Violation of work hours with "home call"...

[DebDynamite]

Hello. Since this is an anonymous board, and many of us are about to match, I would like to hear from anyone willing to confess that your program violates the hours restrictions when the resident is on "home call". I'm specifically curious about Psych programs. I recently was told that this can happen routinely during the PGY2 & 3 year when on back-up call or home call. I thought it an interesting topic for an anonymous forum.

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[OTD]

Home call is NOT a violation of the work hours. Lying and saying you are on home call when you are not IS a violation.

Home call means you take call from home, and log all hours spent in house on that home call night. If your regular day ends at 5PM and you have to stay till 8 you log 3 hours as home call, if you then have to come back in from 1-3 then you would log 2 more hours. As long as you don't have more hours in house than at home then you can work the next day without a violation and there is no "10 hour" rule between shifts.

IF you work say 7 hours or so, at the point you determine that you have spent the majority of the shift in house it "converts" to in house call and all rules apply, even if you go home and sleep in your own bed from 1230 am till 0430 you still must only work 6 hours "post call" and have to go home.

The 80 hours per week is still in effect, if you put in 40 hours in house during your "home calls" for the week those 40 still count in your total. If you didn't get called in and stayed at home during your home call then you would not have any hours counted against you, but that only makes sense since you were at HOME and not at the hospital.

Personally I like home call because I get to sleep in my bed (4 hours in my bed is better than 8 hours in some stinkin hospital call room) and I get to stay and do cases the next day.

 

[Blade28]

I don't like home call because it's so damn painful to come in for the stupidest things - e.g to write a simple PCA order at the VA (they can't take verbal orders for these sorts of things).

Also, it's usually Q2 instead of Q4. And you can theoretically get almost no sleep, yet have to work until 10 pm the next day.

 

[Winged Scapula]

I don't like home call because it's so damn painful to come in for the stupidest things - e.g to write a simple PCA order at the VA (they can't take verbal orders for these sorts of things).

Also, it's usually Q2 instead of Q4. And you can theoretically get almost no sleep, yet have to work until 10 pm the next day.

Exactly why I hate it. Its a farce on some rotations (like PRS on Face and Hand Trauma...I was in pretty much every night) and my program didn't count the hours as described above and "turn it into" in-house call. You still stayed as if you had never came in. While its painful to come in for most anything, it was the bs stuff that killed me...like the PRS consults for any facial trauma...when they (the trauma team) knew very well it was me, the PRS INTERN who would be coming in from home to do it, rather than a real plastic surgeon. Like one of their own couldn't do it...I tried very hard as a Chief not to do that to them.

Or the direct admits to the VA from another VA facility for post-op rehab; they always arrived after we'd left for the day, the attending never told us they were coming (so we could write the orders ahead of time) and we had to admit them to Surgery in the middle of the night...because Rehab didn't take admissions after 3 pm (but somehow it was ok for surgery to do so).

Home call as a Chief resident blew as well...especially Vascular. It was generally q2 except when the fellow was gone for job interviews or vacation when it became q1. Fun...real fun.

 

[Blade28]

Yeah, exactly.

I once did 11 straight days of home call as a 2 on Burns...my god that was painful. Didn't even go home 3 of those nights.

 

[doc02]

Home call as a Chief resident blew as well...especially Vascular. It was generally q2 except when the fellow was gone for job interviews or vacation when it became q1. Fun...real fun.

See, this is what I don't get. Home call for some services really sucks. For example, on Urology, we get called in to place Foleys on any patient with BPH by the ER (that's not a joke). You might as well just stay at the hospital and pummel your ER doc voodoo doll while you wait for your beeper to go off. But on Vascular, Chiefs actually don't come in all that often. At some places, Chiefs get home call and only come in to do emergency overnight cases (which aren't all that common, even in large institutions); the trade-off for such easy home calls is that they're basically on call the entire year. So it's sort of dependent on the institution and how they set it up.

 

[DebDynamite]

I do appreciate the replies. As a fourth year med student who will match soon, I really want to know what I'm getting into. Not that I will necessarily seek out a program for it's call schedule (I'm not "afraid" of call- and I am going into psych- so even when I'm up all night it won't be like being in an OR all night- I can move around, sit, etc).

What I really just don't like is the dishonesty of many programs about the call schedule. I have been warned in independent meetings by residents in their PGY3 & 4 years that they are still essentialy Q2-4 (depending on the service) with home call- and no they are not allowed to convert the time they come into the hospital to in house hours- so maybe that depends on where you go. They take paperwork home and chart all night etc.

