Residents, how late do you stay?

[TrailRun]

Quick question...

Our residents typically stay 30min -2hrs late after a shift cleaning up, battling for admission, etc. I'd say about half the time I'm between 90min-2hrs late, and the other half 45-60min. I know a few places I interviewed at (Brown?) had dedicated sign out time for residents and attendings together so everyone got out on time. But our program has residents and attendings offset. I know as a resident progresses from intern year onward we typically get more efficient. We don't usually take new patients in our last hour which helps somewhat but still doesn't seem sufficient.

Has anyone's program transitioned to the above synchronous sign out with attendings or any other strategies to help people get out on time?

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[Angry Birds]

I usually left on time. Sometimes half hour late. Rarely more than that.

Make sure you’re not inefficient, especially compared to your peers. It’s a habit that I see people not grow out of and they continue to do it as attendings.

 

[deleted547339]

What time the attending leaves has nothing to do with when the resident leaves. Consistently leaving late is a sign of poor time management if it’s just a few people, or poor workflow/systemic problems if it’s everyone - sounds like the latter.

 

[OneTwoThreeFour]

New intern. Usually signout takes 20-30 minutes and I finish notes for 30 minutes. A couple of times I pushed procedures to the end of my shift though.

 

[Buckeye1992]

New intern here.
Its hard for me to gauge for myself. I push myself to see more patients to help and to see more volume. I see more patients than the other interns but also tend to have to stay latter than others to chart.

 

[doggydog]

As an intern I think I left >30 minutes after sign out less than ten times. Now I routinely stay a while after shift because as a second year we are in charge of moving the department. The slower ones or the ones not concerned about moving the department are still getting out on time.

It's not all about efficiency/time management skills.

 

[Cinclus]

PGY3 here. I am usually able leave within 30 minutes of signout completion, and rarely more than 1 hour after. I have stayed 90 minutes after maybe 2-3 times in residency so far, generally after absolute ****shows of shifts. I always finish notes before leaving; I refuse to chart at home.

 

[AlmostAnMD]

First year: 1-2 hrs late consistently
second year: 30-60 minutes
chief: always on time with rare exception

 

[doggydog]

How many patients per shift are y'all seeing? How long before sign out do you stop seeing patients?

 

[Epinephreus]

PGY2 - Usually not more than 30 mins to wrap up after sign out. Our program has a pretty good culture about not picking up patients up in the last hour (who aren't critical) so it's pretty easy to plan things and take care of dispos/to-dos before sign out.

I do tend to chart at home, which for a typical shift (10-14 new pts), is about an hour.

 

[Millennial ER Doc]

I would evaluate WHY you're staying so late. If you're not picking up patients within the last hour of the shift, then is the reason you're staying late because:

• you're waiting for a consultant to call back
• you're waiting for a lab/image to result
• or to see if a patient tolerates a PO challenge/ambulates

Unless there's multiple sick patients showing up within 1-2 hours of sign out; the above issues should be anticipated long before sign out is approaching.

And the key word with the above issues is "waiting" - if you know a patient isn't getting to X-ray/CT/MRI, why don't you wheel them over if the staff is busy/lazy? If a lab isn't resulted in a timely fashion, did you trouble shoot this? Did you make sure it was drawn? Sent? Processed? Did you call the lab?

The bottle necks of dispos are normally the same everywhere, once you figure out what they are, it's up to you to make sure they're being dealt with long before sign out.

When I was a senior resident, I handled the volume (by this point you should know your institution specific bottle necks), telling the intern to focus on a just a few patients, but to make sure they were thorough in their learning and management.

My 2 cents.

PS - you should be on top of your notes at all times (especially as an intern)

 

[LostinLift]

As an intern I'm usually out in 15-30 minutes, sometimes right on time if everything is tied up nicely. 2-3 late shifts so far due to procedures or sick patients. Would grabbing 1-2 extra patients a shift make a huge difference over the next year while pushing myself past the "slightly uncomfortable" of what I'm currently doing? Maybe, but I'm pretty quick and I like the balance I've found.

