What does "call" entail?

[deleted307836]

As I read SDN posts on residencies or sometimes even clinical rotations, "call" is frequently mentioned and I'm curious about what call entails exactly. If a residency has "q4 night call", does that mean you can be called every fourth night - and does that mean you are called to come into the hospital, or is it strictly call from home? So like a consult type thing?

Does "call" differ in medical school (Sub-I's etc.) and residency? i.e., is call for medical students always to come into the hospital to see an interesting case, while call for residents is more of a consultative thing?

And what about for attendings -- is their call pretty much the same as for residents?

Just curious about what this usually means. Thanks.

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[LizzyM]

As I read SDN posts on residencies or sometimes even clinical rotations, "call" is frequently mentioned and I'm curious about what call entails exactly. If a residency has "q4 night call", does that mean you can be called every fourth night - and does that mean you are called to come into the hospital, or is it strictly call from home? So like a consult type thing?

Does "call" differ in medical school (Sub-I's etc.) and residency? i.e., is call for medical students always to come into the hospital to see an interesting case, while call for residents is more of a consultative thing?

And what about for attendings -- is their call pretty much the same as for residents?

Just curious about what this usually means. Thanks.

For med students and residents, "call" means you are on duty and on the premises to handle whatever happens overnight. Now maybe some call is from home -- for example, derm residents may be on call every night for a month but I think that they can do that from home provided they can get in quickly if needed, because frankly, they don't have that many admissions in the overnight hours or requests for transfers or consults overnight-- but for most everyone else "call" is a few times a week of trying to sleep in an "on call room" and hoping to get a little rest between requests from the floor(s).

Residents are not being consulted, they are taking care of patients. Medical students participate, depending on the rotation. So, a new admission needs a history, physical, and orders. Results of tests and examinations (for example, chest x-ray, blood tests) could be reviewed and can result in additional orders (more tests, specific medications, scheduled procedures, emergency procedures). Residents pretty much run the show overnight.

Depending on the specialty, attendings may never come in overnight or they may come in when on call to deliver a baby, operate on a patient with an emergent problem, etc. Trauma surgeons take call in the hospital because accredited trauma centers must have a trauma surgeon on the premises at all times.

 

[Catalystik]

As I read SDN posts on residencies or sometimes even clinical rotations, "call" is frequently mentioned and I'm curious about what call entails exactly. If a residency has "q4 night call", does that mean you can be called every fourth night - and does that mean you are called to come into the hospital, or is it strictly call from home? So like a consult type thing?

Does "call" differ in medical school (Sub-I's etc.) and residency? i.e., is call for medical students always to come into the hospital to see an interesting case, while call for residents is more of a consultative thing?

And what about for attendings -- is their call pretty much the same as for residents?

Just curious about what this usually means. Thanks.

Back in the day, q4 call meant being required to stay overnight at the hospital every 4 nights, whether one was a resident or med student. These days there are variations on the theme, that may include in-house call only until 10 pm every 3-4 nights (after which a night float takes over the duty), shift work where you are on duty for 12 hours then off for 12 hours, and taking call from home, where you only go in if your physical presence is needed (more common for senior residents who have interns to do the work), as well as other creative solutions to the work hour restrictions that have gone into effect. Med students, even sub-Is, these days may be sent home at 10 pm so they aren't overly taxed.

Attendings are more likely to take call from home, but some specialists stay in-house, like neonatologists, laborists, hospitalists, ER docs, etc, when they are on duty.

 

[Law2Doc]

As I read SDN posts on residencies or sometimes even clinical rotations, "call" is frequently mentioned and I'm curious about what call entails exactly. If a residency has "q4 night call", does that mean you can be called every fourth night - and does that mean you are called to come into the hospital, or is it strictly call from home? So like a consult type thing?

Does "call" differ in medical school (Sub-I's etc.) and residency? i.e., is call for medical students always to come into the hospital to see an interesting case, while call for residents is more of a consultative thing?

And what about for attendings -- is their call pretty much the same as for residents?

Just curious about what this usually means. Thanks.

First, the vast majority of people are not on cushy things like derm where they take call from home and rarely come in. When I say call, I mean I am staying in the hospital overnight, often for a 24 hour period. Similarly, when you are on call as a Med student, you are staying overnight at the hospital, nobody is going to call you in from home to see n interesting case. You see it because you are there. Call differs in med school than residency only in that you have duty hour limitations as Resident that may not protect you as a Med student, and you do a heck of a Lot more as a resident. I wouldn't call call a consultative thing, you are there working, often without time to sleep. You may be carrying multiple teams pagers, covering all of their patients. Every time a nurse calls about a patient, or radiology calls about one of their scans, or the lab calls about a lab value, it's you who has to handle it.

 

[KnuxNole]

Some family medicine residencies have call from home too 😍

 

[image187]

last night I was ob call. I had the day off in the morning, and then went to the hospital and worked from 5pm-8am. I had the rest of the day off today and tomorrow is a regular 5:30-5 day. On a surgery rotation at my school, you take call from the early morning through the night and into round the next morning, get the rest of that day to rest (post-call) and then have a regular day the next day. On medicine, "call" meant that q 4 days instead of working from 7 till about 4, I stayed till about 7 and our team admitted all the new patients that day until the night float tool over. Lastly, some rotations like psych, neurology, family med, electives etc... we dont take call.

