ROL and Call Schedule

[Prof Moriarty]

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I'm making my ROL. Taking a look at my top 3, I'm having a hard time ranking them against each other. So for the sake of comparison I started looking at a few things that are different about each of these programs. One of them is the call schedule.

Program A has a front loaded call schedule. The call covers ~20 beds and is not known to be too onerous.

• PGY-2 has 4.5 months of q4 in-house overnight call with post-call day off, 4.5 months of Sunday coverage (8a-8p or 8p-8a with no post-call day off), and 3 months of coverage of every other Saturday.
• PGY-3 has 4.5 months of q4 in-house overnight call with post-call day off, and 3 months of every other Friday.
• PGY-4 is back-up call only.
• This adds up to a total of ~72 weeknights of call (with ~50 post-call days off) and 26 weekend coverage days (with no post-call day off).
• 98 total call/coverage days.

Program B takes all call from home, usually one week at a time. Coverage is for a few sites and totals ~30 beds. Most issues are dealt with on the phone, and there are no post-call days off. Other than the call schedule, all weekends are free.

• PGY-2 has 5 weeks of home call, including rounding on 30 beds on the assigned weekend days. Also, there are 4 additional Saturdays of home call for a different (also small) facility.
• PGY-3 has 4 weeks of home call, including rounding on those weekends, plus 4 additional Saturdays.
• PGY-4 has 3 weeks of home call with the weekend rounding, plus 2 additional Saturdays.
• This adds up to a total of ~55 weeknights of home call (with no post-call days off) and ~30 weekend home call days including rounding (again no post-call day off).
• 88 total call/coverage days.

Program C has a reputation as a hard-working program with tougher overnight calls covering a large (>100 bed) rehab hospital.

• PGY-2 has 18 overnight calls (24-hour shift, 8am-8am) with post-call day off. 8 additional weekend day shifts.
• PGY-3 has 15 overnight calls with post-call day off and 8 additional weekend day shifts.
• PGY-4 has 2 overnight calls with post-call day off and 4 additional weekend day shifts.
• This adds up to a total of ~35 calls (could include weekends) with post-call day off, and ~20 weekend day shifts.
• 55 total call/weekend shift days, with probably ~25 post-call days off.

Mapping these #'s out, I am struck by a few things:

• The program with the most call days (Program A) also gets the most post-call days off.
• The program with the "mellow" home call (Program B) ends up with the most coverage overall (considering there are no post-call days off).
• The program with the toughest reputation (Program C) has the least call by far. Even if it's harder, there's a lot less of it.

Questions:

1. More important factors being equal, how would you consider call schedules in your rankings?
2. Which one of these call schedules is better or worse in your opinion, and why?

 

[oreosandsake]

from what I have observed, many programs that have home call, you will infrequently get called at all. even more rare for you to get called in. if you are not at a independent rehab facility, codes are run by the floor IM team. you will show up to discharge the patient officially.

having calculated out all call requirements is a little overboard IMO...
this is not surgery, or medicine and your call requirement is low as it is.

of all the variables in assessing a PM&R program, I think call schedule should be near the bottom.

 

[Prof Moriarty]

having calculated out all call requirements is a little overboard IMO...

It wasn't so difficult really. I used a calculator. But "a little overboard"... yes, probably. 🙂

of all the variables in assessing a PM&R program, I think call schedule should be near the bottom.

It is near the bottom. But in trying to differentiate strong programs it's a natural variable to look at. And I generally like to know what I'm signing up for. Your comment that home call gets infrequently called is interesting. Anyone else have this experience?

 

[lobelsteve]

Scratch your whole plan buckeroo.

1. Who will provide you with the best training for what you want to do when you graduate?

2. See above.

 

[RUOkie]

Scratch your whole plan buckeroo.

1. Who will provide you with the best training for what you want to do when you graduate?

2. See above.

Listen to Steve. He is a wise man. Work hard during residency and don't worry about call schedules. They will likely change anyway.🙄

 

[MSKalltheway]

Hey oreo, the call schedule for Program C should sound fairly familiar...

I agree with all of the above, I didnt even consider call schedule when ranking. But for the record, if anything, I prefer less frequent and more difficult call if you asked me. More educational and more sleeping in your own bed each month. Besides, once you do intern year and get enough of "Dr. Prof, patient's HR is ~200 and their bp is 70/palp, what do we do?" while on call q4, PM&R doesnt seem so bad. You'll still have bad times, but everyone will tell you, its not like intern year.