Also how long are your shifts? Ours are 9s and 10s mostly. Regularly turning those into 12s would be draining.

 

[clibby]

I am a PGY 2 at a program with good sign out, so there is rarely a need to stay late for patient care. If I am being lazy and not staying up with documentation, I can end up staying 1-1.5 hours after. However, as long as I don't do that, I can leave within 15 min of my shift ending. We stop picking up new ones 1 hour prior and just do an MSE exam unless they are really quick. Staying late is totally whether I am being lazy with documentation even on the busy days.

 

[hundreddaysoff]

We had 8h shifts and most of us stayed ~1h after signout to chart, but that's only because our EHR (Soarian) was very slow and crashed a lot. We had group signout although most of us considered it a waste of time (was much faster to do 1-1 signout asynchronously as group signout tended to be derailed by a handful of Chicken Little attendings).

The worst residents to take signout from were the ones who were unable to give up ownership of their patients and just go home. Sometimes they would stay for an extra 1-2h finishing up stuff without even telling me they were still around. Don't be that guy; it becomes a pt safety issue. Leave the ER after signout, chart if you must, and then get out. Yes, you've been a workaholic your entire life, but now is the time to chill out a bit. You will not get fired for getting out on time. Don't worry about it.

At the same time, people who tell you "you need to keep up with your charting on-shift" are often being unrealistic and have never worked at big county places w/ terrible EHRs. This is not always possible. If you have enough time to chart on shift then do it, but pt care and in particular *prioritizing discharge over ~everything else* should take priority if you work in a total zoo like I did. Remember that you might luck into an attending job where you actually get paid to chart after shift and it is in your group's culture.

 

[theseeker4]

PGY3 here. Since second half of intern year I have been leaving either right after signing out, or within 30 minutes of relief coming on the vast majority of the time. Occasionally longer but usually not. I also finish all my notes before leaving. Most times that I am stuck longer is because I haven't been able to staff my patients with the attending to confirm my plan with them until it is almost time for shift change, so I am stuck putting in discharges/admits on 5-6 patients and finishing their notes at the very end.

 

[Frazier]

How many patients per shift are y'all seeing? How long before sign out do you stop seeing patients?

We dont have signout at our place unless it is something crazy... like unexpected 4 hour wait crazy.

We do 10 hour shifts and stop picking up new pts with ~3 hours to go.

Averages:

Interns see 0.7pph,
pgy2's 1.5pph,
pgy3's 2pph.

Typically leave 0-15 min late.

 

[Groove]

Practice makes perfect. I wouldn't worry about it unless you're finishing residency and are still having problems getting out on time. Just remember, whatever time management skills you internalize and hardwire, will carry over to attendinghood. The exact same goes with bad habits. In residency, we weren't allowed to leave without all admitted pt's notes completed. I managed to complete most of my notes by the end of my shift, but honestly it wasn't until my first or second year out that I transitioned to completing 100% of my notes by the end of my shift. I think it's incredibly sloppy to leave work on admitted pt's without the note completed. And we wonder why consultants and admitting docs place more value on the nursing notes than ours...

By and large, the biggest issue having a deleterious effect on time management in residency is the same thing people do as an attending and that's feeling the pressure to pick up pt's on the tracking board without a name on them. You therefore sign up for way too many people than you can comfortably see, and it kills your metrics as well as your time management putting you perpetually behind during your shift.

The second thing is being able to identify bottlenecks and hurdles to disposition within the last hour and a half such as a particular lab hasn't been collected, CT hasn't been done, US or MRI pending..(have they been called in?) and addressing these early, as well as identifying within your last 30 mins the pt's that are failed dispo's with SOS written all over them and no way that you can possibly finish everything even when staying an hour over your shift. (You got a dimer that was +, sent to CTA and they are too fat for good vascular opacification or the contrast timing was off or both and the study is worthless and now you are considering VQ and they are just calling them in 5 mins before you are supposed to leave, etc...) For the failed dispo pt's, put your pride aside and just sign the pt out if possible. I realize that in residency, sign outs should be much more common, but for practices where it's not as common (i.e. RVU based), I think it's important to be able to sign these out to the oncoming doc and get out on time. I've seen some of our new docs stay 2-3 hours after a shift to finish up a single pt that they are too prideful to sign out and nobody needs to be stuck at work that long after your shift. Help your colleagues get out on time and chances are they will help you do the same.

