New Resident work hour rules and effect on Psych residency

[jokerabc]

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These new residency work hour rules by the ACGME is going to bring problems to the psych seniors. For example, all the programs in the local area are now going to be giving overnight call to 3rd and 4th years, something which they normally do not too. Because most psych programs are front -heavy. This is bad, as most of those residents put in their time for call, and all psych residents look forward to an easier schedule later years.

What are your psych programs doing to adapt to the new work hour rules? How is it affecting seniors?

 

[rss56]

I'm currently on the interview trail. Most of the places I looked at are hiring moonlighters or having their own residents do it was moonlighting to prevent a mutiny.

Though, many of them will be vague about what they are planning to do. They just say, "don't worry, we have a plan... we are figuring out"

These new residency work hour rules by the ACGME is going to bring problems to the psych seniors. For example, all the programs in the local area are now going to be giving overnight call to 3rd and 4th years, something which they normally do not too. Because most psych programs are front -heavy. This is bad, as most of those residents put in their time for call, and all psych residents look forward to an easier schedule later years.

What are your psych programs doing to adapt to the new work hour rules? How is it affecting seniors?

 

[sunlioness]

We switched to a Night Float system this past November that is staffed by R2s. We also no longer have 24/7 in house coverage.

 

[WhoisJohnGalt]

These new residency work hour rules by the ACGME is going to bring problems to the psych seniors. For example, all the programs in the local area are now going to be giving overnight call to 3rd and 4th years, something which they normally do not too. Because most psych programs are front -heavy. This is bad, as most of those residents put in their time for call, and all psych residents look forward to an easier schedule later years.

What are your psych programs doing to adapt to the new work hour rules? How is it affecting seniors?

You hit the nail on the head. This is *especially* bad for current PGY1's, who at many programs (including ours) are doing the brunt of their call this year, and who will likely receive the brunt of the call burden next year as well. I guess it had to be somebody, may as well be us 🙁 We have no plan, but will likely end up doing more NF as PGY2's and increasing the currently near-absent call burden for 3's, and will still possibly have to introduce 4's into the call pool for the first time ever. My program is definitely aware that mutiny is a possibility, which is why I think they're delaying the official announcement as long as possible. It sucks. If you ask me, these new guidelines are completely ridiculous for psych.

 

[Doctor Bagel]

We haven't heard an update in a while, so I don't know what's happening. The last plan I heard involved doubling the responsibility for R2s on night float and adding a few additional calls to R2s on a rotation that is traditionally call free. If this works, then R3s and R4s can remain out of the call pool, which honestly has a strong academic reason -- you want to be able to devote a significant time in your training to outpatient work.

We're poor, so I don't think hiring more people or moonlighting are options, which sucks. So next year is maybe going to be impossibly hard at times for my class, but hopefully 3rd and 4th year will be the same as they've been in the past.

 

[The Long Way]

At my program R1's provide the bulk of overnight coverage and the remainder is picked up by R2's. With the changes, my program investigated switching to a NF system that would be predominantly covered by R2's, but the amount of NF would be pretty brutal. In the end, I think that my program is just going to shift the brunt of call up one year. So...next year I'll be taking the bulk of the call again.

One concern that I have with all of this is that ACGME has explicitly stated in their most recent draft of the work hour rules that their expectation is that the level of responsibility is commensurate with the resident's level of training. Programs (like mine) that are simply shifting the bulk of call back to the R2 year may end up having to change again in a year or two if ACGME decides to further regulate the distribution of call. As it stands now, programs with R1 heavy call have their least trained and least experienced residents taking care of some pretty sick, high acuity patients, with the least amount of supervision... I don't think that it is too far fetched to think that the ACGME may put an end to this and that we may see further regulation down the road. If they mandate that the bulk of call be handled by senior residents, then the current R1 class could potentially handle the bulk of call throughout most of their residency. Not only does this suck for lifestyle considerations, but taking call is disruptive to clinical rotations and in my experience makes keeping up with my reading more difficult when I'm post-call.

Any thoughts on this?

 

[WhoisJohnGalt]

At my program R1's provide the bulk of overnight coverage and the remainder is picked up by R2's. With the changes, my program investigated switching to a NF system that would be predominantly covered by R2's, but the amount of NF would be pretty brutal. In the end, I think that my program is just going to shift the brunt of call up one year. So...next year I'll be taking the bulk of the call again.

One concern that I have with all of this is that ACGME has explicitly stated in their most recent draft of the work hour rules that their expectation is that the level of responsibility is commensurate with the resident's level of training. Programs (like mine) that are simply shifting the bulk of call back to the R2 year may end up having to change again in a year or two if ACGME decides to further regulate the distribution of call. As it stands now, programs with R1 heavy call have their least trained and least experienced residents taking care of some pretty sick, high acuity patients, with the least amount of supervision... I don't think that it is too far fetched to think that the ACGME may put an end to this and that we may see further regulation down the road. If they mandate that the bulk of call be handled by senior residents, then the current R1 class could potentially handle the bulk of call throughout most of their residency. Not only does this suck for lifestyle considerations, but taking call is disruptive to clinical rotations and in my experience makes keeping up with my reading more difficult when I'm post-call.

Any thoughts on this?

Agree with every word, and don't think anyone cares but our class. What makes me especially mad about all this is that it would certainly seem that the intent of the new regulations was NOT to take R1's out of the call pool but to provide them with adequate supervision and more reasonable hours. I don't know of any psych programs even *considering* increasing the level of supervision; it was certainly never pondered for a second at my program that the attendings would supervise the interns, though this would provide the best learning experience for the residents. Definitely frustrating.