What sucks about the match is that no one will tell you this stuff up front and they all tell you how perfect you will be for their program (at least, in Peds, Psych and FM). They wine you and dine you and send you lots of warm fuzzy feelings while they lick their chops over your work ethic, CV etc behind your back. It reminds me of the cycle of domestic violence: woo them in the beginning and then chain them to the kitchen stove, isolate them and make them perform daily for years to come...

 

[Winged Scapula]

See, this is what I don't get. Home call for some services really sucks. For example, on Urology, we get called in to place Foleys on any patient with BPH by the ER (that's not a joke). You might as well just stay at the hospital and pummel your ER doc voodoo doll while you wait for your beeper to go off. But on Vascular, Chiefs actually don't come in all that often. At some places, Chiefs get home call and only come in to do emergency overnight cases (which aren't all that common, even in large institutions); the trade-off for such easy home calls is that they're basically on call the entire year. So it's sort of dependent on the institution and how they set it up.

You're right...it is entirely service dependent. Home call on vascular wasn't so painful for coming in to do cases but because: a) that meant you were up all night taking calls from the interns who needed some help (I had the pleasure of doing it at the beginning of my Chief year) and b) our attendings expected you to come in for all admits, problems with patients, etc. not just cases. The PD tried to get the Vascular attendings to allow the in-house senior to see the admits, problem patients, etc. but they refused...it HAD to be the Chief. Then again, in the summer we did have more Vascular trauma which once resulted in me not going home for 3 days (the fellow was off); so its sort of luck of the draw.

And just like Urology, on my Plastics rotation I was in a lot because we were on Hand and Face. Some of the consults were plainly just abusive, IMHO. I never had a rotation in which I didn't take call, but I hear those exist.

 

[OTD]

I guess I am lucky as our program makes an honest effort to follow the rules as best they can.

See if you were in house longer than home it wasn't really home call was it because you were in house all night. That's why we "convert", because if you spent more time in house then it really was in house call. Once you convert then all the rules apply (30 hours total, no admissions after 24, go home post call).

If you don't have to convert, even if you stayed till midnight(the cutoff) then you can stay all day the next day but it gives you breathing room with the hours for the month. If you went home at 8pm and came back in at 5 am that's 9 hours off the hours you were scheduled that week. That can be helpful if you are close for the month.

Our home call usually isn't that painful, they can take any order over the phone so you only have to go back in if you have an admission or someone crashing etc. We only use it on the 'light" rotations or if you are the backup call person, it's not done on the heavy ones because you would be converting all the time anyway.

 

[doc02]

woo them in the beginning and then chain them to the kitchen stove, isolate them and make them perform daily for years to come...

What? I just usually chain them to the stove as step one. 😕

 

[Hurricane]

At our psych program, we take home call at the various sites we cover. At most of the sites it's pretty light. We have a dedicated pscyh ER, so most of the calls we get overnight are floor calls that take 5 min on the phone, or admissions from the ER, that take maybe 10-15 minutes on the phone, depending on whether that site requires you to call the attending or not. The only times you have to go in is if there's a medical emergency, or someone needs to go into seclusion, which is rare.

The one exception is the VA. We take home call for the VA, and we can put in orders from home through their computer system for floor calls and admissions. But we have to cover their ER too, and the combination can result in you being up most of the night, and you do have to come in if you want to refuse admission to a patient in the ER. But you have the option of staying in house, and the call room is pretty nice, and in that case it's treated just like a regular call, and you get to leave after your 30 hours.

 

[Blade28]

Let me just say that there's no way you'll ever fully be aware of any program's call schedule before you're a resident there. Don't let it affect your rank list too much, because no matter how many candid conversations you have with residents, you'll never really know what it's truly like.

 

[DebDynamite]

Let me just say that there's no way you'll ever fully be aware of any program's call schedule before you're a resident there. Don't let it affect your rank list too much, because no matter how many candid conversations you have with residents, you'll never really know what it's truly like.

Yeah, this is the conclusion I have basically come to. Also that one of the most important things I can do along the inerview trail is just observe the overall morale of the residents. I think it speaks volumes.

 

[OB1🤙]

I don't like home call because it's so damn painful to come in for the stupidest things - e.g to write a simple PCA order at the VA (they can't take verbal orders for these sorts of things).

You know you can set up CPRS for access at home for this kind of stuff, right?

 

[Blade28]

You know you can set up CPRS for access at home for this kind of stuff, right?

They stopped doing this (at least at the Atlanta VA) when the DC VA had that break-in a while back, no?

Here, only the attendings have home CPRS access.

 

[OB1🤙]

I haven't done it myself yet, but in July we were given instructions on how to set it up. It has to go through an approval process that somehow involves the program director, but I know for sure that some of my co-interns access it at home.