 

[Law2Doc]

Back in the day, q4 call meant being required to stay overnight at the hospital every 4 nights, whether one was a resident or med student. These days there are variations on the theme, that may include in-house call only until 10 pm every 3-4 nights (after which a night float takes over the duty), shift work where you are on duty for 12 hours then off for 12 hours, and taking call from home, where you only go in if your physical presence is needed (more common for senior residents who have interns to do the work), as well as other creative solutions to the work hour restrictions that have gone into effect. Med students, even sub-Is, these days may be sent home at 10 pm so they aren't overly taxed.

Attendings are more likely to take call from home, but some specialists stay in-house, like neonatologists, laborists, hospitalists, ER docs, etc, when they are on duty.

Even where residencies do night float they still usually have call on the weekends for the simple reason that the rules don't allow more than 6 days in a row of night float. Call exists similar to how it always has, sans the 30 hour shifts. Most call heavy services give med students the true experience when they are on rotation, and keep them overnight where I'm at. I'd say that's pretty common, at least in this region.

 

[Law2Doc]

Some family medicine residencies have call from home too 😍

family med residents often do a certain number of mandatory surgery and ICU rotations and get beat down with the rest of us.

 

[deleted307836]

Thanks for the informative replies everyone, that really helps clarify it.

To get back to my q4 night call example -- would this usually mean the resident is staying overnight every four nights with the next day off? That seems inefficient - why not just do a week of nights per month or something?

 

[deleted307836]

Catalystik pretty much answered my question in my post above... just curious about what is most common or what most residents are seeing now. Let's assume this is something like IM or neuro.

 

[Law2Doc]

Thanks for the informative replies everyone, that really helps clarify it.

To get back to my q4 night call example -- would this usually mean the resident is staying overnight every four nights with the next day off? That seems inefficient - why not just do a week of nights per month or something?

Yes it means that. It's only inefficient if you look at it as shift work. In fact it provides continuity of care, with the same person there for a longer stretch, which some people consider better care. As for why not being on a week, you have to realize that everything has to fit in with the duty hour rules. You need to get off for 24 hours somewhere in each 7 day period. You aren't allowed to be on more than 6 sequential days in a row. Interns can only work 16 hours in a row, you can't average more than 80 hours a week, etc. It's a myriad of rules designed to make it impossible to create an easy schedule..

 

[Law2Doc]

Catalystik pretty much answered my question in my post above... just curious about what is most common or what most residents are seeing now. Let's assume this is something like IM or neuro.

Most residents in IM do some combo of night float and true call. Neuro takes call, but depending on the facility, might have some home call.

 

[KnuxNole]

family med residents often do a certain number of mandatory surgery and ICU rotations and get beat down with the rest of us.

Oh I know, while I'm not looking forward to those, seeing it from an educational standpoint makes it less painful. Plus, being able to do non-OR procedures and get experience with that is always a plus, in terms of skillset 🙂

 

[deleted307836]

Yes it means that. It's only inefficient if you look at it as shift work. In fact it provides continuity of care, with the same person there for a longer stretch, which some people consider better care. As for why not being on a week, you have to realize that everything has to fit in with the duty hour rules. You need to get off for 24 hours somewhere in each 7 day period. You aren't allowed to be on more than 6 sequential days in a row. Interns can only work 16 hours in a row, you can't average more than 80 hours a week, etc. It's a myriad of rules designed to make it impossible to create an easy schedule..

That's interesting and a good point about continuity of care. I didn't realize how complex the duty hours rules were.

 

[Catalystik]

Catalystik pretty much answered my question in my post above... just curious about what is most common or what most residents are seeing now. Let's assume this is something like IM or neuro.

With Internal Medicine, one rotates through different departments through the year, with a certain number of ward rotations, plus perhaps MICU and CICU, Ambulatory Care, and electives. One might or might not have call responsibilities during the latter two, depending on the institution. When applying for residencies, it's important to know what to expect. The FREIDA site at https://freida.ama-assn.org/Freida/eula.do or residency websites will generally have this information so you choose wisely. Keep in mind that picking one with the least duty hours also means you may be choosing to gain less experience.

 

[Law2Doc]

...Keep in mind that picking one with the least duty hours also means you may be choosing to gain less experience.

I would echo this. I actually don't know anyone who has been through it who doesn't agree that when you are alone at night on the wards for a long stretch of hours during intern year is when you actually learn how to be a doctor. Until you are carrying the pagers, making on the spot decisions about care without calling a senior, having patients trying to die on you, etc, you simply aren't going to get very good. You learn poise, self confidence, the ability to make good decisions with the available information, dealing with people during stressful tines, and learn when you are flailing and really do need to wake somebody up. Until then, you always are relying on others to make the hard calls, and you can only learn so much by books and osmosis. Show me someone who goes home at 10 every night during intern year and I'll show you the guy I don't want overseeing my care as a senior. You simply need to learn to get over a few hurdles before you can confidently say you are able to run the race competitively.

