What are features to look for/avoid when looking at Inpatient call schedule/ team setup?

[ILikePie233]

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I haven't had too much experience with different inpatient formats and so am wondering what are some structures that I should keep an eye out for or definitely try to avoid as I look at residency staffing structures?

 

[Beacopp665]

The two main things I looked at in general were patient caps per intern (saw as low as 6 and the max is 10). Aside from the official cap always ask the residents who complain about the program (there is always one or two everywhere you go) if they go over cap a lot of time or not so often. Now that a lot of places are in the iCompare study you should pay attention to if interns have overnight call or not. I personally would rather have overnight call as an intern as I think it actually ends up being less days that you work total but that's just me.

 

[ILikePie233]

Thanks - is there a list of the iCompare trial programs? Also does intern overnight call in the trial mean you just work nights at some point during the rotations and get the next day off or is it like a non-night float system where you are on q3 or q4 call?

 

[Beacopp665]

This link should work for the list (which you can google): http://www.jhcct.org/icompare/listprograms.asp . Programs in the flex arm can allow interns to do overnight (>16 hour) shifts which the current rules do not allow. My program is not in the FLEX arm so I can't speak to how programs are implementing this. The reason I think it is better is I would rather stay overnight and get the next day off Q4 or whatever as opposed to working up to 16 hours/day for 6 days of the week.

 

[chessknt]

You want to look for admission caps, admission cycles (x admits every y days) or timing cutoffs (ie does everything up until the second signout starts fall on you which would make the hours much longer on unlucky days), if there is a system to get people out early on some days, EMR type, and procedural support. I doubt there is anywhere that is perfect on all of these, but a hit on any of these will result in more hours worked despite your best efforts.

I think the better question would be educational/procedural experience rather than minimizing number of hours worked, but I think everyone can agree doing 6x 14 hour days every week will drain a lot of the benefits due to pure burnout eventually.

 

[Instatewaiter]

Having done night float, a non-night float but 16h cap system, and the old q4 call, I can say I vastly preferred the old q4 call. It felt like you had more personal time and you had time off during the day to get hair cuts, go to the bank etc.

I say don't focus on the specifics and focus more on whether you will be a good fit with the program. Quite frankly, without going through it, you can't know which you will like and what problems a given system has

 

[dozitgetchahi]

You want to look for admission caps, admission cycles (x admits every y days) or timing cutoffs (ie does everything up until the second signout starts fall on you which would make the hours much longer on unlucky days), if there is a system to get people out early on some days, EMR type, and procedural support. I doubt there is anywhere that is perfect on all of these, but a hit on any of these will result in more hours worked despite your best efforts.

I think the better question would be educational/procedural experience rather than minimizing number of hours worked, but I think everyone can agree doing 6x 14 hour days every week will drain a lot of the benefits due to pure burnout eventually.

All good points.

Having done no overnight call as an intern and q4 call on many rotations as an upper level, I can tell you that both of these styles are taxing but in different ways. I did a 5 month block of pure day shifts as an intern and a 5 month block of q4 call as a 2nd year, and I felt about equally horrible at the end of both stretches (although I did feel somewhat worse after the q4 call run). I slightly prefer overnight call as you get the postcall day and you have a much better opportunity to rest and get the other 'real life' issues taken care of, but I do think it's more taxing overall. I also think overnight call has the advantage of having greater continuity with admitted pts - you're able to see how the game plays out after admitting someone rather than signing them out shortly thereafter.

At the end of the day, I think part of it comes down to your own physiology and tolerance for sleep deprivation - some people just cannot deal with 'all nighters' and shut down and become way less effective. If this is you, avoid overnight call schemes.

 

[CatFactorial]

Regardless of what system is in place at your program, you'll eventually adapt.

 

[ArkansasMed]

Thanks - is there a list of the iCompare trial programs? Also does intern overnight call in the trial mean you just work nights at some point during the rotations and get the next day off or is it like a non-night float system where you are on q3 or q4 call?

I can only speak for my program. I am at Hopkins and it has the q4 28 hour call. I have done 16 hour call on a few of our other services here. Here are the pros and cons.

28 hr call:
Pros: you know your patients and there is very little handoff for the actual management of your patients. Makes it super easy to stay on top of them.
Your free time off is actually more in the wake hours of the day.
There is one (well really 1.5) days to be on call and the other days are more relaxed.

Cons:
Fatigue is greater when presenting new patients on rounds after being up for that long. Usually people are pretty forgiving
Sleep schedules are a bit wacky adjusting to napping mid day on post call.

16 hr call
Pros: less fatigue in AM when plans are made
Do not have to be up all night and less overall fatigue in a given day.
Someone else may do your admissions for you overnight

Cons: have to constantly sign people out. May get admissions overnight who you didn't work up and the plan is total crap and you don't have time to manage it. Never are off during normal hours of the day. Never mentally feel you are getting a break.