 

[fozzy40]

My program is in-house call and probably one of the more rigorous in the country and it's not bad any which way you cut it. My friends who are at programs with home call rarely have to come in. If it's something acute, there is usually a medicine team that can initiate the transfer to the medical floor.

 

[Prof Moriarty]

Scratch your whole plan buckeroo.

1. Who will provide you with the best training for what you want to do when you graduate?

2. See above.

Not sure why ROL questions elicit such 😱 responses. No where in my post did I remotely suggest that my "whole plan" was based on call schedules (which would obviously be ridiculous!). What I said was:

1. More important factors being equal, how would you consider call schedules in your rankings?
2. Which one of these call schedules is better or worse in your opinion, and why?

=========

Work hard during residency and don't worry about call schedules.

😕 I will work hard wherever I go. That's not my question. I'm not worried about call schedules. I'm curious about the opinion of people who have more experience with them than I do. I've gotten the impression from residents that call varies between programs. If I acknowledge that it's a very small consideration for me (if at all), after the obviously more important factors, what's the harm in asking the question?

=========

Hey oreo, the call schedule for Program C should sound fairly familiar...

Bingo. 😉

I prefer less frequent and more difficult call if you asked me. More educational and more sleeping in your own bed each month. Besides, once you do intern year and get enough of "Dr. Prof, patient's HR is ~200 and their bp is 70/palp, what do we do?" while on call q4, PM&R doesnt seem so bad. You'll still have bad times, but everyone will tell you, its not like intern year.

Thank you for answering my question!

=========

My program is in-house call and probably one of the more rigorous in the country and it's not bad any which way you cut it.

Program C has a reputation similar to your program's. But when I ran the #'s, it's got significantly less call than the other programs, albeit more intense. I thought that was interesting, and I'm not sure what to make of it. Thus I posed the question.😀

 

[RUOkie]

OP, Look at the status of the people who responded to you. The people who told you to ignore call schedules are the people who are long done with residency. It is meaningless. Call is either easy or hard depending upon the day and whether you are lucky or not. In my carreer as a physician, I have dealt with critically ill patients from home and in house. It was more stress from home while driving 80mph to the hospital. But that is more in line with what we do in real life. I also ran codes from in house. The only way to pick a program is to decide where the best fit for you is whether that be with the staff/residents you meet and by reputation.

In short, I feel that it is foolish to even consider call schedule in you rankings. I hope I do not offend. None is intended

 

[oreosandsake]

Call is either easy or hard depending upon the day and whether you are lucky or not.
.

👍


it is the way you pose this question that has ruffled a few feathers. looking at your OP, you have obviously put a good amount of thought into this.


the good advice you are getting is that it is unwise that call schedule should remotely come close to be the deciding factor between those 3 "equal" programs.

like MSK said, the consideration never came up at all.

 

[oreosandsake]

So for the sake of comparison I started looking at a few things that are different about each of these programs.

I'll point out a few things that I thought could be important 🙂

quality of the cafeteria food
- spaulding had great food, freshly cooked. almost gourmet

how "cool" the attendings were
- Kessler has some of coolest and most approachable attendings I've ever met. absolute characters that made the workday very enjoyable

the closest availability of really good sushi
- LA = NYC > boston, chicago

the camraderie of the residents

how protected, is their "protected" didactic time
- 👍 to the Kessler weekly didactics with bagels and coffee!

standalone rehab hospital vs adjoined
- knowing you will run your own codes at some point might make you pay closer attention during internship while your senior resident is keeping someone alive

not sure if you thought about these things, but they might help break the tie.

 

[lobelsteve]

I'll point out a few things that I thought could be important 🙂

quality of the cafeteria food
- spaulding had great food, freshly cooked. almost gourmet

how "cool" the attendings were
- Kessler has some of coolest and most approachable attendings I've ever met. absolute characters that made the workday very enjoyable

the closest availability of really good sushi
- LA = NYC > boston, chicago

the camraderie of the residents

how protected, is their "protected" didactic time
- 👍 to the Kessler weekly didactics with bagels and coffee!

standalone rehab hospital vs adjoined
- knowing you will run your own codes at some point might make you pay closer attention during internship while your senior resident is keeping someone alive

not sure if you thought about these things, but they might help break the tie.

