28-Hour Call (a.k.a. Democracy in Action)

November 04, 2018
by Mark David Siegel

Hi everyone,

I’m proud of our residency and want to make it even better. A key to our success is our commitment to democratic ideals.

At Friday’s Birthday Party/Program Director’s meeting, we wrestled with 28-hour call. As most of you know, Peter Kahn and Megan McCullough, representing the Program Evaluation Committee (PEC), conducted a survey seeking your input. Most residents participated, which speaks to how important this issue is and how engaged you are in making our residency better.

Most residents dislike call, at least as it’s currently configured. There is widespread concern that call increases burnout, undermines resident health and safety, contributes to medical errors, and fails to improve education. These concerns create a compelling argument to end or transform call, but, as many respondents recognized, the best path forward is unclear.

Most of our peer programs (e.g., Hopkins, Penn, BID, UCSF, Stanford, etc.) have at least some overnight call, the exception being programs in New York, where call is forbidden. Compared to other programs, we have an average amount of call- some have more, some less.

When it comes to call, I’m agnostic. I’m not convinced that call fosters education. The benefit of watching cases unfold dynamically, for example in the ICU, is undermined by fatigue. Published data on patient safety are inconclusive, given concerns about information being dropped during handoffs. The impact of call on burnout is also uncertain, at least according to data from iCOMPARE. In contrast, the negative impact of call on wellness seems indisputable- how could anyone feel well after being up all night? What's less clear is whether alternative approaches can fix the problems without creating equally vexing new ones.

The challenges become clear when we consider options to replace call. Assuming we don't want to eliminate teaching services, we would have to create new night shifts on Fitkin, at the VA, and in the YSC MICU. These shifts would have to be staffed by residents or hospitalists. A non-resident solution would mean YNHH and the VA would have to hire many more nighttime hospitalists. Beyond the expense, we'd face the daunting challenge of recruiting hospitalists in the midst of a hospitalist shortage. This approach could also undermine education by increasing the number of holdover admissions, meaning we'd be managing more patients we didn't admit ourselves.

Staffing the night with residents generates logistic challenges. For every new night shift, we’d need to create two new positions since residents spend approximately half the year on inpatient rotations. To accomplish this, we’d have to expand the residency or shift trainees out of daytime roles. Expanding the residency could undermine the dynamics of our program, which is already large (though far from the largest), and it would introduce problems finding clinic space. We’d also have to find a funding source to pay for new residents and persuade the ACGME to let us add trainees to meet a workload need, which could be a tough sell. For these reasons, it's unclear that expanding the residency is feasible or desirable.

What about shifting residents into more nighttime rotations? This too seems problematic, at least to me. While night rotations are educationally valuable (as a resident, I loved being on at night), they do reduce access to teaching conferences and diminish face time with attendings. More night rotations would also increase the amount of time residents spend out of sync with friends and family. Moreover, if we created more nighttime rotations, we'd have to take residents from somewhere, which would mean moving residents off current rotations. Potential options might include decreasing elective time, eliminating golden weekends, or creating scheduled pulls from jeopardy and other services. However, each of these solutions seems self-evidently problematic and would create new challenges for wellness and education.

Another option would be to move residents from daytime to nighttime shifts. However, doing this would force us to dismantle the 1:1 resident to intern ratio we have on most rotations, which is a longstanding, cherished, and somewhat unusual feature of our program. The 1:1 structure fosters mentoring relationships, increases opportunities for residents to rotate on subspecialty services, ensures at least one resident is available each day to work with the interns, and improves education and safety by keeping workloads reasonable. For all these reasons, we’ve actually added residents in recent years to daytime shifts on Oncology, Duffy, and Klatskin. For similar reasons, we moved interns in the MICU off evening and night shifts, which eliminated unpopular roles and increased daytime staffing from 4 to 6. As a result, the intern census dropped from an unmanageable 8-9 to a reasonable 5-6.

As should be clear, simply eliminating overnight call is logistically challenging and could create new problems. Would it be reasonable instead to guarantee that residents sleep when they’re on call? Would it be possible to stop admitting new patients to resident teams after a predetermined hour? Could we mandate official times to sign out and relinquish Mobile Heartbeats so residents can sleep? What if we made rotations with overnight call shorter, for example no longer than two weeks? What if we spread out call nights, for example making them one in eight instead of one in four? Would it be sufficient to eliminate call on some rotations while maintaining it on others?

Clearly these questions call for more discussion. We finished Friday’s meeting with a decision to create a working group to address overnight call. The group would be charged with addressing our current call structures with the goal of fostering patient safety, education, and resident well-being. If you want to participate in this group, please let me know. Please also share any questions, comments, or concerns you might have.

I can’t thank everyone enough for contributing to this dialog, especially Peter, Megan, and the rest of the PEC for conducting their survey. Friday’s Program Director’s meeting was an extraordinary example of democracy in action, highlighting the value of creative thinking, careful listening, and working together towards a common goal. This is among the many things our residency does best- collaborating to make our program as good is it can be.

Speaking of “democracy in action,” don’t forget to vote on Tuesday if you are eligible, and let us know if you need help getting to the polls.

Finally, Happy birthday to all the November babies,

Mark

PS For further reading:

  1. The iCOMPARE Investigators (including our very own Alyssa Yeager). Education Outcomes in a Duty-Hour Flexibility Trial in Internal Medicine. N Engl J Med 2018; 378:1494-1508
  2. Parshuram CS et al., Patient safety, resident well-being and continuity of care with different resident duty schedules in the intensive care unit: a randomized trial. CMAJ. 2015 Mar 17; 187(5): 321–329

MDS

PPS Good luck to Lauren Pischel, Jadry Gruen, and Kayle Shapero, who are running the NYC Marathon today! 

M

 

Submitted by Mark David Siegel on November 04, 2018