I have to say, I actually like the 28 hour call a lot more. I am tired as hell on the O presenting my new patients in the AM but I am the one who made the plan and actually have time free during the day. Also, it's pretty cool to work someone up at night and know that you are passing them off in the afternoon and have the correct plan in place. I was super worried about the 28 hr call but really prefer it. The 16 hr calls I feel so exhausted coming in the next day and mentally burn out more. You have more opportunity to be home to eat with significant others, family or friends.

 

[LovelyBRass]

they both suck and drain you. go where people are happy and don't write down any program's call schedules. it really doesn't matter. actually i would pick based on X+Y system! which system is going to make you do 28hr-q4 v 16hr x 6 days for less amount of time? that's what really matters

 

[TastyCurrantJelly]

With the 28 hour call, is a 4 hour protected sleep period mandatory per ACGME rules or are you awake for 28 straight hours at most programs?

 

[chessknt]

With the 28 hour call, is a 4 hour protected sleep period mandatory per ACGME rules or are you awake for 28 straight hours at most programs?

Can you cite something showing that? I have never seen this before and it honestly seems impossible since the entire point of being on call is to be available. Having a 4 hour period where you can't be reached is not realistic or professional.

 

[dozitgetchahi]

This rule only applies to medical students, iirc.

The med students at our institution are always asking for their 'protected naps' during the 28 hour call shifts.

Way more important than the call schedule is the clinic schedule IMHO. 4+1 or 3+2 or whatever schedule can be put together that gives you dedicated ward time and dedicated clinic time is >>>>>>>>> than the 1/2 day a week crap that my program still does. The other benefit of this (esp with 4+1) is that you generally get a scheduled 'golden weekend' at the end of it - which means at the end of a rough wards or ICU month everyone gets a weeklong breather with a weekend off thrown in.

Doing back to back to back to back to back months of call wards with no breaks whatsoever totally, utterly blows.

 

[ArkansasMed]

With the 28 hour call, is a 4 hour protected sleep period mandatory per ACGME rules or are you awake for 28 straight hours at most programs?

Hahaha oh god no. Some programs have built this in but they are far and few. More important than sleep, look at the total number of pts you are to cover, complexity of the cases you see and if you have to cover admissions/ how many per night (cap). Also what time your admission window starts and ends. Some places split this, those that do usually cover like dozens of patients all at once. Admitting can range as low as 2 to like 7 a call depending on length of time.

 

[TastyCurrantJelly]

So I don't get why some people are saying they prefer q4 28 hour shifts to 6 days of 10- 16 hours? If you are 28 hours Monday morning - Tuesday at noon, you don't get Wednesday off, right? If not, what could the possible advantage be of a 28 hour shift where you become sleep deprived and mess up your sleep schedule just to have to come back to work the next morning for a long day shift before having to do it all over again in a few days?

 

[ArkansasMed]

So I don't get why some people are saying they prefer q4 28 hour shifts to 6 days of 10- 16 hours? If you are 28 hours Monday morning - Tuesday at noon, you don't get Wednesday off, right? If not, what could the possible advantage be of a 28 hour shift where you become sleep deprived and mess up your sleep schedule just to have to come back to work the next morning for a long day shift before having to do it all over again in a few days?

You'll be worked hard no matter what schedule you work and will be tired regardless. If you get off at noon you sleep for a few hours you can still go out during normal hours and get things done and eat with friends/loved ones. The 6am-6pm or worse 6am to 9-10pm you essentially live at the hospital and are never out at a good time during the day. The other issue with not doing 28 hr call is you have no clue about who you admitted overnight and usually will have to come in earlier than 6am to learn/check the work up of your colleagues before you present the patient yourself. It's extra work during the day playing catchup learning new patients. Does that make sense?

 

[meliora27]

How are the wards team structured? 2 seniors + 2 interns + AI vs. 1 senior + 2 interns + AI

On wards, how do admissions work: Drip vs Bolus

Bottom line is that you'll get used to however it is where you're at. As you move along, you'll have less wards months and more elective time.

 

[TastyCurrantJelly]

what are the differences between 2 seniors+ 2 interns vs 1 senior and 1 intern,is AI attending?

Also, is drip or bolus admissions generally preferable?

 

[gutonc]

what are the differences between 2 seniors+ 2 interns vs 1 senior and 1 intern,is AI attending?

Also, is drip or bolus admissions generally preferable?

You ignored the last line of @meliora27's post, which is arguably the money part of it.

And AI=SubI=useless waste of time in most programs

 

[Crayola227]

Bolus system way better in my opinion. There's something very magical to having a day where you take NO new patients. Or those days where you dc'd a bunch and only had like 5/10 for that magical day.