 

[rpkall]

We switched to a NF system, 8PM - 8AM, for predominantly PGY2s but the plan is to have PGY2s do 4-5 weeks of NF, PGY3s doing 2 weeks, and then the remainder getting divvied up by lottery between 2s and 3s, or we're flirting with the idea of having 4th years do 1 week of NF each to clean up the rest of the weeks in the year.

The other shifts have been split into 12 hr blocks and are covered among 2s and 3s (Friday night--which is a longer shift from 5PM til 8 am Sat; Sat 12 hrs 8-8, Sat night overnight til 8 AM Sunday, and Sunday 8 AM -8 PM, then NF starts again Sun nite through Thursday night).

The hours from 5PM - 8 PM (when NF comes on during weekdays) are covered by a PGY1 resident on "short call" who is "supervised" by a PGY2 or PGY3 in house, who also serves as backup for that night but who would leave at 8 PM if backup is not needed. The PGY1 short call is from 5 PM - 9 or 10 PM so the transition is covered smoothly.


So.

My question is this..

As a current PGY2, I don't understand why no one wants to do call in PGY4 year. I get the argument about "frontloading" the residency with crappy intense experiences. But I guess I just feel like since so many residents are getting stuck doing multiple years of more intense calls, 4th years should be pitching in to help (i.e., the shaftedness should be spread evenly throughout the entire team). I'm not saying 4s should be doing nearly the same amt of call, but why can't it be something like a 4:2:1 ratio, among 2s, 3s, and 4s, respectively? Such as 4wks-5wks of NF for 2nd years, 2 weeks for 3rd years, and 1 week for 4th years?

If they let us take vacations on outpatient years, why can't the clinics cover the senior residents for those additional weeks as well?

I don't get it. I know it's an unpopular position to have. But it makes more sense to me to share the pain. No one resident's time off work (with family, friends, other enriching life experiences) is more or less valuable than another's.

 

[WhoisJohnGalt]

We haven't heard an update in a while, so I don't know what's happening. The last plan I heard involved doubling the responsibility for R2s on night float and adding a few additional calls to R2s on a rotation that is traditionally call free. If this works, then R3s and R4s can remain out of the call pool, which honestly has a strong academic reason -- you want to be able to devote a significant time in your training to outpatient work.

We're poor, so I don't think hiring more people or moonlighting are options, which sucks. So next year is maybe going to be impossibly hard at times for my class, but hopefully 3rd and 4th year will be the same as they've been in the past.

Ditto all this as well. *sigh* It really sucks to be us. It's somewhat comforting to know this is hitting other programs too. Just wish my program wasn't so dirt poor and tiny, which would probably allow us to handle this in a more humane way.

 

[WhoisJohnGalt]

We switched to a NF system, 8PM - 8AM, for predominantly PGY2s but the plan is to have PGY2s do 4-5 weeks of NF, PGY3s doing 2 weeks, and then the remainder getting divvied up by lottery between 2s and 3s, or we're flirting with the idea of having 4th years do 1 week of NF each to clean up the rest of the weeks in the year.

The other shifts have been split into 12 hr blocks and are covered among 2s and 3s (Friday night--which is a longer shift from 5PM til 8 am Sat; Sat 12 hrs 8-8, Sat night overnight til 8 AM Sunday, and Sunday 8 AM -8 PM, then NF starts again Sun nite through Thursday night).

The hours from 5PM - 8 PM (when NF comes on during weekdays) are covered by a PGY1 resident on "short call" who is "supervised" by a PGY2 or PGY3 in house, who also serves as backup for that night but who would leave at 8 PM if backup is not needed. The PGY1 short call is from 5 PM - 9 or 10 PM so the transition is covered smoothly.


So.

My question is this..

As a current PGY2, I don't understand why no one wants to do call in PGY4 year. I get the argument about "frontloading" the residency with crappy intense experiences. But I guess I just feel like since so many residents are getting stuck doing multiple years of more intense calls, 4th years should be pitching in to help (i.e., the shaftedness should be spread evenly throughout the entire team). I'm not saying 4s should be doing nearly the same amt of call, but why can't it be something like a 4:2:1 ratio, among 2s, 3s, and 4s, respectively? Such as 4wks-5wks of NF for 2nd years, 2 weeks for 3rd years, and 1 week for 4th years?

If they let us take vacations on outpatient years, why can't the clinics cover the senior residents for those additional weeks as well?

I don't get it. I know it's an unpopular position to have. But it makes more sense to me to share the pain. No one resident's time off work (with family, friends, other enriching life experiences) is more or less valuable than another's.

If you were a current second or third year, would you want to increase your call burden? At least at my program the issue is being outvoted. There's 1/3 of our class to 2/3 of their classes, and of course they're all going to say let's keep it "front-loaded" because then they get by with less call. I don't know if I blame them or not; I'd really like to think that if I were in their position I would recognize the shaftedness of our class and try to help at least a little, but it's hard to say when I'm not in that position and obviously have my own vested interest in wanting them to help with the burden. Considering how little the fourth years work at my program, it's hard to imagine that I wouldn't prefer to have a little call 4th year vs. having even-more-intense call 2nd year, but unfortunately I don't think I'll really get the choice.

 

[rpkall]

I'm in the same position. I've been pretty vocal at my program that I feel 4th years should split NF 4:2:1 with us and feel they should be included in the pool for the remainder of the piddly little shifts (short calls, weekend 12 hr shifts), because this makes a *significant* difference in the call frequency for the PGY2s and PGY3s, especially for weekends (i.e., including PGY4s in the weekend call pool makes it so we all have call 1 out of every 4 (or 5 weekends if you get lucky), vs 1 out of every 3 weekends guaranteed).

