Post-call before starting new rotation

[Seona]

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Hey guys,

I'm starting my intern year and realized that my first rotation (general medicine) ends on a call day...which means I will be post-call on the Monday of my next rotation (out-pt clinic).

What do your programs usually do about this? I mean, I assume the clinic rotation will want me there early in the morning on my first day...but surely, I still have to present and round on my medicine patients instead of passing it off to the incoming intern on the morning of my post-call day?

 

[gutonc]

Hey guys,

I'm starting my intern year and realized that my first rotation (general medicine) ends on a call day...which means I will be post-call on the Monday of my next rotation (out-pt clinic).

What do your programs usually do about this? I mean, I assume the clinic rotation will want me there early in the morning on my first day...but surely, I still have to present and round on my medicine patients instead of passing it off to the incoming intern on the morning of my post-call day?

In my program, you would finish the post-cal work, just like any other day and then go home. You'd go to clinic the next morning. Work hour rules still apply, even if you're switching rotations. It should be the responsibility of your Chief (or whoever does the scheduling/managing) to notify the outpt rotation that you are post-call and won't be there that day.

 

[Law2Doc]

...It should be the responsibility of your Chief (or whoever does the scheduling/managing) to notify the outpt rotation that you are post-call and won't be there that day.

Agree with you except for the above sentence. In a lot of places it's up to you to let the next rotation know that you are post-call and won't be there.

 

[Seona]

Agree with you except for the above sentence. In a lot of places it's up to you to let the next rotation know that you are post-call and won't be there.

Thanks! That's kind of what I was thinking, but I didn't want to tell the next rotation that I'm post-call and force them into giving me the day off (and have them view me as a slacker or something). Also, I'm in a transitional program so the two rotations are from different departments. Anyway, I feel so much better now that I know it's the norm to have that day off!

 

[turquoiseblue]

Hey guys,

I'm starting my intern year and realized that my first rotation (general medicine) ends on a call day...which means I will be post-call on the Monday of my next rotation (out-pt clinic).

What do your programs usually do about this? I mean, I assume the clinic rotation will want me there early in the morning on my first day...but surely, I still have to present and round on my medicine patients instead of passing it off to the incoming intern on the morning of my post-call day?

i agree... usually they let you have your postcall day off and you come back the next day. they usually set it up so that someone else is working on the day you were postcall. otherwise, i believe they would be breaking ACGME rules, since you are supposed to have predefined hours on and off work, so you don't over or under work.

 

[MattD]

Thanks! That's kind of what I was thinking, but I didn't want to tell the next rotation that I'm post-call and force them into giving me the day off (and have them view me as a slacker or something).

Well, keep in mind that it's not just you being a 'slacker' and wanting your postcall time off. There's also the pesky physical impossibility of you being present both at postcall rounds and your new clinic. There's nothing you can do about that, they just have to accept it. Now, if they wanted you to come to clinic after rounds, that would suck 🙂

 

[gutonc]

Agree with you except for the above sentence. In a lot of places it's up to you to let the next rotation know that you are post-call and won't be there.

...which is totally bogus. Not saying it doesn't happen, just that, somebody else put you in that position to begin with, that person (or everyone's whipping boy/girl, the Chief Resident(s)) should nut up and take the responsibility of letting the next rotation know what's up.

 

[Law2Doc]

...which is totally bogus. Not saying it doesn't happen, just that, somebody else put you in that position to begin with, that person (or everyone's whipping boy/girl, the Chief Resident(s)) should nut up and take the responsibility of letting the next rotation know what's up.

Perhaps, but as long as everyone knows that's the system, it's really no big deal.

 

[notinkansas]

I would make absolutely sure that whoever might be expecting you the first day of new rotation knows you'll be post call that day. Communication between different areas can be dropped easily. You'll look less like a slacker if you notify them a couple days before not to expect you due to post call status than if you rely on some department secretary to notify the appropriate person and the message doesn't get through. If the message doesn't get through, you could look like an no show. It's all easily verified by producing your call schedule.

I developed the habit of saving all my schedules, just in case anybody ever decides to question where you were vs where you should have been. I also document the details of any interaction that might later come back to bite me (nurse upset with me for something, etc) I had an incident where I wished I had done this. It made me a bit paranoid. I've never had to go back to any of my documentation, but it makes me feel better knowing that I documented it while it was fresh in my mind. I just throw it in a file and it's there if I ever need it.