What I can say is a team that is 1 senior and 1 intern (if you will be senior-less one day for the senior's day off there will be a cap of 10 for your team for you to carry alone those days per ACGME rules) BLOWS because you will frequently have 10 patients all to your lonesome that day and if the program does 1/2 day clinic, the days when you and senior are in clinic are brutal. 3 days a week 10 patients where it was either me by myself, or me without the senior after noon, or I would leave for clinic at noon. Luckily signed pager to senior for clinic but being intern 10 patients 10 notes a clinic day with one senior can be killer. It depends on your senior too, some will be more helpful than others and others will make you do ALL the work for 10 patients wards day 1, aside from looking over your shoulder that no one dies and putting in orders to that effect leaving you totally out of the loop looking like an idiot to the attending on rounds. You don't always run at full cap is possible of course. Some seniors are more helpful than what I wrote. The benefit of 1 senior 1 intern is that you're definitely not getting lost in terms of supervision even if the senior sucks at teaching. All of your problems are the senior's problems too in theory. Long call was admitting 5 that day if we had space, at least then the senior helped when I got behind, but was still a total dick about it (this was month 2 for me).

On the other hand, in a team with 1 senior 2 interns or 1 senior 3 interns or 2 senior 2 interns, there can be a level of chaos where you can't get a senior's attention long enough to be in the loop on anything and that's pretty ****ty feeling. On the other hand you often have less than 10 patients.

Depends on rotation too. ICU with 1 senior and 3 interns and subI with cap at 20 meant that I think once every 3 days having to cover the other intern's patients plus with NF accept, all I can say is the whole thing was chaotic, I ended up first month of PGY1 that AM with like 2 old patients, 2 brand new to me, and another 3 that were the other interns (and crap notes) so I had 7 ICU patients to that AM and 5 unfamilar to me to catch up on. And there's never time to check up on plans for that many patients with one senior in the am.

I don't suggest any program where as an intern day 1 you may be expected to carry 10 patients wards or up to 10 in ICU. (that day I was lucky to have 7).

SubI's can be WAY WAY awesome to have but only if their notes count/result in less notes to write and the senior mostly handles them, however obviously when you are senior you will then have the whole service and all the subI patients who would otherwise go to intern if it is seniors that supervise subIs. That results in senior doing more admits with subI, senior is usually helping intern when they get overwhelmed with admits anyway. So I think subIs are only beneficial to the intern workload at some programs, and overall a team suck at others.

 

[jdh71]

So I don't get why some people are saying they prefer q4 28 hour shifts to 6 days of 10- 16 hours? If you are 28 hours Monday morning - Tuesday at noon, you don't get Wednesday off, right? If not, what could the possible advantage be of a 28 hour shift where you become sleep deprived and mess up your sleep schedule just to have to come back to work the next morning for a long day shift before having to do it all over again in a few days?

You clearly haven't done residency yet.

 

[VA Hopeful Dr]

You clearly haven't done residency yet.

Agreed.

You know what really sucked about the new work hours (started after my intern year)? Losing the Golden Weekend. I'd take 30 hour call q4 in a heart beat to have a whole weekend off once a month compared to only getting 1 day at a time off but never staying overnight.

 

[Crayola227]

You clearly haven't done residency yet.

Why pop in here with some snide condescension? Obviously they haven't, THAT'S THE WHOLE POINT OF THIS ****ING THREAD. The MS4s as you have so adeptly noted, have no residency experience therefore they are asking questions about the unknown to help guide them and give them an idea about what programs are like while trying to learn and decide amongst programs.

I'm just so sick of the glee on SDN for someone to say something condescending when in reality it's you missing the point.

So besides pointing out the obvious, do you have an actual answer?

 

[jdh71]

Why pop in here with some snide condescension? Obviously they haven't, THAT'S THE WHOLE POINT OF THIS ****ING THREAD. The MS4s as you have so adeptly noted, have no residency experience therefore they are asking questions about the unknown to help guide them and give them an idea about what programs are like while trying to learn and decide amongst programs.

I'm just so sick of the glee on SDN for someone to say something condescending when in reality it's you missing the point.

So besides pointing out the obvious, do you have an actual answer?

Every year there are a few of you who like to tell me how on fire my comments make your ass holes. I suggest icing it and then walking it off. No "glee" was had by me with my comment. I have no pleasure in your pain or confusion. Hell. I post in this forum for you guys not for me. I've got mine. Been there. Done that. I do my best to pass along my experience. I've helped more people here, directly, than I bet you would ever imagine. So please save me the sanctimonious lecture.

I trained back in the days when interns could do 30 hour shifts. It's better for your schedule and your learning to have more time in house in a row that in turn relates to more time in a row out of the house. 12 to 16 hour shifts can smoulder forever and ever and ever and ever.

But at the end of the day it's not actually really an important question at all. I'm not missing any points. You all are. What's better a brown or a black hunting dog? Well. It doesn't really matter. You need to find a program that matches with your personality that you like and will give you one sick gomer after another to learn to take care of. You can't see everything in residency. You can't even come close. You won't learn how to manage everything in the specific. Only in the general. You better find a spot that teaches you how to admit anything and think around tricky corners. Because that's the real world. Anything. And I literally mean anything plus the tricky corners. This is IM son. No man's land. Abandon all hope all ye who enter here. Every other specialty in the world will turf off what they will deal with and even then most will turf directly to you even their very own patients. So you better figure it out and get it dialed in. Admit your patients in 16 or 28 hours. Whatever. Just do it. And make sure you get a lot of it.

