overnight call at top tier programs?

[interviewer2006]

I'm curious, of the top tier IM programs, who's still doing overnight call, who's doing night float, and how do these systems work? I'd love to hear from residents at some of these programs, to get a sense for what changes have been seen as positive by the residents, and what changes have negatively impacted your training in some way. I've been trying to figure some of this out from lots of searches here, on scutwork.com, and from reviewing program websites, but most of them don't have much info, if any, about the nitty gritty details of their call systems. Either that or it's outdated, since so many programs have changed in the last year or two in order to meet increasingly stringent dury-hour requirements. Here's what I've found so far...please correct me where I'm wrong (I imagine there are several errors). I'm sure I've left out some great programs here too, so feel free to add others.

MGH - interns take overnight call q4, but arrive at noon and leave at noon the next day, so it's just 24hrs. 2nd/3rd years don't do overnight (?).

BWH - no overnight call for interns or residents; night float system instead. But when do you stop admitting? Is the "10 hour between shifts" rule kept well? How much float do you do each year? Are their overnight residents for backup?

Hopkins - traditional q4 overnight call for 10.5 months as an intern! But what do the residents do? Are they home, or some in house overnight??

Duke - traditional q4 overnight call for interns for 8-9 months. Overnight call for 2nd/3rd year residents too.

UCSF - traditional q4 overnight call for interns for 8-10 months. Overnight call for residents too, about 3-6 mos/yr depending on 2nd or 3rd year status.

Penn - traditional q4 overnight call for interns for 8-9 months. Do residents take overnight call too?

Michigan - traditional q4 overnight call for interns for 9 months. Residents go home at night?

Wash U - totally night float, for interns and residents. They do about 2 weeks of night float per year, and are supposed to leave by ~9-10pm on call days.

BID - totally night float, for interns and residents.

UW - totally night float, for interns and residents.

---

Members don't see this ad.

 

[indiamacbean]

I believe that BWH changed their call system in some way back towards a more traditional call system but since I didn't go there I am not sure.

UCSF is as you describe but the call is not strictly q4 because it can be as frequent as Q3 or as spread out as q6 which is hospital by hospital and rotation by rotation. UCSF had piloted a late start system a while back but it was rejected by residents. I guess just goes to show that what works at one place won't always work at another. Also, this year there was some consideration of having interns take call by themselves but this was also rejected because we felt like taking call as a team was a part of what we like as a program. again no one hundred correct way to do it just variations on a theme.
I think that the truth is that if there were a "best" system people would have adopted it. I think we probably all work more than we would like but (hopefully) enjoy what we are doing.

 

[GoBearsGo]

Correct that at MGH interns do 24 hour (noon to noon) call ~nine months out of twelve. Juniors have four months of more traditional 30 hour call (two q4 in the ICU and two q5 in the CCU/SDU). As a senior you never spend more than 12 hours in the hospital at a time.

From what I hear this year BWH is piloting a return to overnight call, as the nightfloat system led to problems with enough time between shifts (specifically people staying very late on call nights and having to work a full day post call).

I hear Wash U's night float system works very well and they are a well rested and happy bunch.

 

[normansatx]

UW is traditional q4 overnight on inpatient services, except at harborview where it is q5, as an intern for like 8 months. They also added a two week elective as an intern, which was exciting.

 

[interviewer2006]

UW is traditional q4 overnight on inpatient services, except at harborview where it is q5, as an intern for like 8 months. They also added a two week elective as an intern, which was exciting.

Are the 2nd and 3rd year residents taking overnight call too, or do they have some sort of night float system?

 

[normansatx]

Are the 2nd and 3rd year residents taking overnight call too, or do they have some sort of night float system?

I'm pretty sure they have nightfloat for ward months and overnight for CCU and MICU months. We do two weeks of nightfloat per year as an intern so there must be one somewhere...

 

[sub3h]

At BWH we (interns) take call overnight, out the next day by noon or one. No admissions after 2 am or earlier if you cap. The only exception is cards (admits until 9pm), although the plan is to make this overnight call next year. Residents stay until 9-10 pm on call days, interns are covered after that by team-specific night floats. Units are q3 overnight for interns, with residents being day/night in the MICU, overnight in the CCU.

 

[MidwestMD]

As of last yr, Michigan senior residents do not take overnight call except for:

1. MICU- overnight call q 4 w/ the intern

2. Newburgh- overnight call q 4 (no intern). A senior resident team that admits 5 pts after the gen med teams have capped or after midnight, which ever comes first (2 2wk blocks per yr). On the day of call, you usually get to go home after finishing your work earlier that day (~5pm) and then come back in ~10pm or 11pm depending on above and leave the next day by 12pm.

We also have a senior NF system for the overflow pts that admit holdovers for the next AM (1-2 2 wk blocks each yr).

 

[BaylorLion]

Vanderbilt is traditional q4 overnight at Vanderbilt Hospital and (I believe) q6 at the on-campus VA. 9 months of call as a PGY-1, 6 as a PGY-2, and 3 or 4 as a PGY-3.

