Psychiatry residency on call at night

[AnonymousPsychRes]

Hiya everyone.

I made an anonymous account because my regular one is known by many.
My program has always had a back up call system for when folks are sick or have emergencies. Entirely reasonable. We’re on this call for a week at a time.

There’s discussion about using this back up resident at night when the ED has too many consults at once.
Considering it’s “home call”, it technically doesn’t break duty hour violations.
Does anyone else’s residency do this? Are there other surge policies other programs have?
It seems like a terrible solution to a problem that’s been going on for years.

Appreciate the feedback!

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[TexasPhysician]

I don’t believe that Psych has emergencies in the ER that can’t wait til morning. EM docs and their staff can wait a few hours.

 

[AnonymousPsychRes]

I don’t believe that Psych has emergencies in the ER that can’t wait til morning. EM docs and their staff can wait a few hours.

I 100% agree with this. We have 24/7 staff in our hospital, and I have seen up to 12 patients in a 12 hour shift. Sometimes these consults are “the patient is sad” which is incredibly frustrating. We’re not allowed to turn down any consults.

They’re demanding that any ED patient needs disposition within 2 hours of the time the consult is placed, there’s been pressure from hospital admin and apparently this is the solution we’re moving towards in a couple weeks and it feels ridiculous.

 

[adiradirim]

There needs to be communication between the Psych dept and Emergency dept heads about what is appropriate to consult for.
Another option would be to hire a social worker for the CL service to screen some of these weak consults or do safety evals for the ED.

 

[AnonymousPsychRes]

There needs to be communication between the Psych dept and Emergency dept heads about what is appropriate to consult for.
Another option would be to hire a social worker for the CL service to screen some of these weak consults or do safety evals for the ED.

This would be beautiful. We get called on anyone who has any inclination of passive SI.
I once had to do an entire emergency eval on a 90+ year old who said she’d rather die than go in a nursing home.
Is it typical to have a SW on service? We do not.

 

[AnonymousPsychRes]

Of note earlier this year I also pushed for an internal moonlight system where a resident can choose to be on call but I guess we decided against that.

 

[adiradirim]

I've seen it at some hospitals where they have a SW on the CL service. It's extremely beneficial.

The only thing the residents can do themselves it get support from the Chiefs and refuse to do this as an entire residency class.
This would require the chiefs to be strong and on the residents' side though...

 

[AnonymousPsychRes]

I've seen it at some hospitals where they have a SW on the CL service. It's extremely beneficial.

The only thing the residents can do themselves it get support from the Chiefs and refuse to do this as an entire residency class.
This would require the chiefs to be strong and on the residents' side though...

my class is going to discuss boundaries tomorrow and what we plan on doing.
I’m not really sure where our chiefs will stand on the issue. We have 2, one of them wanted it and the other took it because there was no other option

 

[hamstergang]

It seems like a terrible solution to a problem that’s been going on for years.

Even if you don't think it's a good solution, it's certainly allowable. So depending on your relationship with the residency management, I'd caution against pushing back too hard.

 

[AnonymousPsychRes]

Even if you don't think it's a good solution, it's certainly allowable. So depending on your relationship with the residency management, I'd caution against pushing back too hard.

If I’m doing this, I’m doing it as a united front with the rest of my class. I’m in pretty good standing and have had a good relationship with the PD, but they’re getting push from department chairs.

 

[wolfvgang22]

Is it typical to have a SW on service? We do not.

Yes, when there are no residents to abuse and only attendings, who have many other opportunities.

 

[calvnandhobbs68]

Yes, when there are no residents to abuse and only attendings, who have many other opportunities.

Yup. Classic case of not wanting to pay a social worker when you can get residents to do it for free. Most of what goes on in the ER gets triaged by social workers in the community to filter out all the obvious dumb stuff or easy discharges. You don’t need an MD to learn how to do an SI risk assessment which is a huge chunk of ER consults.

 

[docksan]

I don’t believe that Psych has emergencies in the ER that can’t wait til morning. EM docs and their staff can wait a few hours.

Oh ho if only all residencies were like this

 

[FlowRate]

This was the norm in our residency.