The third thing I commonly see is a personal decision and that's whether to half finish your note in order to see more pt's in your shift, with the plan on leaving on time but having to chart 2 hours after your shift. I feel really strongly about this one and my CMG doesn't pay me to chart and I refuse to chart on pt's after work. I may not be the fastest, but my avg is still 2.3 pph and I have 100% charts completed by the time I leave. I'm ok with that as I am much less stressed when I leave work and don't have to worry about not being able to recall small details 6 hours or a 1-2 days after my shift.

Long post, but the short of it is... just do your best and find what works for you because it may not work for everyone. Whatever system you utilize, get proficient at it and chances are it will serve you well after residency. I would encourage you to aim at finishing your admitted pt's notes at the very least by the time you leave (or by the time of admission if you can do that...) and whatever you feel comfortable with regarding the rest. You'll get there.

 

[scummie]

Practice makes perfect. I wouldn't worry about it unless you're finishing residency and are still having problems getting out on time. Just remember, whatever time management skills you internalize and hardwire, will carry over to attendinghood. The exact same goes with bad habits. In residency, we weren't allowed to leave without all admitted pt's notes completed. I managed to complete most of my notes by the end of my shift, but honestly it wasn't until my first or second year out that I transitioned to completing 100% of my notes by the end of my shift. I think it's incredibly sloppy to leave work on admitted pt's without the note completed. And we wonder why consultants and admitting docs place more value on the nursing notes than ours...

By and large, the biggest issue having a deleterious effect on time management in residency is the same thing people do as an attending and that's feeling the pressure to pick up pt's on the tracking board without a name on them. You therefore sign up for way too many people than you can comfortably see, and it kills your metrics as well as your time management putting you perpetually behind during your shift.

The second thing is being able to identify bottlenecks and hurdles to disposition within the last hour and a half such as a particular lab hasn't been collected, CT hasn't been done, US or MRI pending..(have they been called in?) and addressing these early, as well as identifying within your last 30 mins the pt's that are failed dispo's with SOS written all over them and no way that you can possibly finish everything even when staying an hour over your shift. (You got a dimer that was +, sent to CTA and they are too fat for good vascular opacification or the contrast timing was off or both and the study is worthless and now you are considering VQ and they are just calling them in 5 mins before you are supposed to leave, etc...) For the failed dispo pt's, put your pride aside and just sign the pt out if possible. I realize that in residency, sign outs should be much more common, but for practices where it's not as common (i.e. RVU based), I think it's important to be able to sign these out to the oncoming doc and get out on time. I've seen some of our new docs stay 2-3 hours after a shift to finish up a single pt that they are too prideful to sign out and nobody needs to be stuck at work that long after your shift. Help your colleagues get out on time and chances are they will help you do the same.

The third thing I commonly see is a personal decision and that's whether to half finish your note in order to see more pt's in your shift, with the plan on leaving on time but having to chart 2 hours after your shift. I feel really strongly about this one and my CMG doesn't pay me to chart and I refuse to chart on pt's after work. I may not be the fastest, but my avg is still 2.3 pph and I have 100% charts completed by the time I leave. I'm ok with that as I am much less stressed when I leave work and don't have to worry about not being able to recall small details 6 hours or a 1-2 days after my shift.

Long post, but the short of it is... just do your best and find what works for you because it may not work for everyone. Whatever system you utilize, get proficient at it and chances are it will serve you well after residency. I would encourage you to aim at finishing your admitted pt's notes at the very least by the time you leave (or by the time of admission if you can do that...) and whatever you feel comfortable with regarding the rest. You'll get there.