 

[ArkansasMed]

Every year there are a few of you who like to tell me how on fire my comments make your ass holes. I suggest icing it and then walking it off. No "glee" was had by me with my comment. I have no pleasure in your pain or confusion. Hell. I post in this forum for you guys not for me. I've got mine. Been there. Done that. I do my best to pass along my experience. I've helped more people here, directly, than I bet you would ever imagine. So please save me the sanctimonious lecture.

I trained back in the days when interns could do 30 hour shifts. It's better for your schedule and your learning to have more time in house in a row that in turn relates to more time in a row out of the house. 12 to 16 hour shifts can smoulder forever and ever and ever and ever.

But at the end of the day it's not actually really an important question at all. I'm not missing any points. You all are. What's better a brown or a black hunting dog? Well. It doesn't really matter. You need to find a program that matches with your personality that you like and will give you one sick gomer after another to learn to take care of. You can't see everything in residency. You can't even come close. You won't learn how to manage everything in the specific. Only in the general. You better find a spot that teaches you how to admit anything and think around tricky corners. Because that's the real world. Anything. And I literally mean anything plus the tricky corners. This is IM son. No man's land. Abandon all hope all ye who enter here. Every other specialty in the world will turf off what they will deal with and even then most will turf directly to you even their very own patients. So you better figure it out and get it dialed in. Admit your patients in 16 or 28 hours. Whatever. Just do it. And make sure you get a lot of it.

He brings up a valid point. Probably the best skill I have learned thus far is being able to take anything and admit them appropriately. Go to a program where you actually see very SICK patients. Usually this is found in big cities, very poor cities (Baltimore, St Louis, Detroit etc) or hospitals that get a lot of outside hospital transfers even from big medical centers. I always get a bit scared (it's totally normal) when an outside transfer from a major medical institution comes our way and they want us to figure it out/manage it. It puts hair on your chest and prepares you for anything. It's the one major downfall of training at a community program, you will turf the exciting stuff to big academic centers and will have less chances to have to essentially "sink or swim" aka figure out a plan for them when many people in medicine cannot. You want to come out feeling like you can treat anything (or at least figure it out), trust me. Same goes for the clinic. Go to one where the patients are sick so you can essentially manage any outpatient issue accordingly and learn how to deal with someone who has more medical problems than their stated age....

He is also right about the turfing things. You will always get dumped on in medicine. You should be proud of this because it says that you actually are trained better to handle complex medical problems and get the job done even if it's in their field.

Also, learn a system to find the correct answer fast overnight (UpToDate, purple MGH book, An intern guide etc). When I have no clue I usually read one of those sources and if need be, ask a colleague for a second opinion.

JDH has the wisdom. I'd listen to him, he's almost always spot on.

 

[Instatewaiter]

So I don't get why some people are saying they prefer q4 28 hour shifts to 6 days of 10- 16 hours? If you are 28 hours Monday morning - Tuesday at noon, you don't get Wednesday off, right? If not, what could the possible advantage be of a 28 hour shift where you become sleep deprived and mess up your sleep schedule just to have to come back to work the next morning for a long day shift before having to do it all over again in a few days?

The benefit in the call system is the time away from the hospital. You feel like you have some free time. In the other system of 6 12-16 hour shifts ( it is rarely 10 hours) you never feel like you are away from the hospital. Let's take a 13-14 hour system which is more gentle than many that do 15 or 16 hour shifts:

Wake up at 5, shower, get ready, eat, drive in. In By 630. Pre-round, round, get your work done. Leave at 730-830 pm. Home by 8-9. Eat dinner and have to go to sleep immediately afterwards otherwise you're getting less than 7 hours of sleep. That wears on you. You feel like you never have time. Imagine trying to fit laundry, or getting work on your car done into this system. Your life is essentially on hold. Even worse, because it takes more handoffs, many systems don't have the man power to give you a real day off. Your "day off" is the switch from day to night (so your day off starts when you leave monday night and you come in the next evening). Technically this is 24 hours off.

In the call system, wake up at 6, in by 730. 24 hour call +/- 4 hours. Home by 12 the next day. If you wanted to, you could sleep 17 hours (more than possible in the other system). Or you could have hours to yourself to get stuff done and still have 12 or 14 hours of sleep (same as in the other system) It is very easy to continue your life. Your days off are true days off during the day as well. IMHO, it isn't even close what I prefer.