All of these more important than call schedule. If I hear someone asking about the call schedule- I think lazy resident is coming.

1. How good is the training I am going to get?
2. Will I be prepared for my career?
3. All else is superfluous

But Sushi, friendship, learning environment, alumni library status for online info, things to do when not working are way more important.
I was so poor and the food was so bad at Sentara Norfolk when I trained, we made patient's NPO and ate their lunch.

 

[Llenroc]

"Nobody ever comes in on call." is what they all say. The reality of home call in a PM&R residency is a little different.

In my experience, PM&R home call only works at the programs that have <30 inpatient beds, with virtually all of them being stroke or debility type patients.

I know of one program that has 50 beds (including dedicated SCI and TBI units), in which the on call resident gets called in from home 50% of the time. That's painful. They also make the on call resident do late admissions. I would definitely not be happy in a program like that.

Of course, they usually don't tell you these things on the interview day. In fact, I did a rotation at the above program and never knew that until I found out some years later from a friend whose in it. I've heard similar such stories from people in other programs. The only ones who really don't come in while on call are as I stated above: people in small programs (usually at the main hospital) with basic rehab units.

Meanwhile a lot of the in house call programs are fairly light on the call, since you're not doing admissions overnight. The rehab nurses call the doctor way less than inpatient medicine or surgery nurses at an acute care hospital do.

 

[Prof Moriarty]

I hope I do not offend. None is intended

None taken. Nor is my post meant to offend, or rile anyone up. I much appreciate the forum and the insight shared here. Though some of the assumptions made about the intentions behind my post are not accurate.

There tends to be a backlash against ROL questions here. The last guy who posted such a query eventually went back and removed his post. In light of that I considered opening this post with a statement to the effect that obviously a ROL is selected on the basis of fit, training, family concerns, etc. But that's just it, it's so obvious that it felt unnecessary to write it. So I didn't.

Oreos, love your list of extra considerations. I have a similar one. Mine includes:

• Collegiality with faculty
• Good relationship between residents and non-physician staff (I've seen this one really run the gamut)
• Whether or not I have to wear a tie everyday😎
• View from the various places in the hospital I'll be spending significant amounts of time (minus points for places without windows)
• And many others...

=========

1. How good is the training I am going to get?
2. Will I be prepared for my career?
3. All else is superfluous

I respectfully disagree on #3. That may have been the case for you, but I have many other considerations going into this decision after #'s 1 & 2.

=========

I think it's interesting that the program with the reputedly toughest call has the least call (of these 3 anyway; there are programs further down my list with much less and much lighter call). As a candidate, when I hear "this program is known for tough call and overall rigorousness," I think there must be a lot of call in comparison to other places. But after breaking out my trusty abacus, I see that it's not about amount, it's about quality of the call. That's news to me, and I thought worth noting.

Getting these additional perspectives on home call is interesting too (thanks Llenroc). I have heard some residents say they would never want it, though the residents in Program B seem to like it (they fit into Llenroc's "<30 bed" category too).

 

[PMR 4 MSK]

If all things are truly equal and you will come out of all three equally trained and competent, take "C"

But keep in mind, this is PM&R call, not surgery. No calls from the ER q 15 min for another admit. A call for anything beyond dulcolax or tylenol is rare.

Some programs do late admits. For PM&R that's 7 pm. For surgery that's 3 am.

It's all about perspective. On our SCI rotation, we often had a urology resident doing their 1 month rotation in SCI. It was our hardest rotation, their easiest.

In my program, (back in the stone age) we were on call continuously from Mon 8 am - Fri 5 pm for our own pts while on an inpt rotation, then a rotating schedule for weekends. I bet I got called in to general rehab after 5 pm, where I actually had to go in, maybe 2-3 times, and another 2-3 times for SCI after-hours. Otherwise, maybe 3-4 pages per week for simple stuff that taught me how to avoid getting those calls by setting things up correctly before I left.

 

[Prof Moriarty]

Thanks to all who have contributed thoughts on the topic. I definitely got some insight into these different approaches to call. And for those worried I might base this important decision on call schedule: don't worry, I wouldn't do that, but thanks for your concern.