1st year covers inpatient unit at hospital A and is available to help out in ED of hospital A where 2nd year is covering CL and ED consults (and supervising 1st year). But 1st years are slow AF at ED consults so only the really strong ones are actually any help.

2nd years cover ED/CL at hospital A and ED/CL/Inpatient unit at hospital B.

3rd years cover ED/CL at hospital C.

4th year is home/supervision call and can be called in to any of the above hospitals (usually hospital A, sometimes B or C) if the resident feels completely overwhelmed (think ~20 consults in a 14 hour overnight shift or 4-6 concurrent reasonable consults within the same hour).

We were given authority to defer and push back some things, especially at hospital C. But hospitals A and B needed to keep psych flow going overnight to keep their ED's functional. Especially hospital B since it had a small ED.

I also agree with the above that there were probably other options that didn't exploit resident labor.

 

[UTsksk]

My program has a back up system but it is rarely used since it’s seen as weak to ask for back up. We also get a lot of pushback from ED to dispo people and it gets annoying. Unless hospital consults are “emergent” then we save those for the morning and put in a quick plan of care note saying that. The night resident can do night consults if they’re bored but not often. I was one of the dumb ones that did the work to help out while on nights. I was pretty naive to the teamwork philosophy when sometimes it’s more survival of fittest.

 

[AnonymousPsychRes]

This was the norm in our residency.

1st year covers inpatient unit at hospital A and is available to help out in ED of hospital A where 2nd year is covering CL and ED consults (and supervising 1st year). But 1st years are slow AF at ED consults so only the really strong ones are actually any help.

2nd years cover ED/CL at hospital A and ED/CL/Inpatient unit at hospital B.

3rd years cover ED/CL at hospital C.

4th year is home/supervision call and can be called in to any of the above hospitals (usually hospital A, sometimes B or C) if the resident feels completely overwhelmed (think ~20 consults in a 14 hour overnight shift or 4-6 concurrent reasonable consults within the same hour).

We were given authority to defer and push back some things, especially at hospital C. But hospitals A and B needed to keep psych flow going overnight to keep their ED's functional. Especially hospital B since it had a small ED.

I also agree with the above that there were probably other options that didn't exploit resident labor.

Whew 3 hospitals is a lot. What it sounds like they’re planning for us to be called in is if it gets over 3 patients/hr. And that happens fairly regularly.

We cover 2 and they’re resident dependent. We’re not a very large program.
We already do 3-4 months of ED coverage on top of 4-5 months of C/L. I guess the thought of getting more of that makes us all squirm.

 

[FlowRate]

Whew 3 hospitals is a lot. What it sounds like they’re planning for us to be called in is if it gets over 3 patients/hr. And that happens fairly regularly.

We cover 2 and they’re resident dependent. We’re not a very large program.
We already do 3-4 months of ED coverage on top of 4-5 months of C/L. I guess the thought of getting more of that makes us all squirm.

I think I called in the 4th year maybe 2-3 times during residency and lucked out in that I was only called in 2-3 times as a 4th year. It was maybe a once a week thing by my estimation. We were allowed to take a post-call half day (or full day if needed) if we were called in.

 

[AnonymousPsychRes]

I think I called in the 4th year maybe 2-3 times during residency and lucked out in that I was only called in 2-3 times as a 4th year. It was maybe a once a week thing by my estimation. We were allowed to take a post-call half day (or full day if needed) if we were called in.

It would be 2nd and 3rd years taking the call. A post call half day is something I plan on advocating for.

 

[comp1]

It's definitely not prohibited by the ACGME. However, I personally think it's a poor use of resident resources. There is very little education involved here as there is by definition no regular attending supervision in the middle of the night. It's one thing to be called for prns or to give verbal admission orders. It's quite another to be called to do formal assessments at 3 AM. My residency definitely had social workers do this sort of thing. I concur that there are no "psychiatric emergencies" that cannot be managed by an ED physician whose schedule is shift work. Nobody is getting placed within 2 hours in the community, so I'm not sure why they even mention that.

 

[aim-agm]

I'm not clear on the marginal benefit to the ED of having overnight resident coverage. Their main objective is to "move the meat" and get patients out of the ED one way or another.

Are you going to be able to get collateral overnight from family? You certainly aren't going to get it from their outpatient treatment teams.

