i had 7 total nights in a 14 night span)
outpatient month: M-F and worked like 4-8 hrs a day
all rotations were 1 month long rotations. had 2 inpt med, 2 icu, 3 surg, 1 consult, 1 pain service, 2 wks NF, 2 wks anesthesia elective, 1 mo outpt, 1 mo ER
Had a transitional year (categorical resident).
I'm pretty sure I never worked more than 7 days consecutively. Always had 1 weekend day/week off on medicine. Worked 6 out of 7 days/week. Schedule was from 7am-4pm (I usually finished around 4 unless I was on q4 short call, which would put me in the hosp till 10-11p).
Surg... worked 6 out of 7 days with 1 golden weekend per month. hrs were around 14-16 hrs/day
Consults: M-F
ER: worked 3-4 consecutive shifts then had a few days off before another 3-4 consec shifts. Worked overall like 18-20 shifts?
Pain service: M-F
ICU: same schedule as medicine wards except no short call. 7-4p, work 6 out of 7 days, 1 wkend day off/wk
NF: work every other night from 4p-8a (i think i had 7 total nights in a 14 night span)
outpatient month: M-F and worked like 4-8 hrs a day
all rotations were 1 month long rotations. had 2 inpt med, 2 icu, 3 surg, 1 consult, 1 pain service, 2 wks NF, 2 wks anesthesia elective, 1 mo outpt, 1 mo ER
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Citations please. As far as I know there has been zero evidence that the new work hour restrictions reduce error.
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deleted103644
I'm not sure of the specific references, but there have been studies that proved pretty decisively that the error rate for a resident increased as they approached 30 hrs in the hospital.
Studies that have tried to show an advantage from reducing resident hours have so far been inconclusive, but there's no question that residents were making more errors at 30 hrs than at 10 hrs.
The increased number of handoffs is one possible reason why the theoretical advantage of the new rules have not appeared.
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I agree with you. But you need to compare that to an intern at say the end of night 3 in a row of nightfloat. Just because we have shown that people make more mistakes after 30 hours than 10 doesn't mean that we aren't replacing that with something even more unsafe for patients.
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I think a lot of us who now worked in both systems have seen from personal experience that there's at least as much, if not more, ball dropping in a night float system. The ACGME premise is wrong. Handoffs and lack of continuity of care have big roles to play in error rates, and folks doing endless weeks of 6 days in a row of night float and probably sleeping poorly during the days as they try to transition from diurnal to nocturnal hours end up far more tired than those missing a single nights sleep. So you still have very tired doctors, but now they know their patients less, and are working from more spotty information handed off to them. Sounds ideal.
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The simple answer to this is better handoffs. More and more private docs are going to shift work (hospitalists or various forms), and I think it would make more sense to practice and get good at patient handoffs in residency.
I was the last intern class that did 30 hour shifts, and having seen both systems its very much (as has been said before) six one way and half a dozen the other. Given how non-surgical specialities are trending in they way they deal with inpatient call, I think the new way makes sense.
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Saying "just do better handoffs" is equivalent to saying the powers in the Middle East should just sit down and work things out. It intuitively sounds reasonable but can't happen. They have been struggling with handoffs since th 70s. You have to give enough information that the person coming onto shift can do their job, but not so much that the handing off process cuts into duty hours. Bearing in mind that in the age of cross coverage, the handoffs can include 40 patients. Some fields lend itself to shift work, most don't. I think we have all seen things fall through the cracks at almost every handoff, so increasing numbers of handoffs necessarily increases this. And actually from my experience working with them, hospitalists are sometimes the worst offenders in terms of things slipping through the cracks, so I'm not sure I'd use them as the shining example of how handoffs can work.
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deleted103644
Better handoffs are possible with things like better implementation of EMRs, etc etc.
A lot of errors right now can be traced to something as simple as a typo in a Word document sign out.
A lot of errors right now can be traced to something as simple as a typo in a Word document sign out.
