Resident back-up systems - what do you do?

[NickNaylor]

Hi everyone,

Our program is taking a look at our back-up policy, which specifies how residents cover each other on services if someone is absent for any reason other than vacation (e.g., illness, emergency, etc.). Our current policy specifies several rotations that can generally absorb a resident absence on short notice, and residents rotating on these rotations form the "back-up pool" from which we draw covering residents for our busier services (generally the inpatient services). This policy applies to PGY-1s and 2s and is very rarely invoked - maybe once or twice a year.

We're looking at modifying the current policy but we're also exploring other options/structures. One proposal that we've heard of is an emergency resident-on-call (EROC) system, where the residents rotate being the EROC and, while the EROC, are the designated go-to person in the event back-up coverage is needed.

I'm having trouble coming up with other alternatives, so I wanted to hear from you guys if/how you guys deal with this issue. What kinds of systems do you have? How do you determine back-up coverage if a resident is unexpectedly absent from a service?

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[Monocles]

Call back ups should be viewed from an economists' point of view.

Give people who are on call an incentive to show up (ex: owing +% ratio for having a friend cover)
Give people who are back-up an incentive to come in (ex: getting paid back +% ratio for covering)

The magic number is based on how cohesive a program's residents feel towards each other, and this may vary from year to year.

I'm personally happy to pay back any of my classmates on a near 1:1 ratio (we all know that sh-t happens and are happy to pick up the slack for each other) and this is RARELY/almost never abused and backups occur smoothly, whereas if you're in a program or in a class where people are less trusting and more punitive towards each other (ex: "I know for a fact that John Smith is faking to avoid taking call during coachella, etc), people might opt for a more 2:1 payback ratio.

 

[whopper]

Well, heck, a hospital is supposed to have an attending cover if there's no resident. Residents aren't supposed to be labor replacing an attending, but rather if the resident can't make it the attending can cover on their own.

But aside from this have moonlighting available to residents so they have a profit-based incentive to cover.

 

[wolfvgang22]

Having the resident owe the person who covered his or her shift two shifts worked well for my program. The emergency back up person was usually designated as someone who was not immediately on call before or after the person on call.

Paying the emergency on call resident or having the attending be the back up sounds nice, if you can get it. I would anticipate a lot of resistance by the hospital and attendings on those options, though.

All kinds of problems arise with high expectations of care, under staffing, and over dependence on residents as cheap on call labor.

 

[NickNaylor]

Well, heck, a hospital is supposed to have an attending cover if there's no resident. Residents aren't supposed to be labor replacing an attending, but rather if the resident can't make it the attending can cover on their own.

But aside from this have moonlighting available to residents so they have a profit-based incentive to cover.

This point has been a point of controversy within our program. Of course, what you say is correct and, in practice, that's what happens much of the time. The attendings on the unit have discretion with respect to whether or not back-up coverage is arranged, and more times than not they refuse coverage and simply do the work on their own. That said, I also think it's an important professional lesson and an "ethic" to an internalize that, as physicians, part of your responsibility is to cover one another, particularly in a "group" setting. Patient care comes first. I think this is an important thing to realize or understand as you will certainly be expected to do it no matter what setting you end up in after residency.

The culture of our hospitals is such that internal moonlighting for non-BC/BE residents is extremely difficult (i.e., everyone except for fellows). I don't see this feasibly getting done any reasonable amount of time - if at all - so I don't see this as much of an option.

The token economy of owing call is an interesting and reasonable system, but I don't see that getting much traction here. Nevertheless, an idea that I can pitch and see what kind of response it gets.

 

[NickNaylor]

I should also clarify that this policy doesn't really address call. That is something that is arranged informally among the residents, and swapping, trades, offering to cover more call, etc. is done routinely. This policy covers what we do when a resident is straight-up gone from work - typically on a brief leave for whatever reason (approved by PD) - and we need someone to cover their normal duties during the day.

 

[hamstergang]

We're looking at modifying the current policy but we're also exploring other options/structures.

Why? What's wrong with your current system?

 

[NickNaylor]

Why? What's wrong with your current system?

In my opinion, nothing. In the opinion of some of other residents and due to lots of unhappiness about following the policy recently, many things that would be worth addressing.

 

[clausewitz2]

Our services have the expectation that clinical work will get done even in the absence of residents do we have no such system. If a resident did have to take an extended leave on a busy service other residents on might be asked if they could delay planned vacations but people have never been forced to do this as far as I know.