If you recommend a patient get discharged with referrals, is there SW overnight to make those referrals? Or will they have to wait until morning to see SW?

If you recommend a patient for admission, will the patient transfer overnight or will they get to a unit the same time whether you see them at midnight as in the morning?

How many of the consults are substance related, particularly how many are still intoxicated at the time of the consult?

Do they want you to clear psych holds? If so, how many of those holds are legitimate clinically, or even legally (i.e. meet criteria set out by state law)?

 

[FlowRate]

I'm a little surprised how many people are questioning having overnight residents at all.

I can tell you, having done this work, that I absolutely assessed and placed patients overnight, took patients off of sections and discharged them, and started foundational work for other cases so that the day shift (which was usually slammed as well) could complete the remainder of the plan. And having a resident there means we might be starting a plan 12 hours before the next day shift arrives.

I agree that if the hospital wanted to pay for social workers to do this stuff they could have. As much as I disliked overnight call in residency and thought we had an excessive amount, I do think there was specific educational value as far as opportunity to build confidence/independence. The last hour of call was signout with day team which included feedback on cases. Immediate attending supervision was available by phone (or extremely rarely for emergencies, in person) PRN.

 

[AnonymousPsychRes]

I'm a little surprised how many people are questioning having overnight residents at all.

I can tell you, having done this work, that I absolutely assessed and placed patients overnight, took patients off of sections and discharged them, and started foundational work for other cases so that the day shift (which was usually slammed as well) could complete the remainder of the plan. And having a resident there means we might be starting a plan 12 hours before the next day shift arrives.

I agree that if the hospital wanted to pay for social workers to do this stuff they could have. As much as I disliked overnight call in residency and thought we had an excessive amount, I do think there was specific educational value as far as opportunity to build confidence/independence. The last hour of call was signout with day team which included feedback on cases. Immediate attending supervision was available by phone (or extremely rarely for emergencies, in person) PRN.

We already have a resident in the hospital overnight. I think we do have good educational value in it. But it already exists, we all do 7-8 weeks of nights.
This is a secondary back up call that when a few patients get backed up in the ED were mobilizing the back up call resident to decrease ED wait times.

 

[deleted1100659]

I 100% agree with this. We have 24/7 staff in our hospital, and I have seen up to 12 patients in a 12 hour shift. Sometimes these consults are “the patient is sad” which is incredibly frustrating. We’re not allowed to turn down any consults.

They’re demanding that any ED patient needs disposition within 2 hours of the time the consult is placed, there’s been pressure from hospital admin and apparently this is the solution we’re moving towards in a couple weeks and it feels ridiculous.

is your residency in the southeast? This is what my program did, lol

 

[AnonymousPsychRes]

is your residency in the southeast? This is what my program did, lol

I am in the south east, this hasn’t been implemented yet but we’re going towards it. With our clinic schedule we do community mental health clinics and it seems like a partial post call day may not be realistic either.

 

[GHPA]

Was a chief resident before, was told that there is a difference between "home call" and "internal moonlight". Home call was considered as part of your job, and there is a grey area whether it counts towards residents' hours. But internal moonlight was not allowed in my program, as we receive CMS money and residents were not allowed to "double dip". The argument was "these are the patients you suppose to take care with your resident salary, and you are not supposed to be paid in addition". Weak argument but that how our GME office insisted. Imaging how disappointed as a resident to not being able to get some extra money

 

[FlowRate]

I'm not clear on the marginal benefit to the ED of having overnight resident coverage. Their main objective is to "move the meat" and get patients out of the ED one way or another.

Are you going to be able to get collateral overnight from family? You certainly aren't going to get it from their outpatient treatment teams.

If you recommend a patient get discharged with referrals, is there SW overnight to make those referrals? Or will they have to wait until morning to see SW?

If you recommend a patient for admission, will the patient transfer overnight or will they get to a unit the same time whether you see them at midnight as in the morning?

How many of the consults are substance related, particularly how many are still intoxicated at the time of the consult?

Do they want you to clear psych holds? If so, how many of those holds are legitimate clinically, or even legally (i.e. meet criteria set out by state law)?

We already have a resident in the hospital overnight. I think we do have good educational value in it. But it already exists, we all do 7-8 weeks of nights.
This is a secondary back up call that when a few patients get backed up in the ED were mobilizing the back up call resident to decrease ED wait times.