 

[waldenwoods]

In my program, you would finish the post-cal work, just like any other day and then go home. You'd go to clinic the next morning. Work hour rules still apply, even if you're switching rotations. It should be the responsibility of your Chief (or whoever does the scheduling/managing) to notify the outpt rotation that you are post-call and won't be there that day.

This isn't meant to counter what gutonc is saying. I wanted to clarify how work hours applied, maybe aPD or someone knowledgeable could say for sure. Is it the part of the duty hours rules that states that no new patients may be accepted after 24 hours of continuous duty, which applies here? Assuming that the OP might not have to round post-call and therefore would technically be done with the first rotation early enough in the day to physically make it to clinic, is it that rule that prevents the person from seeing patients on the new rotation?

 

[Law2Doc]

This isn't meant to counter what gutonc is saying. I wanted to clarify how work hours applied, maybe aPD or someone knowledgeable could say for sure. Is it the part of the duty hours rules that states that no new patients may be accepted after 24 hours of continuous duty, which applies here? Assuming that the OP might not have to round post-call and therefore would technically be done with the first rotation early enough in the day to physically make it to clinic, is it that rule that prevents the person from seeing patients on the new rotation?

It's usually the "cannot exceed 30 hours" (and then have 10 hours off) rule that applies here. Meaning you finish your call in one rotation, you probably are up to 24+ hours (assuming you worked am to am), and so you really can't go right into another day of work. In theory you could finish am rounds and then go work somewhere else until lunchtime and still keep it within 30 hours, but I've not seen that done. And you are right, you really aren't supposed to be taking new patients in the last few hours of your shift. But it's simpler than that -- by convention, if you are post-call you go home, and start fresh the next day.

 

[hippiedoc13]

To the OP, bottom line is that each program handles the finer details differently, and you need to ask someone at your program (ie the chief resident) how this will be handled. We here on SDN can speculate and share how our programs handle it, but none of us can tell you exactly how it works at your program.

But all of the info above is true, that ACGME work hours still apply, and you still get a post-call day. Seeing patients in clinic does count as "accepting new patients after 24 hours on duty" so by the work hours regulations, you should not be expected to go to clinic post-call.

 

[gutonc]

This isn't meant to counter what gutonc is saying. I wanted to clarify how work hours applied, maybe aPD or someone knowledgeable could say for sure. Is it the part of the duty hours rules that states that no new patients may be accepted after 24 hours of continuous duty, which applies here? Assuming that the OP might not have to round post-call and therefore would technically be done with the first rotation early enough in the day to physically make it to clinic, is it that rule that prevents the person from seeing patients on the new rotation?

Based on the work-hour rules, you are not allowed to go to your own continuity clinic on a post-call day, so you shouldn't be allowed to go to somebody else's continuity clinic either. As L2D mentions, it violates the 24+6 AND 10h rules.

 

[NotAProgDirector]

Based on the work-hour rules, you are not allowed to go to your own continuity clinic on a post-call day, so you shouldn't be allowed to go to somebody else's continuity clinic either. As L2D mentions, it violates the 24+6 AND 10h rules.

Actually, the ACGME is not so clear on this. This is from the DH FAQ:

Question: What is the ACGME‟s interpretation of the use of the added period of up to six hours at the end of a 24-hour duty and on-call shift?
Answer: The goal of the added hours at the end of the on-call period is to promote didactic learning and continuity of care, including ambulatory and surgical continuity. Some RRCs have exempted longitudinal care experiences and experiences that promote peri-operative or care continuity. Clarifying language for activities that are permitted during the up to six hours after the end of the 24-hour period for each core core specialty can be found on the ACGME‟s Website ( "RRC-specific duty hour language)."

So, some fields allow continuity clinic in the 6 hours post call.

 

[colbgw02]

Thanks! That's kind of what I was thinking, but I didn't want to tell the next rotation that I'm post-call and force them into giving me the day off (and have them view me as a slacker or something). Also, I'm in a transitional program so the two rotations are from different departments. Anyway, I feel so much better now that I know it's the norm to have that day off!

Transitional interns are basically the orphans of the hospital - at least that's how it was for me. Without a strong program director to communicate between departments and protect you, it'll be easy for programs to dump on you to lighten the load for their own interns. Conversely, some programs won't trust you as much as their own interns (and understandably so, especially late in the year), which can lead to lighter duty with fewer responsibilities. However, that can hurt your education.

It's a fine line to walk, and it basically comes down to how trustworthy and proactive your PD is. If you're not sure about your PD, then don't be afraid to speak up for yourself.