I want to think that when I get there, I'll vote to do some NF and be in the call pool as a 4th year (I honestly think I will), because I'm kind of tired of the "well, I paid my dues" attitude and feel that call should be more evenly distributed---especially since we all as a group got blindsided by these new regs. Half of our residents have families, and I don't subscribe the idea that a 4th years "off-time" is more important than the "off-time" of a PGY1, 2, or 3 (especially if some residents are going home to be parents). And even if a 1, 2, or 3 isn't a parent--it doesn't mean that their time to decompress and engage in other activities is any less important either (playing Wii, seeing friends, traveling to see family, or studying to expand their knowledge base). And the most stressful rotations, where we see burnout a lot, are acutally the intense inpatient rotations in PGY2 year, when we need time away from work the most.

 

[Suedehead]

I want to think that when I get there, I'll vote to do some NF and be in the call pool as a 4th year (I honestly think I will), because I'm kind of tired of the "well, I paid my dues" attitude and feel that call should be more evenly distributed---especially since we all as a group got blindsided by these new regs. Half of our residents have families, and I don't subscribe the idea that a 4th years "off-time" is more important than the "off-time" of a PGY1, 2, or 3 (especially if some residents are going home to be parents). And even if a 1, 2, or 3 isn't a parent--it doesn't mean that their time to decompress and engage in other activities is any less important either (playing Wii, seeing friends, traveling to see family, or studying to expand their knowledge base). And the most stressful rotations, where we see burnout a lot, are acutally the intense inpatient rotations in PGY2 year, when we need time away from work the most.

Really, it seems like a matter of delaying gratification. The work has to be done. the question then is.... do YOU want to take call your 4th year? you'll likely so yes now, but when fourth year comes and you're looking for jobs etc, etc, etc... I don't know.

 

[rpkall]

Really, it seems like a matter of delaying gratification. The work has to be done. the question then is.... do YOU want to take call your 4th year? you'll likely so yes now, but when fourth year comes and you're looking for jobs etc, etc, etc... I don't know.

True, true. I don't know. I want to say yes. I guess we'll have to see when I get there.

 

[billypilgrim37]

"No call 4th year" or "No call 3rd and 4th year" are pretty important statements to be able to make when you're recruiting. And the more call you have in upper level years, the less moonlighting opportunities will be available to you. In a scientific study I just made up, 85.7% of folks with any sense will prefer to heavily frontload. And while some people have kids before residency, the vast majority of psych residents start breeding around 3rd year. If you had them earlier, well the rest of us cannot be held accountable for your shameful lifestyle decisions. Yes, I'm kidding.

 

[sunlioness]

This seems to be a perrenial issue ACGME regs aside. I remember in my 4th year we had one junior resisdent out on some sort of leave and 2 others who needed reduced call for various reasons that I am not remembering. The call burden in our small program was then falling disproportionately on a small number of PGY-1s and 2s. They felt crunched. We had a meeting to discuss it in which the juniors asked for seniors to alleviate the burden by taking some of the calls. The PD left it up to the seniors to decide whether they would do so or not. By and large the seniors felt that the juniors should suck it up. They remembered a similar instance a few years prior with a maternity leave situation in which they had faced similar circumstances and the seniors hadn't bailed them out either. I was the only senior who volunteered to take call. I'm not trying to toot my own horn and I think I may actually be too accomodating at times, but I did do so once or twice.

I've just kind of always thought the kneejerk, "I did it so you need to just get over it and do it too" to be not a particularly admirable one. If there are valid reasons for frontloading call (and it's true that there are), that's one thing.

It was interesting doing those calls. Since I had been a junior, the inpatient hospital had gone from paper charts to EMR while the outpatient offices had not. I actually forgot about that when I volunteered. I had been trained on the program with everyone else, but had never actually had to use it. So the first part of my call involved being on phone with the help desk to first re-obtain my login information (that I had forgotten) and then reset my expired password. It was an adventure. I was later comped a vacation day for having done that, which I appreciated greatly but that wasn't part of the original deal.

As for the idea of attendings supervising PGY-1s overnight? That's not going to happen. Unless it's like it was where I did my IM internship in which they had an in-house hospitalist/moonlighter who took over that responsibility because they were there anyway. In a field like psychiatry where 24/7 in-house attending coverage is not generally done or needed, I don't really see that happening.

 

[kugel]

What makes me especially mad about all this is that it would certainly seem that the intent of the new regulations was NOT to take R1's out of the call pool but to provide them with adequate supervision and more reasonable hours. I don't know of any psych programs even *considering* increasing the level of supervision; it was certainly never pondered for a second at my program that the attendings would supervise the interns, though this would provide the best learning experience for the residents. Definitely frustrating.

This has been my question all along. I would be happy to take call 1-2x per month to supervise students/interns. I was so terribly frustrated as an intern that I was making the decisions on the most acutely ill with my only supervision being an attending by phone (most of whom hadn't taken ER call in over 20 years). Because I'm a devious SOB, I quickly developed a ruse to justify contacting a supervisor I trust more when I thought the scheduled phone-attending wasn't making any sense and the outcome wouldn't be safe. I believe most of my peers and I learned "how to get through the night with the fewest problems and stay out of trouble," but nothing useful about treating patients. Mostly, I think it produced a disdain for patients. Not a great paradigm.