Yes, I know, I was referring to the above which seems to call into question the utility of overnight call in general.

 

[calvnandhobbs68]

Was a chief resident before, was told that there is a difference between "home call" and "internal moonlight". Home call was considered as part of your job, and there is a grey area whether it counts towards residents' hours. But internal moonlight was not allowed in my program, as we receive CMS money and residents were not allowed to "double dip". The argument was "these are the patients you suppose to take care with your resident salary, and you are not supposed to be paid in addition". Weak argument but that how our GME office insisted. Imaging how disappointed as a resident to not being able to get some extra money

That is...a lie. I've been to two different programs in two different specialities, both of which had internal moonlighting. Again, trying to avoid paying for labor.

 

[AnonymousPsychRes]

Was a chief resident before, was told that there is a difference between "home call" and "internal moonlight". Home call was considered as part of your job, and there is a grey area whether it counts towards residents' hours. But internal moonlight was not allowed in my program, as we receive CMS money and residents were not allowed to "double dip". The argument was "these are the patients you suppose to take care with your resident salary, and you are not supposed to be paid in addition". Weak argument but that how our GME office insisted. Imaging how disappointed as a resident to not being able to get some extra money

We already do internal moonlighting within another context. EM and peds do surge moonlighting, get paid $100 to be on call and then $125 a hour if called if. I don’t understand why this is unacceptable for us but **** me I guess.

 

[GHPA]

That is...a lie. I've been to two different programs in two different specialities, both of which had internal moonlighting. Again, trying to avoid paying for labor.

Cheap for sure, and psych program seems to be one of the most conservative specialties also. We think too much about legal and other consequences. Well, I guess that's why our malpractice insurance is cheaper than others

 

[Celexa]

That is...a lie. I've been to two different programs in two different specialities, both of which had internal moonlighting. Again, trying to avoid paying for labor.

The rule about not moonlighting on services that you spend time on in residency, is, as far as I can tell, interpreted with extreme variability from place to place.

 

[Celexa]

I'm not clear on the marginal benefit to the ED of having overnight resident coverage. Their main objective is to "move the meat" and get patients out of the ED one way or another.

Are you going to be able to get collateral overnight from family? You certainly aren't going to get it from their outpatient treatment teams.

If you recommend a patient get discharged with referrals, is there SW overnight to make those referrals? Or will they have to wait until morning to see SW?

If you recommend a patient for admission, will the patient transfer overnight or will they get to a unit the same time whether you see them at midnight as in the morning?

How many of the consults are substance related, particularly how many are still intoxicated at the time of the consult?

Do they want you to clear psych holds? If so, how many of those holds are legitimate clinically, or even legally (i.e. meet criteria set out by state law)?

Of course there's value to the ED. Presumably the psych resident clears people and discharges them, which absolutely 'moves the meat'. In some places placement can also happen overnight, if the hospital has a psych unit or staff doing that once the psychiatric eval is done.

This is particularly relevant if you are at an academic place like mine, where the ED folks don't have never had had to think about psychiatric patients. It's literally an automatic page to psychiatry if someone so much as mumbles the word 'suicidal'. The aggravating fact is if they just read the chart they could discharge the malingering bull**** way faster themselves, but they don't. And even if they could, they want the liability shared.

I do think overnight and ED work has value as a resident but in many programs you do way more time there then is actually educational, because it's **** work and no training hospital will pay the amount of money it takes to put non-resident staff of any type on overnight when they could just make the residents do it.

One important note, though, that tricksy thing the 'full' evaluation. ED evals are not full evals. They are ED evals. You collect enough information to make a good clinical dispo decision and then you STOP. If your ED evals look like h&ps you're spending too much time. The volumes described by the OP do sound terrible regardless though.

 

[AnonymousPsychRes]

I'm not clear on the marginal benefit to the ED of having overnight resident coverage. Their main objective is to "move the meat" and get patients out of the ED one way or another.

Are you going to be able to get collateral overnight from family? You certainly aren't going to get it from their outpatient treatment teams.

If you recommend a patient get discharged with referrals, is there SW overnight to make those referrals? Or will they have to wait until morning to see SW?