I think it'd be helpful to throw in a couple words about Columbia, Stanford and UCLA...

 

[Bull Durham]

Interns:
-Q4 overnight call 8 months of the year.
- 3-4 gen med months, 3 weeks CCU, 3-4 inpatient subspecialty months (onc, neuro, cards, renal, pulm)
-In the MICU as an intern, call is not overnight. Its Q4 "swing shifts" that last until 9 pm (MICU as an intern is at a community hospital DRH)
-Come in at usual time on call (~7am)
-Currently call is 30 hours (leave at 1 pm next day). There is talk of changing to 28 hours and eventually to 26 hours.
-On gen med, day-float resident rounds in the morning and then stays in the afternoon so on-call team can get out on time.
-On Sub-specialty services at least right now there is no resident, so interns take call alone. Backup is usually the MICU resident or fellow. Moonlighting fellows/residents are available as backup on oncology. There is an in-house cards hospitalist at night for backup on cardiology (usually someone straight out of residency interested in cardiology who decided to work for a year or two).
-No pre-rounding even when not on call
-Short white coats officially done with after this year

Second year ("JAR")
- Five and half overnight call months
- 3 gen med months are Q4
- 6 weeks MICU at Duke Q3
- 1 month CCU Q3

Third year ("SAR")
- Up to 4 months of overnight call
- 3 gen med months Q4 call
- 1 month MICU or CCU Q4 call
- A number of SARs are selected as assistant chiefs (2 month gig) - these SARs are often exempt from 2 months of gen med (so only 2 overnight call months).

Outpatient clinic: different from other programs in that on most overnight call months there is no clinic. On ambulatory months you spend 1-2 full days a week in your outpatient clinic.

Gen med:
- Each team consists of 1 resident and 1 intern.
- Team can admit up to 7 overnight. Of these, intern admits 5 and resident takes 2.
- The day after post call is short call (team can admit up to 2 until noon)
- Day before call is pre-call (no new admissions)
- Team can carry max of 14 patients
- Excess patients on gen med and subspecialty services are admitted by moonlighting resident (titled "4040" since that is their pager #). Busy gig but pays well (close to a 1000 bucks a night). 4040 can admit up to 7 patients then calls in backup ("1010") which is also a similarly reimbursed shift if you have to come in.
-Intern handles admission orders, cross-cover, and H&P
-Resident H&P can be skimpy on history, physical, etc but must have detailed plan that cites literature. Resident also does discharge summaries.

 

[proffit]

Actually the above info about UW is incorrect. We do almost all 30h overnight call for all three years as follows:

R1: 9.5 'hard'/call months (6 mo q4, 2 mo q5, 1 mo ER, 0.5 mo night float)
R2: 6.5 'hard'/call months (4 mo q4, 1 mo q5, 1 mo ER, 0.5 mo night float)
R3: 6.5 'hard'/call months (4 mo q4, 1 mo ER, 1 mo onc or heart failure, 0.5
mo night float)

R1 yr includes 2 closed MICU months, and 4 additional call months that are open ICU, so heavy on critical care exposure. Night float is supplementary to overnight call and handles admits over the caps or after 4 AM, and cross-cover after 9PM. Intern caps are 5 + 2, total 12 patients. ER in the R2/R3 yrs is extremely busy at our county hosp, 21-22 12-13h shifts + qwk continuity clinic. R3 onc/CHF are busy rotations w/o call (80 hr wks w/ 4 days off/mo, 2 interns/senior admitting QOD), probably akin to senior months at the institutions with a 'true' night float.

Yes it can be brutal but I believe I've gotten terrific clinical training, particularly in the independent management of very sick patients. Overnight call for interns and seniors is beneficial in terms of continuity of patient care and establishment of a 'team' environment, and I truly wouldn't change a thing.

 

[normansatx]

Actually the above info about UW is incorrect. We do almost all 30h overnight call for all three years as follows:

R1: 9.5 'hard'/call months (6 mo q4, 2 mo q5, 1 mo ER, 0.5 mo night float)
R2: 6.5 'hard'/call months (4 mo q4, 1 mo q5, 1 mo ER, 0.5 mo night float)
R3: 6.5 'hard'/call months (4 mo q4, 1 mo ER, 1 mo onc or heart failure, 0.5
mo night float)

R1 yr includes 2 closed MICU months, and 4 additional call months that are open ICU, so heavy on critical care exposure. Night float is supplementary to overnight call and handles admits over the caps or after 4 AM, and cross-cover after 9PM. Intern caps are 5 + 2, total 12 patients. ER in the R2/R3 yrs is extremely busy at our county hosp, 21-22 12-13h shifts + qwk continuity clinic. R3 onc/CHF are busy rotations w/o call (80 hr wks w/ 4 days off/mo, 2 interns/senior admitting QOD), probably akin to senior months at the institutions with a 'true' night float.

Yes it can be brutal but I believe I've gotten terrific clinical training, particularly in the independent management of very sick patients. Overnight call for interns and seniors is beneficial in terms of continuity of patient care and establishment of a 'team' environment, and I truly wouldn't change a thing.