Some great advice here, kids!

By the time you are a third year, I would say that you should have your notes and be leaving within an hour of your shift being done. Granted, sometimes a patient deteriorates at sign out, or the CT just comes back with appendicitis, but remember this—as an attending, you do not get paid extra to stay after your shift to chart. So yeah, you can see 20 patients but if you spend 2 hours after writing your notes, was it really the same number of PPH? I would much rather spend that time doing fun stuff than trying to remember all the chest pain I saw during a shift.

Our program also released metrics, so knew who had the highest PPH and RVUs. Talk to those people!

 

[mimelim]

My biggest issue toward the end of residency was that I would routinely be operating while sign out is going on. Probably happened 3 out of 5 days in a work week. So then you run into the issue of, how do you do an effective sign out? Keep people in the hospital until I'm out? Do it over the phone? Etc. When you have 60+ patients on service and have 4-5 cases still going at 6pm every day it is really hard to get people out 'on time'. I pretty much gave up on 'hours' by the end. On the other hand, we were rather generous with our days off, so it was hard to really complain since none of us really wanted to change things.

 

[doggydog]

My biggest issue toward the end of residency was that I would routinely be operating while sign out is going on. Probably happened 3 out of 5 days in a work week. So then you run into the issue of, how do you do an effective sign out? Keep people in the hospital until I'm out? Do it over the phone? Etc. When you have 60+ patients on service and have 4-5 cases still going at 6pm every day it is really hard to get people out 'on time'. I pretty much gave up on 'hours' by the end. On the other hand, we were rather generous with our days off, so it was hard to really complain since none of us really wanted to change things.

I just operate better. I always finish my operations thirty minutes before sign out so I can have a nap too. Just be better.

 

[HLxDrummer]

Third year here. Anywhere from on time to 2 hours late. Usually on time to 45 mins late. Issue for me is that CT/labs/etc. come back right before sign out so I have to call a consult/wait for them to call back to avoid giving the next resident more work. I also have my patients "typed up to go" meaning that the DC instructions/scripts are ready for anyone not definitely getting admitted. I also have all my notes done before I leave. This is averaging like 2PPH.

 

[deleted547339]

We dont have signout at our place unless it is something crazy... like unexpected 4 hour wait crazy.

We do 10 hour shifts and stop picking up new pts with ~3 hours to go.

Averages:

Interns see 0.7pph,
pgy2's 1.5pph,
pgy3's 2pph.

Typically leave 0-15 min late.

You stop picking up patients 3 hours before your shift ends!? You should be leaving an hour and a half early. Holy cow. That’s nuts. I’ve never heard of a program that does that. Some places allow the last hour, but 3 hours is crazy. Don’t expect that when you finish training. When I was a resident, I would stop seeing patients about 15-30mins before the end of the shift. We signed out, but you had to do all procedures and all dispos. Essentially, you signed our people pending imaging or consults as labs turned around quickly. So if you had 10 patients, the oncoming resident may have 2-3 patients that required work and the rest would be done.

When moonlighting in the community I stop about an hour before end of shift with the exception of patients who are easy to dispo.

 

[deleted547339]

Third year here. Anywhere from on time to 2 hours late. Usually on time to 45 mins late. Issue for me is that CT/labs/etc. come back right before sign out so I have to call a consult/wait for them to call back to avoid giving the next resident more work. I also have my patients "typed up to go" meaning that the DC instructions/scripts are ready for anyone not definitely getting admitted. I also have all my notes done before I leave. This is averaging like 2PPH.

You sound like my favorite type of coworkers.

 

[Dr.CCM]

Practice makes perfect. I wouldn't worry about it unless you're finishing residency and are still having problems getting out on time. Just remember, whatever time management skills you internalize and hardwire, will carry over to attendinghood. The exact same goes with bad habits. In residency, we weren't allowed to leave without all admitted pt's notes completed. I managed to complete most of my notes by the end of my shift, but honestly it wasn't until my first or second year out that I transitioned to completing 100% of my notes by the end of my shift. I think it's incredibly sloppy to leave work on admitted pt's without the note completed. And we wonder why consultants and admitting docs place more value on the nursing notes than ours...

