In my last post I shared an overview of a single week in our home and explored the ways in which both our lives tend to revolve around J's schedule. Today, I'm going to dive a little deeper into "Call," "Post-call," what it means for J in his general surgery program, and how it differs from those in other surgical residency programs like orthopedics, ENT, and plastics. In preparing this blog post I reached out to other spouses of surgeons and surgical residents to ask them what call was like for their partners throughout residency. The answers were insightful, eye-opening, and far more varied than I was anticipating. They incited strong feelings of solidarity alongside plenty of head-shaking. They reminded us all of the ways our partner's schedules seem to defy the arbitrary distinctions in calendars and dates. And they revealed some of the flaws in the overall surgical education system, flaws which I hope to explore with more research (and not just gut reactions) in the coming months. 1. What is Call?
When a surgical resident is on call, they are responsible for addressing all the new patients that come in. This includes patients coming in through the Emergency Department or Trauma bay, as well as consults from other specialties, like when the Internal Medicine team wants a patient with abdominal pain checked out by the Surgery team in case it would require an invasive procedure. Being on call also means managing patients on the floor (those who have already been admitted to the surgical team) and addressing any issues as they arise. The frequency with which residents are on call depends entirely on the program, the specific team they're on for any given month, and their level of training. A schedule where the resident is on call every 3 days or every 4 days is referred to as Q3 and Q4, respectively. Some schedules only require call overnight or on the weekends, or intermittently throughout the month to cover as necessary. 2. What is the difference between Home Call and In-House Call? "In-house call" means you are in the hospital for the entire duration of the call, which is typically scheduled for 24 hours but more commonly lasts 26-30 hours because of the work involved in ensuring proper patient handover to that day's team; finishing up notes, dictations, and other paperwork; and attending residency education lectures, conferences, or meetings. This type of call is most common for general surgery residents. "Home call" is what many attending physicians do after their training years, when they're at home but answer calls and pages about patient concerns at the hospital. They may have to go to the hospital at a moment's notice if something more acute comes up. J has only had home call for one team he was on for two months last year, but this type of call is more common among Orthopedic, ENT, and Plastics surgical residents. Home call might theoretically be easier, but for residents it can be hugely problematic. As was explained to me, home call during residency does not necessarily equate to time at home. Many residents will spend the entire time fielding phone calls and concerns, or might spend most of their time at the hospital anyway. Some even chose to stay at the hospital the entire time just to make things easier. And to make matters more complicated, when programs schedule a resident to take home call they might treat it as if they are non-working hours, regardless of whether or not the resident gets any sleep or spends any time at home. 3. What is Post Call? Post call is the day immediately following a 24-hour in-house call. It might look like this:
Based on the stories people shared with me, residents who take home call do not have a post-call day to sleep, regardless of whether or not they were working. 4. Is a 24-hour call even a good idea? Yes and no. In the affirmative, studies have shown that shorter shifts for residents do not necessarily improve patient care, and in fact longer shifts create better continuity of care. This article from the New York Times gives a concise overview of the arguments for 24-hour call among first-year residents and the status of research on the topic. Basically, every time doctors switch shifts, there is a risk that vital patient information will not be transferred appropriately between physicians. Even minor details could become vital later on, and for very sick patients those hand-offs could prove problematic. Those risks are minimized when a physician is on call for 24 hours and can work with their patients over that prolonged time. However, continuity of patient care is only part of the reason physicians work these long hours. The other part is institutional and cultural - the "this is the way we've always done it" approach. And this is where the problems lie. The drawbacks to being on call - whether in-house or at home - tend to surface in the 12 hours following that shift. Physician mental and physical health very frequently take a backseat to the logistical needs of staff size, patient load, and case load, and the culture of the hospital and that department. In the anecdotes shared by other surgical spouses, many spoke of husbands working a 24-hour in-house call then having to stay at the hospital to work the remainder of that day until at least 7 pm, or working 12 hours shifts during the day then having home call every night and often having to go back in overnight, only to work again at 6 am the next day. 5. Aren't there any protections against over-working residents? Yes . . . and no. The Accreditation Council for Graduate Medical Education (ACGME) oversees and regulates nearly all residency programs in the United States. It has clear guidelines and work-hour restrictions that programs are expected to meet in order to continue functioning, and the guidelines are theoretically meant to ensure the rights and well-being of residents. Here are a handful of requirements from the 2017 ACGME Program Requirements for General Surgery (copied from sections VI.F.1 through VI.F.8, emphasis mine):