But at least as important as the supervision issue, I learned NOTHING from attendings while on-call as an intern, because they only wanted to go back to sleep. As a R2, our rules changed and the attending had to be on-site for at least 4 hrs during call (5pm-9pm). That meant that we TALKED about every case and I got to see multiple interview styles, multiple treatment styles, and got to apply what I was learning in didactics to acute cases. THAT was valuable! In addition, it meant that many attendings got to spend at least 4 hrs with me and 1 student. They got to see my rapport with patients, my interview skills, my diagnostic and treatment skills, my relationship with the rest of the team, and my teaching of the student. And they nudged me along on each of those issues. That did not happen anywhere else in the program.

I always thought that would be part of the fun of being an attending!

 

[Doctor Bagel]

Having an attending house for the early evening would be good. I think that's a consideration for my program for 1st years, and that's something that seems educationally valuable. I'm not sure I want a whole lot of teaching in the middle of the night, though. I've got to admit my goal is like the attendings you call in that I want to get back to bed, too.

Getting back to what sunlioness said about dropping 24/7 coverage, I'm curious how that looks. I know at my medical school program, they did not provide 24/7 coverage for C/L, and so far in my internship year, I haven't seen a reason why we need 24/7 coverage. I just got off a call where I felt like the service was essentially abused by the ED staff in that I got called for consults in the middle of the night, just so they could check off a box saying they consulted psychiatry. My ward consults in the middle of the night have all been delirium so far, which internships and surgeons should be able to deal with. Knowing that none of the hospitals in the city I went to medical school in had 24/7 psychiatry c/l service, I just wonder if it's a service most programs need to continue to offer, especially when lots of us are looking at busier calls with first years not on overnight.

 

[Doctor Bagel]

Bumping this thread:

Any other updates from residents out there about how your program is handling these changes? Are you satisfied with the amount of information you've gotten, and do you feel well-included in the conversation? Are the changes fair to lower levels in the program?

 

[MDchouette]

Bumping this thread:

Any other updates from residents out there about how your program is handling these changes? Are you satisfied with the amount of information you've gotten, and do you feel well-included in the conversation? Are the changes fair to lower levels in the program?

My program has handled this in a transparent manner with much resident involvement and feedback. They are going out of their way to be fair to all residents, and it's made me proud to be at my program. We will go to a 5-night nightfloat system for PGY1s, and one month of medicine will be replaced by one month of psych nightfloat. I think there will be additional calls for the PGY1s to cover the weekends, which will mean 4 PGY1s will need to be "on" at some point during each weekend. This isn't ideal but I think the PDs and residents involved decided it was easier than doing a 6-night nightfloat system. I don't know whether they have explored having 2 PGY1s cover the weekend (one on days and one on nights). I have the impression that there will be a slight added call burden for PGY2-3s (not sure about 4s) to provide supervision as needed to the 1s. I've been off service for the last few months so I'm not totally up to date.

There are a number of elements of our program that made this transition easier: (1) PGY1s and PGY2s take call at the same location, so there is already some supervision built into the program; (2) we had some medicine months to spare in exchange for nightfloat; and (3) our program is larger.

DoctorBagel, I'm sorry to hear what's happened with your program. Sounds like you've taken the right steps with approaching the PDs as a class.

 

[Doctor Bagel]

My program has handled this in a transparent manner with much resident involvement and feedback. They are going out of their way to be fair to all residents, and it's made me proud to be at my program. We will go to a 5-night nightfloat system for PGY1s, and one month of medicine will be replaced by one month of psych nightfloat. I think there will be additional calls for the PGY1s to cover the weekends, which will mean 4 PGY1s will need to be "on" at some point during each weekend. This isn't ideal but I think the PDs and residents involved decided it was easier than doing a 6-night nightfloat system. I don't know whether they have explored having 2 PGY1s cover the weekend (one on days and one on nights). I have the impression that there will be a slight added call burden for PGY2-3s (not sure about 4s) to provide supervision as needed to the 1s. I've been off service for the last few months so I'm not totally up to date.

There are a number of elements of our program that made this transition easier: (1) PGY1s and PGY2s take call at the same location, so there is already some supervision built into the program; (2) we had some medicine months to spare in exchange for nightfloat; and (3) our program is larger.

DoctorBagel, I'm sorry to hear what's happened with your program. Sounds like you've taken the right steps with approaching the PDs as a class.

Thanks for your reply. I'm glad to hear your program is handling this fairly and really including you guys in the dialogue. You know, in the long run things probably will work out at my program. It's just that recent stuff (like releasing a call schedule that violates ACGME rules) have really crystallized how troubled I am by the lack of communication with us regarding these changes. It just seems like psychiatrists of all people should get that poor communication leads to frustration and anxiety.

 

[WhoisJohnGalt]

Bumping this thread:

Any other updates from residents out there about how your program is handling these changes? Are you satisfied with the amount of information you've gotten, and do you feel well-included in the conversation? Are the changes fair to lower levels in the program?

As near as I can tell, our program is screwing my class six ways to Sunday. Initially we were given all this crap about how the dean of medical education would support us doing whatever we were able to do that was still educational for us and would ensure that the hospitals took care of what was left over, so there was talk of our call ending at 9pm. In that scenario, the 3's were willing to take a slightly increased burden from what they were expecting, and with the decreased burden in general, it would have been somewhat doable for us to cover the rest though we would still have gotten screwed. Now the talk is that our chair isn't willing for our call to stop at 9pm, and the to-be 3's are backing off of what they agreed to, so I wouldn't be surprised if we've got 5 PGY-2's pulling Q5 for the year, which is worse than we're doing now. They seriously might lose residents if they go through with this. I'm jut so fed up with it... the unfairness, the assumption that our class should shoulder all the burden, the lies, the lack of communication from the administration, the passiveness that has caused NOTHING to be discussed about this from the administration standpoint until now, when there's not time to put anything in place other than screwing the residents... ugh. Sorry for the vent. Just not a good situation at our program right now.