We also have robust internal moonlighting system so probably a senior resident or child fellow would step up. Otherwise we are lousy with researchers who would probably leap at the chance to knock out their 20% clinical time on something as controlled as an inpatient service.

 

[DisorderedDoc417]

New admissions are divided among the remaining inpatient residents and the attending usually just handled the progress notes on old folks.

 

[sloop]

Well, heck, a hospital is supposed to have an attending cover if there's no resident. Residents aren't supposed to be labor replacing an attending, but rather if the resident can't make it the attending can cover on their own.

But aside from this have moonlighting available to residents so they have a profit-based incentive to cover.

Really?

This would never fly at my program. There exist one or two attendings who might even consider doing an admission on their own but this is extremely rare and even so the coverage structure kicks in and the attending winds up with a resident before they even need to make that decision. I've never seen an admission note written by an attending.

I can't say that our inpatient coverage system is anyone's favorite part of the program but it operates like this: each of our floors has three residents on different services. Normal coverage for post-call and vacation entails being covered by the other residents on the floor. If someone is sick or out for some other reason, usually the other residents on the floor will also cover. Sometimes people are sick while someone is on vacation or post-call on the floor which leaves only one resident for all three services but, even then, usually the remaining resident will cover (entailing floor matters and admissions). Back up for the inpatient service generally only goes into effect if the residents on a floor alert the chief to an overwhelming quantity of admissions and the chief determines that the situation on the floor justifies activation of backup. We have one day hospital rotation that is considered to be less intensive and sometimes try to ask this PGY-2 to help with floor admissions on top of their day hospital duties but after this (since our PGY-2 year is entirely inpatient and with the exception of that day hospital resident all of them will have their own services, the only residents who can really be pulled are 3s and 4s), a PGY-3/4 will be pulled from a jeopardy pool to help. This jeopardy pool also serves as the emergency pool for the ED. Call coverage of the inpatient units is a PGY-2 responsibility and emergency coverage is achieved by a back up call system where each call shift lists an on-call resident and a back up resident.

The jeopardy residents get called in relatively frequently. ED volume is the most common offender but getting called due to inpatient staffing issues also is not super uncommon (probably happens at least every 1-2 months).

 

[splik]

Really?

This would never fly at my program.

yeah, your program sucks, but you knew that already. sounds like a cushy place to be an attending though!

 

[sloop]

yeah, your program sucks, but you knew that already. sounds like a cushy place to be an attending though!

It’s a great program in terms of the training we get (and based on a post you’ve previously made naming it one of the best clinical psychiatry programs in the country it seems you agree). The expectations and staffing are intense though.

 

[ridethecliche]

/popcorn

 

[Merely]

It’s a great program in terms of the training we get (and based on a post you’ve previously made naming it one of the best clinical psychiatry programs in the country it seems you agree). The expectations and staffing are intense though.

Stockholm syndrome?

 

[clausewitz2]

At our program on some inpatient services residents do not even write notes on Thursdays when we have didactics in the afternoon, attendings take care of it.

True story - I was on an inpatient service with another resident and it ended up that we both were off for a couple weeks during that block at the same time. The attending's only request was that we have draft discharge summaries prepared beforehand that she could update and sign.

@sloop your setup seems kind of hellish.

 

[sloop]

At our program on some inpatient services residents do not even write notes on Thursdays when we have didactics in the afternoon, attendings take care of it.

True story - I was on an inpatient service with another resident and it ended up that we both were off for a couple weeks during that block at the same time. The attending's only request was that we have draft discharge summaries prepared beforehand that she could update and sign.

@sloop your setup seems kind of hellish.

Well one nice thing about our program is that residents are not ever expected to write progress notes on inpatients. That is an attending responsibility.

But yes, our program is not for the faint of heart (at least as psych programs ams go). We work hard.

 

[NickNaylor]

Well one nice thing about our program is that residents are not ever expected to write progress notes on inpatients. That is an attending responsibility.

Huh? That seems strange.

 

[sloop]

Huh? That seems strange.

Generally patients come to the resident's office, which is located on the unit. Attending commandeers the desk and desktop computer for rounds and writes progress notes while the resident (or med student) interviews. Resident has a laptop and enters orders between patients or during nursing report. Works out pretty well from my perspective.

 

[Merely]

Generally patients come to the resident's office, which is located on the unit. Attending commandeers the desk and desktop computer for rounds and writes progress notes while the resident (or med student) interviews. Resident has a laptop and enters orders between patients or during nursing report. Works out pretty well from my perspective.