 

[Crayola227]

He brings up a valid point. Probably the best skill I have learned thus far is being able to take anything and admit them appropriately. Go to a program where you actually see very SICK patients. Usually this is found in big cities, very poor cities (Baltimore, St Louis, Detroit etc) or hospitals that get a lot of outside hospital transfers even from big medical centers. I always get a bit scared (it's totally normal) when an outside transfer from a major medical institution comes our way and they want us to figure it out/manage it. It puts hair on your chest and prepares you for anything. It's the one major downfall of training at a community program, you will turf the exciting stuff to big academic centers and will have less chances to have to essentially "sink or swim" aka figure out a plan for them when many people in medicine cannot. You want to come out feeling like you can treat anything (or at least figure it out), trust me. Same goes for the clinic. Go to one where the patients are sick so you can essentially manage any outpatient issue accordingly and learn how to deal with someone who has more medical problems than their stated age....

He is also right about the turfing things. You will always get dumped on in medicine. You should be proud of this because it says that you actually are trained better to handle complex medical problems and get the job done even if it's in their field.

Also, learn a system to find the correct answer fast overnight (UpToDate, purple MGH book, An intern guide etc). When I have no clue I usually read one of those sources and if need be, ask a colleague for a second opinion.

JDH has the wisdom. I'd listen to him, he's almost always spot on.

Thoughtful answer and good advice.

@jdh71 does offer a lot of pearles of wisdom. What he posted "you clearly haven't done residency" wasn't one of them.

His reply to my post was much more thought out.

Let's not have this thread turn into this http://forums.studentdoctor.net/threads/night-float-weekend.1147541/
Because that thread covered the topic of the old call schedule vs how things are done now in most programs. I was very lucky to have @Law2Doc and some other old timers explain in exquisite detail the old call system before the implementation of the new rules, and we all respectfully compared and contrasted them, noting pros/cons and how that could relate to individual preferences. I thanked them because it is useful to understand the history of medicine. Some students may find themselves in the icompare study (which I think is a fairly small number of programs) and would also benefit from that discussion.

Otherwise, it's more pertinent to answer questions about call schedules and team structures that they are most likely going to encounter on the interview trails here over talking about the good old days.

I don't advocate going for the cushiest program around, as you guys have said, and it is true to find a place where you feel at home with the people. It's true too that if you have adapted well to the challenges of medical school you will likely be up to the challenge of whatever program structure you end up in.

That said, I feel I would have benefitted as an MS1 and new intern having known more about the nuts and bolts of various structures, and it would have played into my choice.

I have a friend in a program where nights are done as 4+1, 4 weeks days on service followed by 1 week nights same service, compared to my program which had 4 week nightfloat block. That sort of schedule would never have worked for me. Having lived the 1/2 day clinic life as I said above, there is great appeal to the x + y inpt/clinic schedule.

And as @Perrotfish pointed out in one of my fave posts ever of his

I've worked in hospitals with both systems: the 4 man team with a second year and the three man team with just two Interns and a senior. I personally like the system with the second year much more. I have no idea why people think that Medical students who are used to handling 2-4 patients will suddenly be able to handle 10 because someone handed them a diploma. A good Intern year should be designed like a weight training program: you add a little more weight every month. That's how our clinic works (the appointment times get shorter ever few months during Intern year) and that's how the best wards I have rotated on work.

While I have seen Interns handed 10 patients on the first day of Intern year, I've never seen it done well, and usually it results in a combination of poor medical care, extreme work hour violations, and most of all seniors/attendings doing Intern work to prevent medical errors and work hour violation. There is very little teaching and I think the Interns actually mature more slowly because they spend so much time drowning in systems issues and fighting sleep deprivation that they never learn anything. Handing new Interns 10 patients is like telling a new lifter just to try bench pressing 400 lbs until he's able to do it.

So as far as I see it there's no reason not to explain to these MS4s exactly the details of different systems rather than just giving them the party line on "go with your gut and don't worry about the details."

 

[Perrotfish]

The benefit in the call system is the time away from the hospital. You feel like you have some free time. In the other system of 6 12-16 hour shifts ( it is rarely 10 hours) you never feel like you are away from the hospital. Let's take a 13-14 hour system which is more gentle than many that do 15 or 16 hour shifts:

Wake up at 5, shower, get ready, eat, drive in. In By 630. Pre-round, round, get your work done. Leave at 730-830 pm. Home by 8-9. Eat dinner and have to go to sleep immediately afterwards otherwise you're getting less than 7 hours of sleep. That wears on you. You feel like you never have time. Imagine trying to fit laundry, or getting work on your car done into this system. Your life is essentially on hold. Even worse, because it takes more handoffs, many systems don't have the man power to give you a real day off. Your "day off" is the switch from day to night (so your day off starts when you leave monday night and you come in the next evening). Technically this is 24 hours off.

In the call system, wake up at 6, in by 730. 24 hour call +/- 4 hours. Home by 12 the next day. If you wanted to, you could sleep 17 hours (more than possible in the other system). Or you could have hours to yourself to get stuff done and still have 12 or 14 hours of sleep (same as in the other system) It is very easy to continue your life. Your days off are true days off during the day as well. IMHO, it isn't even close what I prefer.