 

[keep]

The last thing I heard from our program director and other people here was that Sub-comitee of ACGME (Psychiary) will make the final guidelines based on general rules like whether direct supervision is needed etc. It was supposed to be in Macrh, 2011. Anybody heard anything about that esp Program directors? I do not understand why everybody is rushing to make changes wihtout having the final version of ACGME rules/guidelines.

 

[Doctor Bagel]

As near as I can tell, our program is screwing my class six ways to Sunday. Initially we were given all this crap about how the dean of medical education would support us doing whatever we were able to do that was still educational for us and would ensure that the hospitals took care of what was left over, so there was talk of our call ending at 9pm. In that scenario, the 3's were willing to take a slightly increased burden from what they were expecting, and with the decreased burden in general, it would have been somewhat doable for us to cover the rest though we would still have gotten screwed. Now the talk is that our chair isn't willing for our call to stop at 9pm, and the to-be 3's are backing off of what they agreed to, so I wouldn't be surprised if we've got 5 PGY-2's pulling Q5 for the year, which is worse than we're doing now. They seriously might lose residents if they go through with this. I'm jut so fed up with it... the unfairness, the assumption that our class should shoulder all the burden, the lies, the lack of communication from the administration, the passiveness that has caused NOTHING to be discussed about this from the administration standpoint until now, when there's not time to put anything in place other than screwing the residents... ugh. Sorry for the vent. Just not a good situation at our program right now.

Ugh, that stinks. Bad communication makes it all worse, and it sounds like you guys really are getting screwed. So why would the chair object to you guys ending call at 9 provided the hospital is OK with it? I think we all know there's not a ton of educational value in staying on call after 9, especially for you guys who have tons lots of overnight call already. Is it money?

And yeah, our program seems to operating under the idea that our class should get hit with most of the burden, too, which really does seem wrong. We're all going to be hit by this, but spreading it out makes it so much more palatable.

And about losing people, I'm also wondering how many people in our class at various programs are thinking about jumping ship because of worries about next year. When I saw the call schedule my program released for the next 3 months, I actually went and looked at vacancies, thinking that I have no idea what horribleness is in store for us.

 

[Doctor Bagel]

The last thing I heard from our program director and other people here was that Sub-comitee of ACGME (Psychiary) will make the final guidelines based on general rules like whether direct supervision is needed etc. It was supposed to be in Macrh, 2011. Anybody heard anything about that esp Program directors? I do not understand why everybody is rushing to make changes wihtout having the final version of ACGME rules/guidelines.

My understanding is that whatever the sub-committee decides, certain elements of the ACGME changes are already for certain. Those elements are the 16 hour call for interns, and the supervision issue (with the need for in-house direct supervision). I don't think the sub-committee would have the power to get around that.

 

[Cinnameg]

Ugh, that stinks. Bad communication makes it all worse, and it sounds like you guys really are getting screwed. So why would the chair object to you guys ending call at 9 provided the hospital is OK with it? I think we all know there's not a ton of educational value in staying on call after 9, especially for you guys who have tons lots of overnight call already. Is it money?

And yeah, our program seems to operating under the idea that our class should get hit with most of the burden, too, which really does seem wrong. We're all going to be hit by this, but spreading it out makes it so much more palatable.

And about losing people, I'm also wondering how many people in our class at various programs are thinking about jumping ship because of worries about next year. When I saw the call schedule my program released for the next 3 months, I actually went and looked at vacancies, thinking that I have no idea what horribleness is in store for us.

Dr. Bagel, were you looking at other specialties, or at vacancies elsewhere in psychiatry? I don't think things are a lot better in other specialties right now. Most programs in psychiatry didn't seem to know what they were doing to meet the new requirements either, at least as of my last few interviews in January. Some have emailed updates to their applicants, but only those with good news, mostly proclaiming a new night float system.

 

[toothless rufus]

Aw man, it sounds like the new rules have made what I thought was once awesome into a true horror for psychiatry residency! Waaaaaaah!!

 

[Doctor Bagel]

Cinnameg, other psych programs. It's not that serious of a thought, but it's nice to know you have options.

Update, emailed my PDs on Friday about concerns about next year and about the recently released call schedule for the next 3 months. No replies. Awesome. 🙄

 

[digitlnoize]

Sounds like it's time for a year off for "research."

 

[Doctor Bagel]

Updates on my end. We did get invited to a meeting of the work hours committee. Also, just met with my classmates tonight, and we realized some positive goals of these changes. Traditionally my program is heavily front-loaded, which leads to a decent amount of burnout and negativity both in the members of the primary call pool and those who've escaped the primary call pool. We're setting a goal of moving toward a culture of less pressure on people in early years (this will definitely happen with the first years next year) and consequently less burnout and apathy in the upper years, which might lead to a program where people are more involved with helping others in the program.

To me it's really clarified the downside of front-loaded programs. If you front-load them too much (which maybe we've been doing all along), first and second year are miserable, and people go into 3rd and 4th feeling resentful about all the work they did (and lack of support they got) 1st and 2nd years, perpetuating the whole problem.

 

[notdeadyet]

Thanks, Doctor Bagel. I've been following this thread with interest.