By and large, the biggest issue having a deleterious effect on time management in residency is the same thing people do as an attending and that's feeling the pressure to pick up pt's on the tracking board without a name on them. You therefore sign up for way too many people than you can comfortably see, and it kills your metrics as well as your time management putting you perpetually behind during your shift.

The second thing is being able to identify bottlenecks and hurdles to disposition within the last hour and a half such as a particular lab hasn't been collected, CT hasn't been done, US or MRI pending..(have they been called in?) and addressing these early, as well as identifying within your last 30 mins the pt's that are failed dispo's with SOS written all over them and no way that you can possibly finish everything even when staying an hour over your shift. (You got a dimer that was +, sent to CTA and they are too fat for good vascular opacification or the contrast timing was off or both and the study is worthless and now you are considering VQ and they are just calling them in 5 mins before you are supposed to leave, etc...) For the failed dispo pt's, put your pride aside and just sign the pt out if possible. I realize that in residency, sign outs should be much more common, but for practices where it's not as common (i.e. RVU based), I think it's important to be able to sign these out to the oncoming doc and get out on time. I've seen some of our new docs stay 2-3 hours after a shift to finish up a single pt that they are too prideful to sign out and nobody needs to be stuck at work that long after your shift. Help your colleagues get out on time and chances are they will help you do the same.

The third thing I commonly see is a personal decision and that's whether to half finish your note in order to see more pt's in your shift, with the plan on leaving on time but having to chart 2 hours after your shift. I feel really strongly about this one and my CMG doesn't pay me to chart and I refuse to chart on pt's after work. I may not be the fastest, but my avg is still 2.3 pph and I have 100% charts completed by the time I leave. I'm ok with that as I am much less stressed when I leave work and don't have to worry about not being able to recall small details 6 hours or a 1-2 days after my shift.

Long post, but the short of it is... just do your best and find what works for you because it may not work for everyone. Whatever system you utilize, get proficient at it and chances are it will serve you well after residency. I would encourage you to aim at finishing your admitted pt's notes at the very least by the time you leave (or by the time of admission if you can do that...) and whatever you feel comfortable with regarding the rest. You'll get there.

I think I’d disagree a little bit with you. I work in the ER and ICU. In the ED, I often don’t finish my notes on admitted patients before shifts end. When in the Unit, I honestly don’t care about the ER docs note because it’s just too much crap in there that I’ll have to go through. The mdms don’t give me a lot either being too broad and too vague.

The main things I care about in the Unit are often RARELY addressed in an ER docs note where they are easy to find: why was the patient intubated, what were your ED meds/interventions (including all the fluids given) as all that is difficult to find in most EMRs readily, what was the patients exam prior to intubation. How bad was the airway, what was the initial rhythm during cpr, were the lines sterile, who’d you consult and what did they rec (that’s usually in the ed course but again hard to find in there), who brought the patient and from where, should be a checklist or something that’s easy to figure out when in a handoff format. This isn’t an exhaustive list but important stuff. I know this is tedious on those patients but you can bill extra cc time and it honestly helps out with patient care.

 

[scoKraz4]

PGY-2, typically our sign out is on time to 10min after. I have stayed 1-2hour later a handful of times because of crashing patients coming literally right before new team comes in. Don't see new patients in the last 1-1.5 hours depending on how busy it is, usually see anywhere from 15-25 per 12hour shift. Generally im out once sign out is done. If you are routinely staying 1-2hours late, something is wrong. In my opinion if I'm coming on a new shift, I'd rather the team that's on work on dispo's for their patients in the last 1-2hours then cram in new patients to help clear the room.