 

[TreeOfSouls]

Moriarty, I've noticed the same thing with ROL questions. It may be a generational thing... or maybe not. But, there is a certain sense of machismo mixed with masochism that equates sleep deprivation and levels of personal sacrifice with high quality training, regardless of any scientific knowledge of about sleep requirements of the human body, the actual effects of sleep deprivation, or the correlation with medical errors.

Whenever there is a group that has "endured" some hardship experience to achieve something, that group will subsequently rarely entertain the possibility that (a) it wasn't actually necessary and (b) that others shouldn't have to do the same. So, there is a certain amount of inertia, similar to how hazing perpetuates itself, apparent in the residency process- you're not supposed to question it because everyone before you did it. In fact, don't ever question anything since it probably just indicates that you are lazy or rebellious (maybe both). You certainly can't be seriously committed to medicine as a profession if you aren't willing to do "whatever it takes" as defined by anyone went through the process before you. 🙄

 

[axm397]

The other thing to consider is WHEN you have to take call. I trained at a program similar to program C and most of the calls were front loaded - which was when most of the inpatient rotations were. It is more painful to take call during your outpatient rotation on patients you don't know well and answering pages from nurses who may not know you and speaking to attendings you are not working with. I have to say there was a sense of camaraderie during my PGY2 year because 80-90% of my classmates were on an inpatient rotation and taking call most frequently. This allowed us to have decompress/b*tch sessions, avoid/kiss butt of frequent caller nurses, work on our sign outs via peer pressure (all on the same boat), and cover each other more effectively. (you scratch my back i'll scratch your back). This was also when we noticed who were the team players and who were not.

Also - if you are taking home call - you don't get to go home early the next day. Being in practice and now taking home call - I hate it. My last call, I was paged q2 hours with the last page at 4am on an inpatient who wanted norco 10s instead of norco 5s. Getting little sleep then having to get through a full clinic of needy patients and performing high risk procedures can be difficult. Of course, the residency model wouldn't work in the private practice world because not being able to care for "new patients" the next day would KILL us financially.

prof and treeofsouls - I understand the frustration about attendings commenting on your posts about "lifestyle" and "call schedule". BUT -I talk regularly to residents and fellows about career and job opportunities, and sometimes those in-training seem to forget that it is a luxury to have "protected time" and "duty hour regulations". Residency should be the time you focus on gaining clinical knowledge - BUT - you also should be thinking about what kind of practice you want to have after graduation and how you are going to continue your "lifetime learning" process without the luxury of "protected time" and the insulation/protection of an academic institution. Multi-tasking and efficiency also needs to be learned and if you go too cush, your efficiency will suffer.

 

[Prof Moriarty]

Very interesting axm. I have heard different opinions about the different styles of call, and this was the type of discussion I was hoping to generate.

I have not seen any outrageous call schedules in PM&R training programs. Some look tougher than others, but I think that overall it is a very humane specialty in that regard, and much of the hazing extant in other specialties largely appears to be absent (I hope!).

 

[PMR 4 MSK]

Moriarty, I've noticed the same thing with ROL questions. It may be a generational thing... or maybe not. But, there is a certain sense of machismo mixed with masochism that equates sleep deprivation and levels of personal sacrifice with high quality training, regardless of any scientific knowledge of about sleep requirements of the human body, the actual effects of sleep deprivation, or the correlation with medical errors.

Whenever there is a group that has "endured" some hardship experience to achieve something, that group will subsequently rarely entertain the possibility that (a) it wasn't actually necessary and (b) that others shouldn't have to do the same. So, there is a certain amount of inertia, similar to how hazing perpetuates itself, apparent in the residency process- you're not supposed to question it because everyone before you did it. In fact, don't ever question anything since it probably just indicates that you are lazy or rebellious (maybe both). You certainly can't be seriously committed to medicine as a profession if you aren't willing to do "whatever it takes" as defined by anyone went through the process before you. 🙄

I have felt the exact same way for around 20 years now.

 

[specepic]

What is option D? I looked for programs that had home call when I was interviewing / ranking and I'm far from lazy. I just don't like the idea of pointless extra work. Let me qualify that. If you are hell bent on a career in an intense rehab unit and /or academics where you will be supervising that kind of environment then go for it, otherwise find a quality program where you don't need to suffer needlessly. That is not always avail, but if it is why not do it?