 

[Winged Scapula]

That would be very handy...we were never offered that option and I was turned down when I requested it as an intern at the VA. They also turned down my request for access to the outpatient VA clinic two blocks from my house so I could to there and input orders.

Had to drive the 30 minutes into the VA.🙁

 

[cytoskelement]

home call is truly a farce. i never sleep well while i'm on call. i'm sure that it will improve as i gain experience... but it will never be the same as an evening without call.

 

[Pilot Doc]

Home call means you take call from home, and log all hours spent in house on that home call night. If your regular day ends at 5PM and you have to stay till 8 you log 3 hours as home call, if you then have to come back in from 1-3 then you would log 2 more hours. As long as you don't have more hours in house than at home then you can work the next day without a violation and there is no "10 hour" rule between shifts.

IF you work say 7 hours or so, at the point you determine that you have spent the majority of the shift in house it "converts" to in house call and all rules apply, even if you go home and sleep in your own bed from 1230 am till 0430 you still must only work 6 hours "post call" and have to go home.

Most of what you describe above is your institutional policy and not ACGME rules. For one, the 10 hour rule is written as "should" and not "must" so it has no force whatsoever. As for home call "converting" into in house, I have never heard of that before. It's certainly not done at my institution. Here, if you set foot out of the hospital, the 30 hour clock resets.

Home call means you stay at the hospital whenever there is work to be done and then you go home. You can't average more than 80 hours/week.

 

[Hurricane]

They stopped doing this (at least at the Atlanta VA) when the DC VA had that break-in a while back, no?

Here, only the attendings have home CPRS access.

That sucks. Here we can all have home access, either with VPN on our own computer, or by checking out a VA-owned laptop. In both cases, there is no VA data stored on the home computers, just the software to log into CPRS and VISTA remotely. I've even got it running on my intel Mac 🙂

 

[edmadison]

Most of what you describe above is your institutional policy and not ACGME rules. For one, the 10 hour rule is written as "should" and not "must" so it has no force whatsoever.

From the ACGME website:

Question: The required 10-hour rest period continues to be problematic for my program. How does the ACGME interpret this common duty hour standard?

Answer: The language of this requirement states, “Adequate time for rest and personal activities must be provided. This should consist of a 10-hour time period…” “Should” is used when a requirement is so important that an appropriate educational justification must be offered for its absence. An interpretation of what constitutes “appropriate justification” often cannot be made a priori, but allowing added time for didactic lectures of high importance, rare cases or cases with particular educational value for the given resident are examples most RCs would consider appropriate. It is important to remember that when an abbreviated rest period is offered either
regularly or under special circumstances, the program director and faculty must monitor the resident for the signs of sleep deprivation.

 

[OTD]

Most of what you describe above is your institutional policy and not ACGME rules. For one, the 10 hour rule is written as "should" and not "must" so it has no force whatsoever. As for home call "converting" into in house, I have never heard of that before. It's certainly not done at my institution. Here, if you set foot out of the hospital, the 30 hour clock resets.

Home call means you stay at the hospital whenever there is work to be done and then you go home. You can't average more than 80 hours/week.

As someone already posted the ACGME does have a stance on the 10 hours and it should be rare and with noted exception when there is not 10 hours between shifts. So, that's why our program honors that. You can bet if a question ever comes up you won't get the benifit of the doubt, it will be considered an hours violation to not have 10 hours between shifts because of the way their official stance is worded.

As for the "converting" to in house call if that isn't being done at your institution it should be. Otherwise every program in the country could just let their residents go home for 1 hour and call everything "home" call to get out of the restrictions on 30 hours etc.

I do realize the "converting" depends on your definition of when home call stops and in house call starts, our program kept it simple, if you spent more time in house than at home then you were actually in house call and you "convert" and all rules apply.

Honestly, if you spent more time in house than at home wouldn't it be a lie to call it "home" call?

 

[CouchPotato]

As for the "converting" to in house call if that isn't being done at your institution it should be. Otherwise every program in the country could just let their residents go home for 1 hour and call everything "home" call to get out of the restrictions on 30 hours etc.

That makes sense, but our PD came down on someone because they had a 2 hour break at 4am and chose to sleep in the call room, when they should have gone home for an hour. Half of my intern call is from "home," which I now interpret to mean the corner before I turn onto my street, which is usually where I am when I get paged back to the hospital. I live 10 minutes from the hospital and spend over an hour when on call driving back and forth.

Honestly, if you spent more time in house than at home wouldn't it be a lie to call it "home" call?

I totally agree. Also, if you're answering a page every 5 minutes and your significant other makes you sleep on the sofa, I'd rather be in house...