In my experience the people who like a true call system are the ones who can shift their sleep schedules easily. The ones who love it are the ones who can skip a night's sleep every fourth night and who can treat the post call day as half a day off. My problem is that I am neither of those people.

On my post call days I collapse. I sleep 8 hours, devour a large pizza, sleep 8 more hours. I gained a LOT of weight and got sick. No errands happened, ever. I crashed my car into multiple stationary objects on call (thankfully at low speeds), and we don't have a lot of call months.

My sleep schedule does not adjust well. It take me at least three days to shift from days to night. On blocks of nights that means I'm groggy for the first day or two. On call that means I never really sleep. I get 4 hours a night on some of the days when I am actually allowed to sleep. Even our incredibly light ED rotations (16 8 hour shifts in a month) were enough to keep me half dead with exhaustion, because of the constant schedule shifts. With Q4 call it was just hopeless.

And that's when things go according to plan. Ever had something happen at the start of a call night? Get a bad nights sleep? Feel sick? Get berated by the attending? Its hard to start a marathon by getting punched in the stomach. At least with a shift system, no matter what the hospital does to you, you're only 12 hours from being home.

BTW, does anyone else get hospital based nightmares after calls? Like every f-ing time? Post call I always woke up in a cold sweat still half thinking I forgot an order or missed a page and killed someone.

13 hours a day, 6 days a week, sucks. But it sucked for me in a sustainable way. I could do it forever, if I was fine living forever in a gray haze of sadness and resignation. 28 hours every 4th day, though, wore me down rapidly. If we had had more call months I might not have made it through residency.

 

[jdh71]

Thoughtful answer and good advice.

@jdh71 does offer a lot of pearles of wisdom. What he posted "you clearly haven't done residency" wasn't one of them.

His reply to my post was much more thought out.

Let's not have this thread turn into this http://forums.studentdoctor.net/threads/night-float-weekend.1147541/
Because that thread covered the topic of the old call schedule vs how things are done now in most programs. I was very lucky to have @Law2Doc and some other old timers explain in exquisite detail the old call system before the implementation of the new rules, and we all respectfully compared and contrasted them, noting pros/cons and how that could relate to individual preferences. I thanked them because it is useful to understand the history of medicine. Some students may find themselves in the icompare study (which I think is a fairly small number of programs) and would also benefit from that discussion.

Otherwise, it's more pertinent to answer questions about call schedules and team structures that they are most likely going to encounter on the interview trails here over talking about the good old days.

I don't advocate going for the cushiest program around, as you guys have said, and it is true to find a place where you feel at home with the people. It's true too that if you have adapted well to the challenges of medical school you will likely be up to the challenge of whatever program structure you end up in.

That said, I feel I would have benefitted as an MS1 and new intern having known more about the nuts and bolts of various structures, and it would have played into my choice.

I have a friend in a program where nights are done as 4+1, 4 weeks days on service followed by 1 week nights same service, compared to my program which had 4 week nightfloat block. That sort of schedule would never have worked for me. Having lived the 1/2 day clinic life as I said above, there is great appeal to the x + y inpt/clinic schedule.

And as @Perrotfish pointed out in one of my fave posts ever of his



So as far as I see it there's no reason not to explain to these MS4s exactly the details of different systems rather than just giving them the party line on "go with your gut and don't worry about the details."

Oh. I was making a point. Which was his conjecture wasn't going to be correct. Given the the two things being compared, I think my point should have been clear. I'm not convinced spelling out everything in pedantic detail is some kind of virtue. The comparison between my style and the style of two people who like to hear themselves talk is an interesting one. And maybe the problem is YOUR preference rather than what I said. Hm?

Straining at these details is largely unimportant. Too many of folks wont believe me. That's not on me though. I tell the truth in here. People can do what they want with what I say. Going with your gut isn't "party line" it's simply the most time tested and honored piece of advice that has been proven time and time again. You may scoff at that but one does wonder if you ever run with scissors.

 

[rokshana]

crayola, you are not a big enough dawg to fight with jdh...

 

[ArkansasMed]

In my experience the people who like a true call system are the ones who can shift their sleep schedules easily. The ones who love it are the ones who can skip a night's sleep every fourth night and who can treat the post call day as half a day off. My problem is that I am neither of those people.

On my post call days I collapse. I sleep 8 hours, devour a large pizza, sleep 8 more hours. I gained a LOT of weight and got sick. No errands happened, ever. I crashed my car into multiple stationary objects on call (thankfully at low speeds), and we don't have a lot of call months.

My sleep schedule does not adjust well. It take me at least three days to shift from days to night. On blocks of nights that means I'm groggy for the first day or two. On call that means I never really sleep. I get 4 hours a night on some of the days when I am actually allowed to sleep. Even our incredibly light ED rotations (16 8 hour shifts in a month) were enough to keep me half dead with exhaustion, because of the constant schedule shifts. With Q4 call it was just hopeless.