If you recommend a patient for admission, will the patient transfer overnight or will they get to a unit the same time whether you see them at midnight as in the morning?

How many of the consults are substance related, particularly how many are still intoxicated at the time of the consult?

Do they want you to clear psych holds? If so, how many of those holds are legitimate clinically, or even legally (i.e. meet criteria set out by state law)?

So we do call collateral in the middle of the night, and they get discharged with out appointments. We have a unit so if it has space they get admitted. Intoxication is actually a big problem.

They do want us to clear psych holds, that’s basically why we’re there.

The rule about not moonlighting on services that you spend time on in residency, is, as far as I can tell, interpreted with extreme variability from place to place.

They already have moonlighters covering our child psych unit on the weekend. Don’t see why this would be much different, it’s a resident/fellow run service.

 

[mistafab]

Yeah man, it sucks but theres no stopping your program if they are pushing to do it.

Best advice i can say is get your res prog director to push back against the ED. Mostly im expecting the hospital itself is putting the pressure from above to both ED and psych, but doesnt actually want to pay for additional staff. If your PD has a spine they will ask the additional coverage to be paid internal moonlighting or something. At worst, you guys get boned with extra work without additional benefit.

I’ll say our program does heavy ED work. More than most programs, including overnight. Things can get worse than your set up now. I would push for money to moonlight this rather than say you’re unwilling to do it as a class. Seems like the latter might lead to doing it anyway without additional pay

 

[Candidate2017]

Once an organization has made up its collective mind, it has made up its mind. Especially an organization in which you have zero power. You can gently appeal to their interests and hope you are taken into consideration, but that's about it.

In sum, residency sucks double donkey butt. Try not to overhear faculty meetings where they discuss contracts and deals where they make millions off your labor and it will suck slightly less. But residency will end, learn what you can, and file away this experience as part of the long list of things to which you will reflexively refuse to do when you are an attending.

 

[UTsksk]

Was a chief resident before, was told that there is a difference between "home call" and "internal moonlight". Home call was considered as part of your job, and there is a grey area whether it counts towards residents' hours. But internal moonlight was not allowed in my program, as we receive CMS money and residents were not allowed to "double dip". The argument was "these are the patients you suppose to take care with your resident salary, and you are not supposed to be paid in addition". Weak argument but that how our GME office insisted. Imaging how disappointed as a resident to not being able to get some extra money

Glad to see my program isn’t the only one getting screwed with moonlighting lol

 

[AnonymousPsychRes]

Yeah man, it sucks but theres no stopping your program if they are pushing to do it.

Best advice i can say is get your res prog director to push back against the ED. Mostly im expecting the hospital itself is putting the pressure from above to both ED and psych, but doesnt actually want to pay for additional staff. If your PD has a spine they will ask the additional coverage to be paid internal moonlighting or something. At worst, you guys get boned with extra work without additional benefit.

I’ll say our program does heavy ED work. More than most programs, including overnight. Things can get worse than your set up now. I would push for money to moonlight this rather than say you’re unwilling to do it as a class. Seems like the latter might lead to doing it anyway without additional pay

That’s ultimately what I think we’re doing at this point. We’re asking for for internal moonlighting, given that there are programs within the enterprise that already do this.
Our secondary ask is going to be a partial post call day and making the pool of folks who can be called in bigger than just our class as 3rd years and that the 4th years also share the burden. If the call expectations are swinging so drastically it’s not right for it to be all on my small class.
I don’t think these are unreasonable asks?


How much ED did you all do?
Our weekend coverage, 7-8 weeks of of night float with 6-7 weeks of ED days has felt like such a drag + covering weekends. It’s hard to imagine doing much more.

 

[FlowRate]

Our secondary ask is going to be a partial post call day and making the pool of folks who can be called in bigger than just our class as 3rd years and that the 4th years also share the burden. If the call expectations are swinging so drastically it’s not right for it to be all on my small class.
I don’t think these are unreasonable asks?

Similar solution with some of the changes in our program that happened after my time.

How much ED did you all do?
Our weekend coverage, 7-8 weeks of of night float with 6-7 weeks of ED days has felt like such a drag + covering weekends. It’s hard to imagine doing much more.