So yes, there are protections. But unfortunately many of these guidelines are poorly enforced, and it is our partners who suffer the consequences. Many of the wives who shared their experiences with me, particularly those whose partners are in orthopedics, plastics, and ENT, regarded post-call days as a luxury or even a "unicorn day." In those programs, and in some specific rotations within General Surgery like VA, home call was the standard. The experiences with home call varied greatly between relative quiet and getting called in and staying at the hospital the entire time. One wife even referred to it as "not at home call," describing her husband trying to get a few moments of sleep in the call room between back-to-back shifts, sleeping at the hospital when it was too late to come home, and even working three days in a row with little sleep when taking home call over the weekend. Another wife described a schedule where her husband works 6 am to 6 pm at the hospital (a standard shift), takes home call overnight then works the next day at 6 am. But because he "always gets called in," he often stays at the hospital overnight between his two standard day shifts. In some anecdotes, husbands worked these kinds of non-stop schedules not for days, weeks, or months, but years on end with the occasional "golden weekend" (two days off) thrown in. After reading all the responses, two things became abundantly clear:
One of the problems with home call and the ACGME's policies is that programs typically don't have nearly enough residents to have flexibility in their schedules. While someone taking home call might conceivably do little work to count toward their 80-hour limit, in most cases those residents spend the majority of their time fielding phone calls or actively going into the hospital to address patient needs directly. In those cases, per ACGME rules, the resident should not have to work immediately afterward, or should have another shift reassigned later in the week. These schedules very rarely (if ever) account for changes in the resident's needs and thus treat home call as if those hours are not part of the 80-hour work week. To make matters worse, many residents and their spouses come to believe that home call simply does not count toward the work-hour restrictions, despite the clear language in the ACGME's Program Requirements, and excuses like the limited number of residents in a program are often used as sufficient justification for noncompliance within the program. J's program, by contrast, is surprisingly aligned with the ACGME requirements, with few exceptions. He and I don't have to suffer the realities of many other residents who work far more hours with far more frequency and less time in between. The fact that he even has a post-call day, not to mention that he is usually home by noon on such days, is itself a reason to count one's blessings. It doesn't stop me from complaining about the stresses and abuse he suffers at the hands of a huge, often antiquated system that treats its residents as if they are still literal residents of the hospital, living there 24/7, as in the early days over a century ago. As per American work culture, an "80-hour work restriction" is often treated more as a guideline than a requirement even though programs will never admit to overworking its residents for fear of losing accreditation. Residents, by extension, also avoid honestly reporting their work hours because if the program loses its accreditation, their training may be negatively impacted by having to switch programs (or so they are told to believe). American medical training has come a long way in the last number of generations, but it still has a long way to go. In many ways, the practices of individual institutions have yet to fully align with the ideals of the ACGME, which itself still has flaws. The reasons range from logistical to ideological, both of which I hope to research further in the coming months to shed light on the broader experiences of surgical residents.
2 Comments
MaryBeth Hoover
3/26/2018 05:18:54 pm
Very accurate. My husband always defends long call versus shift mentality. He sites the same concerns during transfer to the next resident. And a “not my problem ” mentality if your patient is only your concern for 12 hours.
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I just asked my husband about the shift mentality and he agrees that it absolutely is a problem, especially in emergency medicine/critical care/trauma when most of it is shift work. I wonder to what degree that's also a way to compartmentalize the challenges of work in order to function at home?
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AuthorNashira is a music teacher and proud Small-Town Jew who, after surthriving six years in Brooklyn for her husband's surgical residency, is finally back in Wisconsin where she belongs! At least until the end of the two-year surgical fellowship, that is. It's a wild ride, and she's ready to tell you all about it! Archives
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