In looking at residency programs, and in speaking to residents, I prefer programs that are front-loaded with call in the PGY1 and PGY2 years. Most of the psych residencies I've been interested in have had the toughest amount of call in PGY1 with a somewhat heavy PGY2 and light PGY3 and PGY4. This set-up is attractive to me because it allows for convenient moonlighting in PGY3 and PGY4.

The latest changes that programs are struggling to accommodate seem to really have the biggest impact on current PGY1's, as they are going to find themselves getting double-dipped. They had the traditionally heavy call schedule in PGY1 and now will have a new heavy call schedule in PGY2 while the incoming residents will have a lighter PGY1 than they had. That's a bummer.

But outside of the current PGY1's (who are understandably upset), I'm wondering who is really getting hit hard by all of this. For new residents, it just looks like there will be an easier PGY1 and harder PGY2, which seems to pretty much equal out at the end.

I'm holding off any inquiries until I found out where I match, but I'm really hoping that programs don't start making PGY3 and PGY4 more call heavy for the sake of making a lighter PGY2. At the end of the day, I want PGY3 and PGY4 to be light. Most incoming residents and senior residents I've talked to seem to want to preserve PGY3 and PGY4 as well.

But again, my condolences to current PGY1's. It's a rough place to be. Hope programs pony up to make this transition easier on you through bringing on additional moonlighting or a palatable nightfloat.

 

[Doctor Bagel]

You know, I don't think the incoming people are going to be that hurt by this stuff. Instead, they're just have different expectations, and probably a call free 3rd year isn't going to be feasible at practically any program.

The people who are really getting hit are those in my class (hence my negativity, and honestly my desire to get some special inclusion in conversations about the duty hours) and current PGY2s. Here, the PGY2s have suffered through two pretty brutal call years (psych call isn't as frequent as medicine call, but is hard it its own way), and they really are going to have to deal with more call than previous classes in 3rd year. Current 3rd years might get hit with more backup call work, which is a natural consequence of stretching the call pool too thin.

And about the front-loading, I really felt the way you did, NDY, and wound up picking one of the most front loaded programs I interviewed at. Now I'm really not so sure it's a great idea, although, yeah, it does free up time for moonlighting. Honestly, though, learning psychiatry, even inpatient psychiatry, is pretty difficult when you're on call so much.

 

[notdeadyet]

Hang in there, Doctor Bagel. Hope your program comes up with a solution that's palatable for you...

 

[snowball1]

What are the 1s going to be doing? Is there daytime weekend attending coverage? Is it feasible to give a 2-onwards the Friday and Sat Night shifts while giving the 1s the Saturday and Sunday day shifts?

 

[Doctor Bagel]

So updates from life (and probably things I shouldn't be posting)

1. my classmates are awesome
2. the other residents in my program are largely awesome (we don't have to worry about current 2nd years refusing to do call next year -- they're actually offering to help us out)
3. my attendings are pretty great, and I'm getting a good education

and 4. our administration doesn't really care that much about the concerns of my class (or at least they are doing a very poor job or showing concern if they do care), and I'm feeling a pretty huge amount of disappointment in that because everyone here presents themselves as being really open.

 

[Doctor Bagel]

What are the 1s going to be doing? Is there daytime weekend attending coverage? Is it feasible to give a 2-onwards the Friday and Sat Night shifts while giving the 1s the Saturday and Sunday day shifts?

Here the ones are going to be doing short call weekday shifts because of the supervision issue. We don't have enough residents to have a junior and senior on call at the same time, and faculty has about zero interest in staying inhouse extra on weekends or overnight.

As WIJG noted above, the true shame is that these reforms were designed to improve supervision for interns. Instead, they're just cutting interns out of the call pool, and shifting work upwards.

 

[snowball1]

I haven't done too many rotations in hospitals that don't have dedicated psych-ERs (and the extensive attending coverage that seems to come with it), so maybe this is very ignorant... but don't you need an attending to admit a patient? Or does that get done over the phone? Is this a common thing?

And does ACGME want in-house supervision during the duration of the call or just until admissions/etc get sorted out? Or is that up in the air still?

 

[Doctor Bagel]

I haven't done too many rotations in hospitals that don't have dedicated psych-ERs (and the extensive attending coverage that seems to come with it), so maybe this is very ignorant... but don't you need an attending to admit a patient? Or does that get done over the phone? Is this a common thing?

And does ACGME want in-house supervision during the duration of the call or just until admissions/etc get sorted out? Or is that up in the air still?

Yeah, that's very different. We don't have a psych ED, and consequently, we don't have psych faculty inhouse except during normal working hours. Programs like those you've rotated at are probably much better off when it comes to shifting to the new rules.

As for the timing of supervision, I believe it needs to be for the whole duration of the call. You can't really predicts when admissions are going to happen, so someone needs to be there immediately. We also cover the psych ward when we're on call, so presumably first years would need immediately available supervision for any issues that might arise there, too (actually those can be the tougher issues than dealing with admissions).

 

[SpiritiualDuck]

As a 3rd year, rising 4th year, I'm sympathetic to the first year residents having to carry more work during their 2nd year.

It's tough, because I have mixed feelings about this. My first year was hell, 2nd year was rough too. And I held on knowing that I had a light 4th year to be with my family, to do electives, and to travel for interviews and to take on some Chief duties. So, the idea that I'd have to go back to doing more call just doesn't sit that well and I know that this is not the fault of the program and beyond our power to change, but it still just bothers many of us.

I also have to admit that I would have liked to have had senior support as an intern. My first month was hell. I was scared many nights.