Now that doesn't mean you have to be a martyr, but shying away from an otherwise good program because they have overnight call is foolish and will hurt your learning more than the few extra hours of sleep are going to benefit you.

 

[Instatewaiter]

I would echo this. I actually don't know anyone who has been through it who doesn't agree that when you are alone at night on the wards for a long stretch of hours during intern year is when you actually learn how to be a doctor. Until you are carrying the pagers, making on the spot decisions about care without calling a senior, having patients trying to die on you, etc, you simply aren't going to get very good.

Now that doesn't mean you have to be a martyr, but shying away from an otherwise good program because they have overnight call is foolish and will hurt your learning more than the few extra hours of sleep are going to benefit you.

I completely agree with this. We are seeing the effects of the new hours in my program now. The new work hours put major caps on how long an intern can be in the hospital and how much supervision (read as hand-holding) you have to have.

The class behind me was the first that was part of this new system and we are seeing their clinical accumen suffer accross the board. Perhaps it is just delayed but the worry is that there will need to be longer residencies to create the same product... We'll be able to tell in a few years when there have been a few classes that have gone through the new hours.

There are some who say that the ACGME wants to make these restrictions (ie 16 hours at a time) for all years. That would be completely disastarous especially for surgical services.

 

[EmergencyMonkey]

When I was an intern they changed the "call" for students and let those lucky guys go home at midnight if they wanted. Obviously not the case for interns and residents. I think each place handles it differently, but ultimately it is the same.

 

[Law2Doc]

The resident hours restriction requirements that came out of the 1984 Libby Zion case where an 18 year-old girl, died under the care of what appeared to be overworked residents and interns. Her father , Sidney Zion, former lawyer and well-know journalist for NY Times and other papers, was the initial driving force for this change. However the flaw of this change was underlying assumption/belief that less hours would also lessen the workload of the residents. The unintended consequence was was simply altering the equation of so an on call resident will have more patients to cover, a larger portion will likely be patients not familiar to him or her.

I am not sure which situation I would rather be in as a patient. A tired doctor who will be likely to be be familiar with my case or one who have 2 or 3 times as many patients in an night of on call who has no idea who I am

Agree with this -- cross covering for patients you aren't familiar with from multiple teams, and carrying multiple pagers each night really doesn't lead to better care. But I also think the bigger problem in the duty hour change is the increased number of sign outs each week, which are always an opportunity for key tidbits of information to get lost in the shuffle. The scariest thing on call is to get called about a patient who isnt doing well and youve never heard of him before because the guy who signed out to you glossed over him by saying "hes stable, nothing to worry about". If you take care of a set of patients for 30 hours in a row, like we did my intern year, yes you are tired at the end and probably a menace on the road on your drive home. But by the end of that 30 hours you knew everything about your charges, and weren't frantically looking up your sheet of sign out scribbles every time you took a page. By contrast, if people are having sign outs every 12 hours, that's more than double the number of times you play a very dangerous game of telephone. So yeah, replacing a longer overnight shift with cross covering and multiple sign outs probably made things worse for patients and the folks caring for them.

Plus by decreasing the number of hours in residency you learn less too (if you aren't there you are missing a variety of learning opportunities, and also by restricting hours programs have been forced to chop down didactics or force people who have already been working close to the limits not to attend). I always found it annoying that I wasn't allowed to stay on for a lecture or grand rounds on a cool topic I wanted to learn something about (either because it was something I hoped to go into or because it was likely to be on the boards) because that would push me over the 80 hour averaged limit, yet if I went home and spent a longer period of time reading up on the same topic, that was fine. So I'm not sure how that benefits patients to have equivalently tired, less educated residents, working off poorer sign out information and covering more patients they've never heard if before their shift. That's the legacy of Sidney Zion.

 

[BigRedBeta]

To add an additional layer to it all, what calls are like can be very, very different.

As a peds critical care fellow, there is no home call. Every single one of my calls are at the hospital and I frequently get a lot of "ouch, rough lifestyle" when I tell other doctors what I do. However, I'd argue that other specialty fellows actually have it rougher, even if they get to take call from home. Here's why - when I take call, even if I'm on service and have to stay until noon the next day, when I leave the hospital, I'm done. There is someone taking care of my patients, there's no chance I have to come back to the hospital and I can go sleep without worrying. The same is true for my attendings who also take in-house call. My friends who are cardiology or heme/onc or neuro fellows...they go home and they have to make sure they have their pager with them, have to make sure they're aware of which parents have been calling multiple times throughout the day for whatever problem. If they have a terrible night in which the ED is paging them for 20 different patients, or calls them in to perform an echocardiogram or whatever, since it was home call, they don't get to go home at noon. They have to keep their clinics the next day. Many of my colleagues are on home call for a week at a time, so they may have multiple nights in a row where things are crazy and they get no sleep. Meanwhile, it doesn't matter how terribly crazy my night is, how many children are actively trying to die, I get to leave. For me, because I'd be worried I slept through a page, the idea of home call for days at a time sounds infinitely worse than what I do or what my attendings do.