12 total weeks night float primarily covering ED, 8 weeks working exclusively ED day shift as an intern. Weekend coverage for the three hospitals spread over two years. Plus a good amount of ED consults while on CL.

 

[mistafab]

Similar solution with some of the changes in our program that happened after my time.

12 total weeks night float primarily covering ED, 8 weeks working exclusively ED day shift as an intern. Weekend coverage for the three hospitals spread over two years. Plus a good amount of ED consults while on CL.

oof. Yes, it can get much worse.

I don't want to blast my program too specifically - but lets say that it is a lot.

 

[comp1]

There's something like a weird Stockholm syndrome about working nights and call for people who went through it. Psychiatry SHOULD be a low stress residency. It's how we attract the best and brightest without having anywhere near the highest pay. Getting "independence" should be through moonlighting opportunities. Just because past generations suffered, doesn't mean everyone going forward should. And I personally trained before any of the work hour restrictions.

 

[FlowRate]

There's something like a weird Stockholm syndrome about working nights and call for people who went through it. Psychiatry SHOULD be a low stress residency. It's how we attract the best and brightest without having anywhere near the highest pay. Getting "independence" should be through moonlighting opportunities. Just because past generations suffered, doesn't mean everyone going forward should. And I personally trained before any of the work hour restrictions.

There are different paths to similar endpoints. Acting as if there's zero educational value to call is IMO silly. You won't see me advocating for having to take nearly as much call as I did (I did explicitly call it out as exploitative) but I think there is a happy medium. Going from always having ample daytime supervision with lots of docs around to being the only doc with no backup all at once is another path but not one I'd prefer. But I guess you left what you meant by "moonlighting" vague so maybe that's not what you're referring to.

 

[GHPA]

My program have 4 weeks 20 (?) shift ED during intern. 1-2 mo of night float as PGY-1 and 2-3 mo night float as PGY-2. The bad part is from 8p to 8a, we are covering 140+ bed inpatient + floor emergency C/L + MEU + ED (65 or so bed). One of my worst night I got like 50-60 pages, had to clear my pager 2 times, yucks!

But I did learn a lot, and still loves the ED consult as mentioned above. Don't care too much about Dx or treatment, just make a quick decision on admit or D/C. And at the end of the shift, no more notes or follow-up calls, someone else will be taking care of the patients. Still doing 1-2 ED shifts a week, in addition to my outpatient PP.

 

[NickNaylor]

The thread has brought up a lot of potential solutions, but the real question is how feasible these things are. "Hire a social worker" may or may not be doable, though to me this seems completely reasonable. From an education perspective, having some kind of backup system in the residency program is reasonable, but the idea of using that backup system as a stop-gap measure for excess clinical work seems dumb. It sounds like the clinical service/education balance is out-of-whack. We have residents in our ED working essentially 24 hours/day, 7 days/week, but the service line is NOT dependent on the residents being available to see consults, and they are one of many clinicians working in the ED at any one time. In fact, the resident's primary responsibility is to be on-call for the other inpatient units our residency program covers, and they see ED patients whenever they aren't busy dealing with those issues.

Sounds like a conversation needs to be had regarding expectations about clinical work and the residents' roles in making the ED service operate.

 

[SubzDoc]

Hiya everyone.

I made an anonymous account because my regular one is known by many.
My program has always had a back up call system for when folks are sick or have emergencies. Entirely reasonable. We’re on this call for a week at a time.

There’s discussion about using this back up resident at night when the ED has too many consults at once.
Considering it’s “home call”, it technically doesn’t break duty hour violations.
Does anyone else’s residency do this? Are there other surge policies other programs have?
It seems like a terrible solution to a problem that’s been going on for years.

Appreciate the feedback!

If the backup is also assigned a week at a time, and home call becomes part of the obligations, it could be an hours violation. 1 day in 7 is supposed to be free of all duties.

Some of the ACGME documentation indicates that home call should be used when the call volume is low, and statistics should be kept to prove that. If you bring some of these things up, it might be enough to put the kibosh on it. When I was in 2nd year, we had a (minor) hours issue that one of the residents reported to ACGME. As a result, we had a bunch of imposed, mandatory meetings that were despised by residents and faculty alike. Sometimes even the suggestion of ACGME issues is enough to kill a proposal as nobody wants the headache.