What program are you at? It would help future students to try and avoid it lol

 

[sloop]

What program are you at? It would help future students to try and avoid it lol

For people who know about the program it's pretty easy to infer from my posts but I prefer not to be explicit about it.

In any case, I truly love this place. There are a handful of places that actually offer the type of clinical exposure we do. You will work hard if you come here, though. We will be forthcoming about this on interviews. Trust me, we know that people who are looking for a cushy program will not be happy here.

Besides, it's not like writing progress notes is incredibly difficult. You learn how to do this as a med student. I don't personally think there's a lot of educational value in writing progress notes. That is time that could be used to learn from admitting more patients or tackling daily clinical care issues. If you do subattending rotations as a senior you get to write plenty of progress notes.

Look guys: The OP asked about how coverage is done elsewhere. I shared how it is done at my program. If people want to say that this system seems like it places a lot of burden on residents, that is fair. I actually agree with that. Several posters have implied that my program is broadly terrible and that is not at all fair. This is a very good, very well-respected program. The fact that a bunch of people are piling on to broadly disparage my program based on knowledge of one aspect of it is stupid and I have no idea what motivates it.

 

[clausewitz2]

For people who know about the program it's pretty easy to infer from my posts but I prefer not to be explicit about it.

In any case, I truly love this place. There are a handful of places that actually offer the type of clinical exposure we do. You will work hard if you come here, though. We will be forthcoming about this on interviews. Trust me, we know that people who are looking for a cushy program will not be happy here.

Besides, it's not like writing progress notes is incredibly difficult. You learn how to do this as a med student. I don't personally think there's a lot of educational value in writing progress notes. That is time that could be used to learn from admitting more patients or tackling daily clinical care issues. If you do subattending rotations as a senior you get to write plenty of progress notes.

Look guys: The OP asked about how coverage is done elsewhere. I shared how it is done at my program. If people want to say that this system seems like it places a lot of burden on residents, that is fair. I actually agree with that. Several posters have implied that my program is broadly terrible and that is not at all fair. This is a very good, very well-respected program. The fact that a bunch of people are piling on to broadly disparage my program based on knowledge of one aspect of it is stupid and I have no idea what motivates it.

Oh, don't get me wrong, I didn't mean to imply your program was low-quality or anything. My program is also incredibly diverse in clinical exposures and an excellent place to train, but our consult service is truly nightmarish with black weekends every three weeks with the expectation that you will see ~20 new consults per weekend all of which require a full psychiatric evaluation (regardless of the consult question) in addition to spending the whole preceding week on home call for five hospitals. You are also expected to make any and all arrangements for follow-up psych care for all patients on your caseload, whether that is inpatient or outpatient, and also petition for and testify at involuntary commitment hearings if no one closer to the patient is available to petition.

Oh right and our service is called for essentially all capacity evaluations. We are not permitted to decline this.

So when I say your situation sounds hellish, I don't mean disrespect, I just mean it sounds awful.

 

[FlowRate]

The token economy of owing call is an interesting and reasonable system, but I don't see that getting much traction here. Nevertheless, an idea that I can pitch and see what kind of response it gets.

I can see why people have call repayment systems. It turns out that we have one, informally, which I think is actually the worst option. I had to miss three nights of a week of night float due to having influenza and then they made me pay back a week of night float the next week for the person who covered. Would have been less annoying if we had a more formalized payback system.

Our services have the expectation that clinical work will get done even in the absence of residents do we have no such system. If a resident did have to take an extended leave on a busy service other residents on might be asked if they could delay planned vacations but people have never been forced to do this as far as I know.

We have a variation in how this goes depending on the service. When we had only afternoon didactics first year, one of the inpatient units basically tried to make us finish our usual daily work before going to didactics. Second year and on, with full day didactics, every service is expected to function without residents for that day.

our consult service

I don't know what it is about consult services that have this sort of attitude. It's miserable for trainees and anyone else who doesn't get a bunch of gratification out of a specific way of practicing CL psychiatry (feeling like an important expert who is always able to find ways to be helpful to everyone in any situation. Or alternatively--seeing what "everyone else is missing.") I don't even think that it's "wrong" or "bad," (in fact, sometimes it's "right") it can just get really draining when forced as a blanket default mode of practice IMO. Sometimes primary teams need to be taught/encouraged/expected to do some things themselves. Maybe then the medicine department will help fund some ancillary services (SW.)