 

[Doctor Bagel]

As a 3rd year, rising 4th year, I'm sympathetic to the first year residents having to carry more work during their 2nd year.

It's tough, because I have mixed feelings about this. My first year was hell, 2nd year was rough too. And I held on knowing that I had a light 4th year to be with my family, to do electives, and to travel for interviews and to take on some Chief duties. So, the idea that I'd have to go back to doing more call just doesn't sit that well and I know that this is not the fault of the program and beyond our power to change, but it still just bothers many of us.

I also have to admit that I would have liked to have had senior support as an intern. My first month was hell. I was scared many nights.

So yeah, it's just all around hard. Overall, I guess things will even out and be good for the incoming class, but for those of us who've invested lots of time in the old system, it stinks to have to do even more later.

 

[Lauraaa]

I am optomistic about the changes. I don't know how it will pan out in the end but this is what I think would be a good fit for our program - cutting down on the R2 rotations each by a few days, introducing a new rotation that is R2 night float from 10-8am. From 5-10pm will be a R1 and R2 short call. Their shift could by til 10 but they could stay in house up til midnight if needed to help out the R2 float who comes in from 10pm til 8am. They would still be able to get a total 8 hours between shifts. During the night, the R2 will be alone but will have a R1 and a R3 on in home back-up to call if needed. If this is the case, the R1 can come in at 1am and then stay til 4pm that day. This way there are never any R1s or R2s post - call. This will not be too much fun for the R1 if they get called in, but on the other hand, the total number of being in house call for both R1 and R2 will be reduced AND both will get to attend post call rounds, where I feel like a lot of learning takes place. 🙂

 

[flash]

I think optimism is reasonable, too, Laura! Cautious optimism 😉 I think as a soon to be PGY1, we'll embrace things fine, we really didn't know better/worse, and, I prefer the new rules from an outsiders perspective. But I really feel for the residents who had 'the game' changed on them during training (particularly soon to be PGY2s it seems). It should depend a great deal between programs, no? E.g., if psych attending already onsite, the new rules change the call schedule/structure/work hours (think). But for those programs without onsite docs, the change is a bigger deal. Attendings, like most people, don't like change 'insisted' on them. I assume for some programs, cost of staffing might be an issue.

 

[Doctor Bagel]

I agree that the rules were designed to improve education and patient safety, and that the long-term effects of them can be really good. For the next few years, I think the positive gains made in my program could be causing less burnout amongst early year residents (sleep deprivation and negativity aren't so hot for education). Also, I feel like the lower level residents in my program have really come together and are willing to help each other out without any tallying or "I did mine, I don't care" type of attitudes.

Just attended a meeting with the duty hours committee and having mixed feelings about it. The biggest bad thing -- some of our administration basically said it's OK to count a post-call day as your day off for ACGME requirements. It might maybe be legal (not sure), but hell, most surgery programs don't even do that. I think having work conditions like that would officially put us into sweatshop territory. Other less bad thing -- it seems like they've made up their mind that we should bear the strong burden of the excess work, coupled with some not so logical justifications (for example -- 3rd years shouldn't have excess call that would interfere with clinic; reality is that night float will cover all weeknight services anyway).

Better things, they were already planning on incorporating 3rd years somewhat into the primary call pool anyway. They also agreed to have more frequent communication.

 

[WhoisJohnGalt]

Also, I feel like the lower level residents in my program have really come together and are willing to help each other out without any tallying or "I did mine, I don't care" type of attitudes.
.

I'm so glad your program is skipping this part. Ours is FULL of that-- when discussing holiday call, at one point a PGY2 said "I've already done my holiday call and told my family I'd never have to do that again!" (Well, what do you think WE told OUR families??) There's definitely tons of tallying and "it was so much worse for us, you should be grateful" being thrown around here. All the inter-class bickering is definitely making this worse. Our program is really falling apart over all this 🙁 I really hope there's at least some decision made soon. Not that I would know, since the communication with us about this issue from the powers-that-be has been non-existent. Ugh.

 

[billypilgrim37]

Aren't some of you going to night float? My program has basically just converted to a night float with the interns (something that residents had actually proposed several times over the last few years anyway), second year call has remained essentially the same, and our call-free 3rd and 4th years are still free to moonlight until we pay off our gambling debts. We are a big program with our sights close together, so we may have been in a👎 unique situation to be able to weather this well. It sucks that some of you, already at the height of burnout and emotional destruction, are forced to face the prospect of things hurting more and for longer than they already did. 🙁

 

[notdeadyet]

Aren't some of you going to night float?

Most programs I interviewed at indicated that they were planning on doing something very similar to what you describe. Seemed logical enough.

 

[Doctor Bagel]

I'm so glad your program is skipping this part. Ours is FULL of that-- when discussing holiday call, at one point a PGY2 said "I've already done my holiday call and told my family I'd never have to do that again!" (Well, what do you think WE told OUR families??) There's definitely tons of tallying and "it was so much worse for us, you should be grateful" being thrown around here. All the inter-class bickering is definitely making this worse. Our program is really falling apart over all this 🙁 I really hope there's at least some decision made soon. Not that I would know, since the communication with us about this issue from the powers-that-be has been non-existent. Ugh.

We are definitely hearing some of this stuff for 4th years, who apparently got majorly screwed when they were first years (having to cover 1.5 months of inpatient psych while down a resident with no assistance from upper levels). Unfortunately, I think some of their bitterness about this horribly unfair experience is shaping their views in regards to a call schedule for the next 3 months when we're down a resident in the primary call pool.

Luckily, though, the 2nd years are great. Both classes are hoping that moving forward we can change the culture to one where people reasonably jump in to help others.