 

[filter07]

Whenever I switched to a new rotation I worked the full day, regardless of whether I was post call or not. Communicating your schedule in advance is the best way, so that it can be worked out beforehand, but communication in the hospital is not always the best. I also feel that some would rather not know, so that they don't have to deal with the problem.

Sometimes I feel bad leaving even if I was post call because the work load is just ridiculous, and I know that my co-intern would bear the majority of the load in my absence. I remember being in clinic on Monday after being on call the entire weekend. That sucked tremendously but I did it. The culture of the program and surgery in general has changed since then, so I don't think things like that happen too often. I will also say however that staying in clinic for a full day after being on call is not the end of the world. It is against the rules and yes it sucks but you will not die from working 36 hours straight once in a while.

 

[Law2Doc]

...I will also say however that staying in clinic for a full day after being on call is not the end of the world. It is against the rules and yes it sucks but you will not die from working 36 hours straight once in a while.

It may not be the end of the world, but it could be the end of your program. Programs in general at least try to have a schedule that, on its face, can be completed within the duty hours requirements. Sometimes things cause you to run over the hour marks, but the system is at least set up that on paper you won't. Which is why in most cases it is the accepted convention that if you are post-call you go home. But when you go from a post-call day to another full day, you break the rules, even in terms of the schedule on its face. Which is a really bad idea, since programs submit both schedules and duty hours to overseers. So most programs would actually be pissed off at you for going from post-call to a clinic day, once they found out. You may feel like you are helping out your co-residents, but in reality you are putting many at jeopardy.

 

[Buzz Me]

We just finish up post-call on the old rotation (sign-out to the oncoming resident), then head over to the new rotation and work until around 12, if possible.

 

[IMdocT]

^^^that's how my residents did it at my school. as someone already mentioned, some of the places i've rotated at during school allowed continuity clinic in the +6 hours after the 24 hour call. but if the resident's clinic was in the afternoon, they could cancel it or maybe reschedule. i'm not sure about my program, will have to take a look at the policies

 

[Coastie]

We just finish up post-call on the old rotation (sign-out to the oncoming resident), then head over to the new rotation and work until around 12, if possible.

LOL, medicine truly sux.

What is wrong with your program? Do they like torturing small animals too?

 

[gutonc]

LOL, medicine truly sux.

What is wrong with your program? Do they like torturing small animals too?

He's a surgeon. 'Nuff said.

 

[jdh71]

As said earlier every program will handle the finer details differently. Where I'm at, you generally work until 30 hours are done, otherwise the first day of any rotation is more chaos than it normally would be, especially if you're PGY2 or PGY3. Granted many times you show up on the new service and the attending, knowing you are post sends you home, BUT I kind of think you need to be there pick up the slack if there's slack that needs picking. We do am clinics post, but not pm. Although, depending on the rotation coming up, often if you let a chief know soon enough, things can be smoothed over for you to have the first day off if you're post as long as no one gets screwed.

 

[UCLAstudent]

I never had to work the first day of a new rotation when I was post-call. That is pretty much the norm at my hospital, especially for people switching to clinic or ER. I know of a few co-interns who switched to a ward month and had to round on their patients on the new service while post-call, but that was not a usual scenario.

 

[Buzz Me]

He's a surgeon. 'Nuff said.

Exactly!

 

[dragonfly99]

You'd better find out what is/will be expected in advance. Of course you can't be in two places at once. At my medicine program, being postcall didn't exempt one from working until noon on the next rotation. A postcall intern or resident on a ward month would not be expected to stay for rounds on the old rotation and present. He/she would go to the new rotation and pick up the patients on the new rotation, and then go home at noon. Otherwise, other people have to do double the work on prerounds and rounds (because of you not being there).

We did have clinics postcall, if they were morning clinics. However, due to the 30 hour rule the afternoon clinics had to be cancelled postcall.

 

[Top Gun]

Usually if I'm post-call on the first day of a new rotation, I don't have to work that day, other than getting the usual post-call stuff done before going home. Its happened to me many times. Just last week, I was post-call from night float, and was due to start my heme-onc rotation that day (the first rotation of third year, by the way). But my chief assured me after checkout that I could go home, and someone else would help cover heme-onc that day. In my intern year, I was post-call once from a 24-hour call while on floor rotation, and was due to start ICU that day. But the ICU resident knew I was post-call and allowed me to just finish the usual post-call work and go home. If you have a good chief, they will usually let the next rotation know that you are post-call.