In general, I agree with NickNaylor about clinical/educational balance. When I was chief, I got into it with some of the ED peeps about some similar issues with call coverage. In retrospect, I would have gotten more traction by pointing out the changes wouldn't improve education (as they were claiming) but would make call suck a whole lot more.

 

[hamstergang]

If the backup is also assigned a week at a time, and home call becomes part of the obligations, it could be an hours violation. 1 day in 7 is supposed to be free of all duties.

Isn't that 1 day off in 7 supposed to be an average over 28 days or something?

 

[Mad Jack]

I 100% agree with this. We have 24/7 staff in our hospital, and I have seen up to 12 patients in a 12 hour shift. Sometimes these consults are “the patient is sad” which is incredibly frustrating. We’re not allowed to turn down any consults.

They’re demanding that any ED patient needs disposition within 2 hours of the time the consult is placed, there’s been pressure from hospital admin and apparently this is the solution we’re moving towards in a couple weeks and it feels ridiculous.

Completely unreasonable. If a psychiatrist in inpatient practice would think it's absurd, a resident shouldn't be having to do this. This would functionally turn you into a crisis service, which is something that typically needs dedicated staff in any sizeable ER.

OP, this sort of call is not conducive to being taken from home and would likely result in impossible violations of between-shift duty hours. Minimum time between shifts needs to be 10 hours and any home call relating to this needs to be minimal. If you're taking more than two hours of call it's a clear violation. Furthermore, if it's call with a requirement to return to the hospital in all but the gravest of emergencies, it's not home call and is a violation.

 

[Mad Jack]

Isn't that 1 day off in 7 supposed to be an average over 28 days or something?

This is correct. Some places give you a black weekend to get you a golden weekend as required once monthly and you average exactly 4 days off per 28 day period.

 

[Stagg737]

How much ED did you all do?
Our weekend coverage, 7-8 weeks of of night float with 6-7 weeks of ED days has felt like such a drag + covering weekends. It’s hard to imagine doing much more.

We cover the ED on our consult rotations at both hospitals totaling around 20 weeks of "ER coverage". We did 8 weeks at the VA where our ER volume is pretty low (rarely more than 3-4 in a day) and often for detox, so pretty straightforward. I averaged 3-5 total consults in a day (ER and floor) on that rotation. At our academic center, we have a full team so ER consults are split up and generally manageable and we have 8-12 weeks of scheduled consults there. It's also common to do that as an elective rotation as it just splits the consults up among more people.

At our VA, the weekend call person covers inpatient and the ER, which is again usually pretty manageable imo. During the week, someone covers the unit and ER from 3-9pm, another who stays overnight from 9pm-7am. They're PGY-1s and 2s and switch after 2 weeks. They do not have other clinical duties at that time and I believe they do that rotation twice during residency. At our academic center, the PGY-2's cover overnight during the week from home which is mainly the inpatient unit. They do go in for stat consults in the ER and floor if necessary, but this probably occurs 20-40% of the call shifts and usually they called us before 10pm.

We only have first call during our first 2 years and then 3 weekend days total during PGY-3, otherwise all primary call is optional for extra pay during 3rd and 4th year. Only PGY-3s and 4s do back-up call, and it's for 7 days straight 2-3x per year. We're essentially there if someone can't get ahold of first call or if that person is sick and are back-up for both hospitals. I've had to cover someone who was sick a total of 2 days/nights and never had to come in because volume was too high, though it can happen for weekend day shifts. Forcing the back-up residents to be present to help clear the ER overnight is absurd imo and frankly this just wouldn't fly at our program. If the ER is busy enough to force back-up call to be physically present overnight, then they're busy enough to justify hiring a social worker dedicated to psych in the ER.

 

[calvnandhobbs68]

Completely unreasonable. If a psychiatrist in inpatient practice would think it's absurd, a resident shouldn't be having to do this. This would functionally turn you into a crisis service, which is something that typically needs dedicated staff in any sizeable ER.

OP, this sort of call is not conducive to being taken from home and would likely result in impossible violations of between-shift duty hours. Minimum time between shifts needs to be 10 hours and any home call relating to this needs to be minimal. If you're taking more than two hours of call it's a clear violation. Furthermore, if it's call with a requirement to return to the hospital in all but the gravest of emergencies, it's not home call and is a violation.