Thanks for clearing up the R2 and R3 call system! You don't hear too much about it during interview season. I'm an incoming Intern at UW, look forward to meeting you! I'm looking at my schedule and, just like you said, there are: - two ICU months
- three GenMed months (2 q4 and one q5)
- A Neuro month that is q4
- Cards q4
- Heme-Onc q4 call
- Two weeks NF
Also there is two weeks of UWMC ER and two weeks elective. There is a month of Geri, three weeks vacation, 1.5 mo of clinic, and a skills/risk rotation (no idea what this is).

 

[velo]

I hear Wash U's night float system works very well and they are a well rested and happy bunch.

I just finished med school at Wash U and, yes, the nightfloat system works extremely well here. I'm not sure why other top programs have had trouble adopting a similar system--all the other places where I interviewed had overnight call (as I think someone mentioned BWH has overnight call again). I think part of what makes it work is the backup of a strong hospitalist system.

Ultimately I needed a change of scenery, but Wash U's nightfloat system was difficult for me to leave...it's not unheard of (although not common) for residents to go out to the bars on a call night after they sign out...pretty sweet

 

[OneFish TwoFish]

Call is q4 just about everywhere. There is a night float system. Each cycle is 30 hours, and new admits are limitted by:
1) maximum of 5 new pts, one less for sub-I's
2) by time - no admits past 9:30 PM weekdays and 11 PM weekends
3) Total census - interns cannot carry more than 10-12 patients at any one time.

Most times you will cap by new admits. You may additionally have night floats that will count towards your cap, decreasing the number of new admits.

Overnight call is ALWAYS with a resident. There is a back-up 3rd year resident beyond that in house at night (Super-senior) at HUP. Basically there are at least 4 residents available for any given situation. During days there is a rapid response team (with attending in background) that is supposed to become 24/7. The rapid response team is also a procedure team when not putting out fires for dedicated teaching on line placement, U/S guided taps, etc. You are supported from the mundane to the catastrophic. There is never resistance to an ICU transfer, which is done at the resident level. The intern's job - simple as it sounds - is to diffrentiate "sick" from "not sick" when patients have a change in status.

Interns also no longer take overnight call in the MICU - this is a new change. They admit during the days only.

 

[Furrball2]

As of last yr, Michigan senior residents do not take overnight call except for:

1. MICU- overnight call q 4 w/ the intern

2. Newburgh- overnight call q 4 (no intern). A senior resident team that admits 5 pts after the gen med teams have capped or after midnight, which ever comes first (2 2wk blocks per yr). On the day of call, you usually get to go home after finishing your work earlier that day (~5pm) and then come back in ~10pm or 11pm depending on above and leave the next day by 12pm.

We also have a senior NF system for the overflow pts that admit holdovers for the next AM (1-2 2 wk blocks each yr).

The above is still true. There are three night floats -- cards, gen med, and medicine sub specialty. The CCMU resident largely stays in the unit. They VA is changing. The MICU is becoming a closed unit. Starting in July, the night float resident is only responsible for the unit. The interns will admit with an attending once their SMR goes home around 9 or 10 pm.

 

[dragonfly99]

My best friend goes to Vandy,
quote above is correct it is Q4 at Vanderbilt and Q6 overnight at VA.
The call is traditional 30 hour call for both interns and residents.
Their MICU is Q3. It used to be Q2 but that went out with the 80 hour workweek. They admit all night on most all of the services, unless they are capped. There is no night float.

WashU does have a cushy system for their medicine residents, the last time I looked. They have a very good hospitalist system to take some of the admits, since there are way too many for the house staff to take them all.

 

[dragonfly99]

Oh yeah,
unless it's changed drastically in the last couple of years, I think you got the number of call months/year wrong for Vanderbilt.
My friend had 1 clinic month when he was an intern, 2 weeks vacation, and all the rest was either MICU or wards, so that's 10.5 months of call. Some people might have a little less but I'm not sure.

 

[0382938]

Anyone want to contribute recent info about BIDMC in this regard? I read on the Freida site that the *average* hours worked during intern year was 80. That's pretty crazy if true (assuming there are a couple of outpatient or other chill months in there, they would have to be going over 80 during the ward/unit months).

 

[BaylorLion]

I think they've kindly decreased our call months at Vanderbilt (I'm an incoming intern). And it is indeed 4 months for R3s...

http://medicine.mc.vanderbilt.edu/Templates/TemplateDivision.aspx?qs=cElEPTI5Mg==

 

[docrocmayo]

At Mayo Rochester

intern call is q6 ( long and short call alternate every third day)- long call typically starts at 1-3 pm( except neuro) and one can technically stay till 6-7 pm the next day-though this does not happen usually).
generally 8 call months.

In the second year, there are 5 months of call usually q4-6 call.
there is variable home call on second year consult services.

R3 is loaded with 6 months of overnight call - q4. it starts at 7 am and you usually get out after a full 30 hours.

8 call months R1, 5 call months R 2, 6 call months R3