As for nightfloat, we already have a system for our university side. We won't have inhouse supervision for 1st years, so nightfloat would have to be staffed by R2s or above anyway. Apparently they are expanding the nightfloat coverage (done by one resident) to the VA with plans of significantly reducing the oncall responsibility on the VA side.

That still leaves weekends, though. It's been determined that the weekends require one person covering each location (VA and university). Since the goal is to keep upper levels largely out of the call pool, that leaves 2nd years covering almost all the weekends all year. The system requires 4 people to be on call in a given weekend, and we have 8 people in our class (one of whom will be on nightfloat). That's where it gets tight.

 

[WhoisJohnGalt]

Aren't some of you going to night float? My program has basically just converted to a night float with the interns (something that residents had actually proposed several times over the last few years anyway), second year call has remained essentially the same, and our call-free 3rd and 4th years are still free to moonlight until we pay off our gambling debts. We are a big program with our sights close together, so we may have been in a👎 unique situation to be able to weather this well. It sucks that some of you, already at the height of burnout and emotional destruction, are forced to face the prospect of things hurting more and for longer than they already did. 🙁

Night float is the obvious choice for larger programs, but it doesn't really help our situation all that much because we only have one person covering all of our sites. 1's are out of the call pool since they can't be on by themselves, and 3's can't do night float because they need "12 un-interrupted months of outpatient" (which we do in the 3rd year), and of course 4's don't want to do night float and we certainly don't want to do night float when we're 4's (especially since some classes only end up with 1-2 R4's when everyone else fast-tracks to child). So that leaves the 4-5 R2's to cover 12 months of night float. 3 months of night float in one year is a pretty arduous proposition, particularly when during the 9 months you're NOT on night float, the 2's would be covering the weekend, again as Dr Bagel mentions essentially every other weekend. So it would really be asking more of us than we're doing right now during intern year, which already feels pretty overwhelming.

 

[Doctor Bagel]

So apparently the psychiatry RRC (or whatever it's called) has modified the supervision requirement so interns can work with direct supervision available (not immediately available) after the program signs off and says they have sufficient competency to do so.

We're hoping maybe we can use 1st years on our 12 hour Sunday call shift after about a month or so of direct supervision. If so, it'll make our lives much easier.

WIJG, maybe this can relieve some of the stress of your program, too.

 

[DD214_DOC]

We switched to a NF system, 8PM - 8AM, for predominantly PGY2s but the plan is to have PGY2s do 4-5 weeks of NF, PGY3s doing 2 weeks, and then the remainder getting divvied up by lottery between 2s and 3s, or we're flirting with the idea of having 4th years do 1 week of NF each to clean up the rest of the weeks in the year.

How do you cover the one or two days per week not covered by night float?



Our interns are likely doing a combination of NF and short call/weekend call. Interns last year did only short call. My class did overnight call around q10. Our PGY2-4 all are in the overnight call pool. Somehow the 3+2 child fellows are exempt.

How many ER consults are you guys getting per night? We average about 4 to 6 but have had nights of 10-15 around once or twice a month. Our note requirements are full intake notes on all consults so it eats up a ton of time. Wards are usually pretty quiet.

 

[Doctor Bagel]

Bumping an old thread with updates from my program. Good news, I think maybe our new schedule will work, and we'll overall do less call than people did before.

Big changes for us:
- no longer doing admissions on the VA side from the ED. The ED attendings will decide who to admit. We'll enter orders. Still consulting, though, so the question is if they'll consult us on everyone. Or just admit everyone until we're full. 🙄 Positives from this, though -- I think we were overburdened in our call duties by covering two different hospitals with only 12 residents doing all the call. Offloading some burdens is a win. Downside, we're losing our one site where we make decisions about admissions, so that will have to be considered somewhere.

- Night float will cover both the university and the VA. See above about the VA changes that will make this flexible. All 2nd years do 6 to 7 weeks of nightfloat (5 nights/12 hour shifts). With above changes, hopefully doable.

- streamlining of work flow for weekends/overnight. Based on night float covering so much, the NF resident will be encouraged to be brief with admits. Developmental history can wait for the morning.

- Based on night float taking over VA coverage, no more overnight weekday call. In the past, residents averaged q5 call when on VA services (3 months of first year, 4.5 months of 2nd year)

- call shifts will be weekday 3 hour short calls from 5 pm to 8 pm, overnight Friday, 24 hour Saturday and 12 hour 8 am to 8 pm on Sundays/holidays.

- interns will cover almost all the short calls and the 12 hour Sunday shifts

- 2nd years will do NF and most of the weekend calls, which works out to working about 2 out of 4 weekends (one Saturday and one Friday). 2nd years will also do backup calls for a few Sundays at the start of each rotation. 2nd years will also be in the call pool for the whole year. Up until now, our 3 months at the state hospital in 2nd year were call free.

- 3rd years average out to about 1 overnight call/six weeks (I think).

- attendings will be inhouse with interns for their first several shorts calls

- adding an inhouse all day attending at our university site. In the past, the attendings on the university side did supervised in the morning and saw their own clinic patients in the afternoon.

So overall, lots of changes, and maybe a pretty miserable night float experience. Less overnight call, though, and 3rd and 4th years are still kept largely out of the primary call pool. Downsides/upsides -- interns get less early autonomy and more direct supervision. Wards might be busier, too, since NF will be doing a less thorough admission than previously. I got to say, though, my call schedule doesn't look too bad, so I think I'm OK with it.

How about everyone else? Things working out OK or are 2nd years still getting screwed elsewhere?