Correct “home call” is supposed to be like derm home call for instance…pretty much the only reason they would physically go into the ED overnight would be for SJS. Otherwise it’s call the derm resident, tell them about a weird rash, they give you recs and hang up the phone. Home call would not involve typically going into the hospital for calls…that’s why it’s home call. This would not count as home call.

 

[AnonymousPsychRes]

Completely unreasonable. If a psychiatrist in inpatient practice would think it's absurd, a resident shouldn't be having to do this. This would functionally turn you into a crisis service, which is something that typically needs dedicated staff in any sizeable ER.

OP, this sort of call is not conducive to being taken from home and would likely result in impossible violations of between-shift duty hours. Minimum time between shifts needs to be 10 hours and any home call relating to this needs to be minimal. If you're taking more than two hours of call it's a clear violation. Furthermore, if it's call with a requirement to return to the hospital in all but the gravest of emergencies, it's not home call and is a violation.

We'll keep a log and take it to ACGME if necessary, the rules with home call are very gray and I think they're thinking of taking advantage of the gray area. We wrote a letter about how it sucks and some potential solutions to the problem (moonlighting, having some resident overlap in the afternoons/early evenings when the ED is busiest, time off the next day if called in). The program hasn't given an official response yet.

We cover the ED on our consult rotations at both hospitals totaling around 20 weeks of "ER coverage". We did 8 weeks at the VA where our ER volume is pretty low (rarely more than 3-4 in a day) and often for detox, so pretty straightforward. I averaged 3-5 total consults in a day (ER and floor) on that rotation. At our academic center, we have a full team so ER consults are split up and generally manageable and we have 8-12 weeks of scheduled consults there. It's also common to do that as an elective rotation as it just splits the consults up among more people.

At our VA, the weekend call person covers inpatient and the ER, which is again usually pretty manageable imo. During the week, someone covers the unit and ER from 3-9pm, another who stays overnight from 9pm-7am. They're PGY-1s and 2s and switch after 2 weeks. They do not have other clinical duties at that time and I believe they do that rotation twice during residency. At our academic center, the PGY-2's cover overnight during the week from home which is mainly the inpatient unit. They do go in for stat consults in the ER and floor if necessary, but this probably occurs 20-40% of the call shifts and usually they called us before 10pm.

We only have first call during our first 2 years and then 3 weekend days total during PGY-3, otherwise all primary call is optional for extra pay during 3rd and 4th year. Only PGY-3s and 4s do back-up call, and it's for 7 days straight 2-3x per year. We're essentially there if someone can't get ahold of first call or if that person is sick and are back-up for both hospitals. I've had to cover someone who was sick a total of 2 days/nights and never had to come in because volume was too high, though it can happen for weekend day shifts. Forcing the back-up residents to be present to help clear the ER overnight is absurd imo and frankly this just wouldn't fly at our program. If the ER is busy enough to force back-up call to be physically present overnight, then they're busy enough to justify hiring a social worker dedicated to psych in the ER.

The back up call has been treated as an emergent situation kind of thing in the past. One resident has been called in a few times to cover shifts for people who were sick/had COVID and that was the luck of the draw. The rest of us have never been called in. We have an attending who argued the same thing you did about a social worker, if it is a disposable time they can higher a QMHP to staff their ED, they don't need us as the solution.

 

[Mass Effect]

I 100% agree with this. We have 24/7 staff in our hospital, and I have seen up to 12 patients in a 12 hour shift. Sometimes these consults are “the patient is sad” which is incredibly frustrating. We’re not allowed to turn down any consults.

They’re demanding that any ED patient needs disposition within 2 hours of the time the consult is placed, there’s been pressure from hospital admin and apparently this is the solution we’re moving towards in a couple weeks and it feels ridiculous.

This is called poor leadership on the part of your department. They are allowing the CL service to be misused. When I got one of those "patient is sad" calls, I asked the primary team attending to cheer them up with show tunes. I do not see the consult unless I'm bored with nothing else to do.

Is it typical to have a SW on service?

Yes it is. I find a lot of community hospitals don't have them, but a lot of academic centers do so I guess my experience is the opposite of posters above.