And that's when things go according to plan. Ever had something happen at the start of a call night? Get a bad nights sleep? Feel sick? Get berated by the attending? Its hard to start a marathon by getting punched in the stomach. At least with a shift system, no matter what the hospital does to you, you're only 12 hours from being home.

BTW, does anyone else get hospital based nightmares after calls? Like every f-ing time? Post call I always woke up in a cold sweat still half thinking I forgot an order or missed a page and killed someone.

13 hours a day, 6 days a week, sucks. But it sucked for me in a sustainable way. I could do it forever, if I was fine living forever in a gray haze of sadness and resignation. 28 hours every 4th day, though, wore me down rapidly. If we had had more call months I might not have made it through residency.

Speaking of that I had a recent nightmare that I ended up admitting someone from the ED with progeria where the ED forgot to ask the patients age and thought he was 70 when in fact he was 7.... I actually wouldn't be surprised if this hasn't happened to someone now that I think about it.

 

[Crayola227]

The worst dreams I had were after writing 5 notes, 5 d/c summaries, 2 transfer summaries, and 5 admits, 2 sig event notes, a death summary, plus a couple clinic notes and some emails, so like typing for like 8 straight hours mostly, I'd go home from those post long call days at 11 pm and my dreams would be that I was typing, typing all night long. I was so disappointed in my dream at my typing speed I dreamt that I was doing an online speed typing course. So I felt some happiness thinking "when I go back to work I'll be so much faster" only to wake up and realize not only was that not the case, but I had spent all my precious time off to rest not resting but typing and worrying about notes. Yuck. It was the equivalent of typing 24 hrs a day. I joked that I shouldn't even bother going home and sleeping.

I'm with @Perrotfish that there are some call schedules I literally couldn't live through. I also wrecked my car a few times too. I agree with his assessment.

 

[Crayola227]

@jdh71

You're right. You gotta go with your gut or pay the price.

I don't run with scissors, I'm far too risk averse.

I am the type to need my hand held pedantically on some things though, caught me there.

MS4s, there's probably no team structure or call schedule that can make a difference if the people on your team are dicks. 1 senior + 1 intern vs 2 seniors + 2 interns won't matter if your seniors leave your ass in the wind.

Good attendings make a huge difference.

At a community program, if you can you want your whole census with 1 teaching attending. You want a triage system that sends you legit sick gomers not social placement nightmare rocks. If there's a hospitalist service that will take placement rocks off your service that's a huge plus but not to be expected. The idea that all patients are educational is horse****. If all they need is a nursing home they do not need you (but you will still have to round on them and write notes for them). Residents like those patients for being easy not educational.

 

[jdh71]

I still have dreams about patients I didn't see.

 

[dozitgetchahi]

Oh. I was making a point. Which was his conjecture wasn't going to be correct. Given the the two things being compared, I think my point should have been clear. I'm not convinced spelling out everything in pedantic detail is some kind of virtue. The comparison between my style and the style of two people who like to hear themselves talk is an interesting one. And maybe the problem is YOUR preference rather than what I said. Hm?

Straining at these details is largely unimportant. Too many of folks wont believe me. That's not on me though. I tell the truth in here. People can do what they want with what I say. Going with your gut isn't "party line" it's simply the most time tested and honored piece of advice that has been proven time and time again. You may scoff at that but one does wonder if you ever run with scissors.

My time in medicine has taught me many things, but one of the most central ones is this: just don't be a d-bag.

I think even you agree with this on some level.

 

[jdh71]

My time in medicine has taught me many things, but one of the most central ones is this: just don't be a d-bag.

I think even you agree with this on some level.

Avoid being a douche can be very helpful most of the time.

 

[dozitgetchahi]

The worst dreams I had were after writing 5 notes, 5 d/c summaries, 2 transfer summaries, and 5 admits, 2 sig event notes, a death summary, plus a couple clinic notes and some emails, so like typing for like 8 straight hours mostly, I'd go home from those post long call days at 11 pm and my dreams would be that I was typing, typing all night long. I was so disappointed in my dream at my typing speed I dreamt that I was doing an online speed typing course. So I felt some happiness thinking "when I go back to work I'll be so much faster" only to wake up and realize not only was that not the case, but I had spent all my precious time off to rest not resting but typing and worrying about notes. Yuck. It was the equivalent of typing 24 hrs a day. I joked that I shouldn't even bother going home and sleeping.

I'm with @Perrotfish that there are some call schedules I literally couldn't live through. I also wrecked my car a few times too. I agree with his assessment.

I remember a hellish wards month at our county hospital intern year that was much like this. (No overnight call as I was an intern, of course.)

The background: a new county hospital had just opened and the whole metropolitan area's super-sick clientele were basically showing up to 'try it out'.

To make matters worse, the senior who was supposed to be on that month had some sort of major health issue and thus each week we had a new senior jeopardized in.

Most of the seniors were super pissed that they were being jeopardized off renal consults or whatever and definitely took it out on us hapless interns. Three of the four wouldn't lift a finger to help us. (One was helpful - hats off to her.)