I think folks are being a bit hard on the OP. Agree with the sentiment of go where the best training is but for a competitive applicant they should go for the ideal pick, which for many may include low call requirements. Lets be frank, a lot of PM&R programs have the residents do this call, not for learning, but for $ savings. Opposed to ICU/IM/cards/surg where the call component can be more important.

In the 'real' world, even if you go into inpt, they have a NP/PA/IM cover at night anyway.

0.02

 

[padresp]

Doing my internship right now. When I was interviewing, I didn't want to have a lot of call (who does?), but I decided to go with program C as it fit me best and it offered the best training. Keep in mind that I haven't even started at this program yet.

The one thing I've learned from my months of inpatient medicine is that you can not replace experience. Doing those overnight MICU calls are painful, but now that they're over I'm glad I did them. There is just no substitute for "should I give them dilt or not?" or "that's the third case of RVR I've seen." Saying that, I also feel that I could have put my 80 hours per week for one month into 40 hours per week for two months and I would have learned a lot more and been a lot safer.

In terms of the original discussion, I'm glad I went to program C. The people who are there don't seem to mind the call, and it's really good experience.

 

[lobelsteve]

Doing my internship right now. When I was interviewing, I didn't want to have a lot of call (who does?), but I decided to go with program C as it fit me best and it offered the best training.

Saying that, I also feel that I could have put my 80 hours per week for one month into 40 hours per week for two months and I would have learned a lot more and been a lot safer.

The people who are there don't seem to mind the call, and it's really good experience.

Some sage advice in there...

It would be great to limit work hours to 40-50 per week. But to get adequate training (I am an authority on the subject), this would nearly double the years to get folks out there that can practice safe and independent.

 

[Jitter Bug]

It's OK to have criteria others think are silly. I made a spreadsheet tracking the number of medicine months of all my transitional year programs because I hate rounding.

As to call, I agree you could show up day#1 and a new PD changes the call schedule. So think of it generically, not as guaranteed. Best way to know how abused you will be on call is to ask current residents when you interview. I was at a program with home call that was almost worst than in house, because of the high volume of calls, lack of good information from the floor nurse calling, and general difficulty triaging care from your armchair (ie before the hospital instituted rapid response team, you had to call some medicine resident from your armchair and convince him why you are staying home but he will go down the hall and evaluate your patient with chest pain.) Other in-house residents will HATE you for your home call if they get consulted at night. Ain't right but it was my experience.

So there is wide variability in busy-ness and acuity of calls for home call programs, make sure you ask lots of questions when you interview to get a general flavor.

 

[deleted185747]

Ha Ha I'm on home call right now!

It sucks, but its only a few weeks per year and someone has to do it. This is a case of what doesn't kill you makes you stronger. Residency is all about learning, and learning how to work hard and efficiency.

 

[PMR 4 MSK]

What do you guys think will happen after you graduate? Do you think call mysteriously goes away?

Even if you do outpt only, you are on call 24/7 for your own patients. If you do inpt, and have other Physiatrists, you'll rotate calls, with weekdays and weekends being separate. Otherwise, it's all on you.

You'll spend more time "on call" as an attending than you ever will as a resident.

 

[MedBronc23]

I agree with this 100%. Call is great. I am on night float right now at my Pre-Lim Medicine program. You learn alot and fast when you are the 2nd to third highest ranking physician for your department in house. I know call is inevitable even as an attending. But call is relatively nice in our field minus the inpatient only docs. I purposely went to a more outpatient focused program because of this. Does it make me lazy...hell no. I did a medicine year so I would be able to take care of people in the hospital. Not one of these transitional, 4th year medical school with ordering priviledges years (no offense to anyone who is doing one...just my opinion). I feel bad for the next generation of residents with the new duty hours...these people will never know in their first year what its liketo be called at 4 am on a 24 hour overnight call. Then when they are out in the real world without duty hours...man things will be crazy.

Call is good in residency...it prepares you for the real world. It provides moments when you are in the fire...and ultimately shows you your strengths and weaknesses.

That being said when I am forty and have 3+ kids...I sure do not want to be getting woke up for Blood Sugars of 65 to hold Lantus. For that I am glad I chose physiatry.