 

[LilKangaroo]

PGY-2, usually stay anywhere from 0-90 minutes late, usually 15-30 minutes. The culture at my program is finish up your patients (admission calls, discharges, etc). It was starting to get ridiculous as we were staying late to admit people when the CT or important labs weren’t back. My class has been working on changing that culture and taking over patients so the off going person gets to go home. On really good days I’ve left about 10 minute early. We have about 30 minutes of overlap with the incoming doc, so we stop picking up patients 30 minutes prior to that doc arriving, so about 1 hour before the shift ends. The biggest problem we are running into now is that the oncoming doc is seeing new patients before we sign out which can delay sign out by quite a bit. We are seeing about 14-18 patients per 8.5 hour shift at the beginning of our second year, have seen up to 22 overnight.

 

[emergentmd]

When I was a resident, I almost never stayed more than 30 min past my shift. That is why you pass everything onto your oncoming partner.

In my community job, I am out the door when the new guy comes 90% of the time and pass the pt off. We get paid by the hour, so no reason for any of us to stay any later.

 

[thegenius]

It's a learned skill to give a good, concise, low risk sign-out. I think the main things are you shouldn't sign-out 1) consults, 2) procedures (imagine if the first doctor said we need to do a pelvic, then 45 minutes later a new doc comes in and says "alright, spread your legs") and it's OK if you sign out like CTs, certain labs, etc.

We all get sign-outs and the best ones are those where risk is minimized for the second doc.

Edit: And you should start thinking about your signout 1-2 hours prior to the end of your shift, so if you need to make a call to the consult, or need to do the LP or pelvic, then just get it done.

 

[hundreddaysoff]

.
Edit: And you should start thinking about your signout 1-2 hours prior to the end of your shift, so if you need to make a call to the consult, or need to do the LP or pelvic, then just get it done.

Main hard exception is when I'm waiting for a CT scan to decide whether to consult surgery. Can take 3h to get the CT read around here. Any suggestions on this one? (I guess "learn to ~read your own CTs" would be one good answer.)

 

[emergentmd]

That is easy. Pass on the CT and let the new doc decide. Give them you phone number if you want everything covered.

I pass on these
1. Consults if they haven't called back in 15 minutes. I refuse to wait for them as my time is just as important. I give my cell # to the clerk, and have the consultant call me for report. I will also tell the doc on just so he knows what is going on.
2. All CT/Imaging unless it will come back in 15 min
3. Labs if they are sent and in process. I am not waiting on the nurse to draw and get results which is another hour. I just tell the doc to take over

What I don't ever. Everything else is fair fame.
1. Procedures

I always Launch into my ready to go home mode about 90 minutes before my shift ends. I check to make sure that all imaging has been done, all labs has been drawn. I will bug the charge nurse if any of this has not been done. I rarely have to deal with blood not sent b/c I am on it 90 min before my shift. Don't watch for this early and you will have some great surprises when you are about to leave.

Also, Don't pick up complicated patients 90 min before your shifts. If you happen to accidentally pick up a complicated pt or someone requiring a CT scan, Order it right away.

Never Nickle and dime your patients. I see docs get into this nickle/dime process and pts are there forever. They order labs, which comes back. Order more labs, which comes back, orders CT, which comes back, and its 4-5 hrs into the process.

I order my labs and any imaging after seeing the patient. I almost never order any extra labs and rarely imaging when things comes back.

Im worried about an appy? Lab + CT. WBC will never change my thinking.

 

[pollyspockets]

I’m typically 60-120 minuets late, but this is always related to ED volume. On days when I see 30+ patients on a 9 hour shift I have to stay late. I also won’t do my charts at home, so I’d rather stay and finish and check out less.

 

[CajunMedic]

PGY-1: We're not expected to sign out anything unless it's going to be longer than 1-1.5 hours to dispo. Shifts are 10 hours with the intention of staying at least 1-2 hours to finish charting. Goal is 1.2 pph by end of intern year. My best shift was getting off on time with all my charts done and pt's dispo'd, worst (2nd intern shift) was an hour and a half late with another 6 hrs finishing up my charts. (at least 11 if I remember correctly)