I had 10 pts almost the entire month. Every day, I would run my ass off to pre-round and round to try to snag a bit of food before noon hit, because once the clock struck 12:00 an endless pager blitz would start that lasted almost the entire afternoon. By the time I was kinda/sorta done writing notes and putting out fires it was usually 9 or 10 o'clock. Usually there was still a discharge summary or something to be done, and said lazy ass seniors would 'invite' me to 'just take that home to finish' - which meant a scramble home to grind out a crappy discharge summary at 11pm/midnight while choking down a sandwich so I could collapse into bed and get 5-6 hours of sleep.

"Call nights" were even more horrible, and I can remember one where the other intern and I finally got our crap done at 2 am (the senior had already left) and we just trudged down to the call rooms and slept 3 hours before starting over again (even though we weren't supposed to be doing that as interns).

To make matters even worse, this rotation took place during the December/January timeframe, and there were several huge snowstorms (including the infamous 'snowpocalypse' storm of 2013) that happened on this rotation. On the day of the 'snowpocalypse', one new intern (an OB intern, long story) who was supposed to start the rotation that day was stuck in California or something because her plane couldn't take off. Another intern was jeopardized in but 'got stuck' (ya, right) and didn't bother showing up. The senior was off for some reason. This meant I had the whole capped service between myself, two medical students and an attending who for whatever reason was not compassionate or reasonable about the whole thing and acted like I was a lazy **** even though I was the only other licensed member of the team who had driven myself to the hospital through 12+ inches of snow and was voluntarily seeing more patients than I was actually supposed to be seeing as an intern.

Our other wards months were not this bad, but nevertheless it was that rotation that made me swear once and for all that I was never going to be a hospitalist.

 

[TastyCurrantJelly]

Agreed.

You know what really sucked about the new work hours (started after my intern year)? Losing the Golden Weekend. I'd take 30 hour call q4 in a heart beat to have a whole weekend off once a month compared to only getting 1 day at a time off but never staying overnight.

It seems like 3+1 or 4+1 programs have the best of both worlds and are the clear way to go to avoid burnout during residency: golden weekends once a month, protected clinic time, and you can get all this without q3/q4 28 hour shifts.

 

[HelpPleaseMD]

I remember a hellish wards month at our county hospital intern year that was much like this. (No overnight call as I was an intern, of course.)

The background: a new county hospital had just opened and the whole metropolitan area's super-sick clientele were basically showing up to 'try it out'.

To make matters worse, the senior who was supposed to be on that month had some sort of major health issue and thus each week we had a new senior jeopardized in.

Most of the seniors were super pissed that they were being jeopardized off renal consults or whatever and definitely took it out on us hapless interns. Three of the four wouldn't lift a finger to help us. (One was helpful - hats off to her.)

I had 10 pts almost the entire month. Every day, I would run my ass off to pre-round and round to try to snag a bit of food before noon hit, because once the clock struck 12:00 an endless pager blitz would start that lasted almost the entire afternoon. By the time I was kinda/sorta done writing notes and putting out fires it was usually 9 or 10 o'clock. Usually there was still a discharge summary or something to be done, and said lazy ass seniors would 'invite' me to 'just take that home to finish' - which meant a scramble home to grind out a crappy discharge summary at 11pm/midnight while choking down a sandwich so I could collapse into bed and get 5-6 hours of sleep.

"Call nights" were even more horrible, and I can remember one where the other intern and I finally got our crap done at 2 am (the senior had already left) and we just trudged down to the call rooms and slept 3 hours before starting over again (even though we weren't supposed to be doing that as interns).

To make matters even worse, this rotation took place during the December/January timeframe, and there were several huge snowstorms (including the infamous 'snowpocalypse' storm of 2013) that happened on this rotation. On the day of the 'snowpocalypse', one new intern (an OB intern, long story) who was supposed to start the rotation that day was stuck in California or something because her plane couldn't take off. Another intern was jeopardized in but 'got stuck' (ya, right) and didn't bother showing up. The senior was off for some reason. This meant I had the whole capped service between myself, two medical students and an attending who for whatever reason was not compassionate or reasonable about the whole thing and acted like I was a lazy **** even though I was the only other licensed member of the team who had driven myself to the hospital through 12+ inches of snow and was voluntarily seeing more patients than I was actually supposed to be seeing as an intern.

Our other wards months were not this bad, but nevertheless it was that rotation that made me swear once and for all that I was never going to be a hospitalist.

for some reason i picture this at IU lol

 

[HAL3000]

There are some programs that exist to train residents to become good doctors. There are others that exist as afterthoughts of greedy hospital admins who profit off the backs of residents and conflate "let's work residents as hard as we can so we don't have to hire real staff with actual benefits" with providing "rigorous training." Regardless of the call schedule, look carefully for signs of the latter. Don't fall for that trick; contrary to what you have been indoctrinated with as a medical student, you are now a professional with rights as a worker and deserve to be treated as such.