4
45408
I don't think our hospitalists sign out to each other at all, unless there's a CT pending or something.
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Couldn't agree more with your thoughts on this. Saying "just do better handoffs" is like saying, "just sleep more while on call" as a strategy to reduce fatigue-induced errors. I find it hard to believe residents are posting this stuff.
Night float at my busiest hospital involves caring for a list of patients that can approach 80 patients on different surgical services. Honestly, it is just impossible to know the patients in this environment. I try to make evening rounds on the sickest ones so I can at least review their charts ahead of time in case they head south. Otherwise it's just figure it out as you go. I don't see how this could be safer for patients, but I guess we're stuck with it now.
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All I know is when I call them about one of their patients who got admitted in a prior shift, they seem to know less than would the typical cross covering resident. I simply wouldn't use this as a shining example that shift work works.
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Its not my job to make your handouts more effective, you can figure out how to make them work for you.
We use an excel worksheet with pertinent labs/pending tests/consults/problems/and so forth. If we don't screw around, a 20 person list takes about 20-30 minutes. In the year we've been doing this, I can count on 1 hand the number of times I got called about a patient and didn't feel up to speed on what was going on.
In addition, the night float resident (me until yesterday) gets to know most of the patients after a day or so. This makes each check out easier as only updates are needed.
Now let me ask you something. At my wife's IM program, prior to the new rules, the 30-hour team still had to cross-cover the other teams' patients. They didn't have a combined rounds or a huge morning report... so how is that different from a night team in terms of continuity for those patients?
4
45408
That's a cop-out to make it look like he was trying to get you to do his work for him, when that wasn't the issue.
If you say "do better sign-out" when we're addressing a nationwide issue, then there needs to be a system-wide solution. If you don't have a solution, then you can't just say we need to do a better job and leave that as your solution to the problem.
And for the surgery programs that cross-cover 80 patients? Sign-out would take 80-120 minutes by your standard. That's not exactly going to help with work hours.
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I disagree with your second point (I wasn't trying to call anyone out). When the work hour rules changed last year, did every program do the same thing? No, each program worked out how to best use their residents to cover the work load.
In my first, lengthier response (which the hospital network ate), I had a bit about this not being as useful for really high volume services. Once again, this comes back to the idea of coming up with your own solution that will work with your particular situation. You don't want me trying to figure out how to make surgical rounds work more efficiently any more than I want a surgeon trying to make medicine rounds work more efficiently.
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I still think the "you need to come up with your own solution" line is a bit if a cop out. Sign outs have been an issue since the 70s. In 40 years nobody has figured out the perfect sign out, if in fact there is one. And since that time residents are carrying more patients, and there are now more sign outs per day. I seriously doubt your sign out system is the ideal, and as Prowler points out, what you describe takes way way way too long for settings with more cross coverage and sicker patients. So what if you have a system that works for a small volume of noncomplicated patients. You are basically saying communism works based on a kibbutz, while ignoring that it does not work in China or the Soviet Union. And I bet more things fall through the cracks even in your perfect system than you'd care to admit or if there were fewer sign outs. I think every system can be tweaked to a point, but when you work on fixing something for 40 years, with a lot brighter minds than you or I, and still have lots of systemic flaws, it might be time to take the view that it might be something that won't ever get a whole lot better. (hence my Mideast comparison).
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deleted103644
Proper signouts and good EMRs go hand in hand I think.
Too many residencies rely on poorly maintained word documents to pass critical information between shifts.
Too many residencies rely on poorly maintained word documents to pass critical information between shifts.
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I think in modern medicine, handoffs are a reality and we need to hone them like any other clinical skill. All of the medical information and decision making that used to exist physically and mentally with the primary physician is now being moved to documentation and EMR usage. I think there is an obligation to make training reflect the eventual practice of medicine, and under that I would put training physicians in patient management across multiple providers as an essential communication skill.
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