The role of call scheduling in resident burnout
Today my son Hunter is 821 days old (2 years, 3 months, 0 days). As a resident, I have spent 129 of those days in the hospital while on call; after-hours care that are over and above my ‘regular’ working day (0 years, 4 months, 3 days). In other words, I have missed 15% of his life while looking after others.
The fact is that for doctors, call will always be an essential part of medicine. Patients get sick 365 days per year (12 months, 0 days) and need people to provide care for them. No one signs up for this job without knowing that call will be a significant part of it. So I’m not here to garner sympathy about having to do call – it’s a fact of the life I chose.
But society began to worry that doctors who worked too many consecutive hours would make avoidable medical errors as a result of exhaustion. Physicians in turn began to recognize a large component of job dissatisfaction and fatigue were a result of poor work-life balance created by such onerous working conditions.
In 2003, the United States mandated 80-hour weekly resident duty limits. Currently, there are no national Canadian guidelines for resident duty hour restriction. Work hour limits are negotiated individually within each province, with some ranging from 16 hours, and others to 30 hours of continuous work. The hope is that by limiting hours, fatigue can be reduced, which would in turn improve patient safety, resident well-being, and resident education.
A recent review of all of the evidence that examined these domains in surgical residents following the institution of duty limits had mixed conclusions around the effect on rates of resident burnout (defined as a triad of emotional exhaustion, depersonalization, and a sense of decreased personal accomplishment). Perhaps different domains involved in resident work hours need to be examined in order to make significant improvements.
Current research supports the notion that a lack of autonomy in a resident’s personal time significantly contributes to resident burnout. I can personally attest to the fact that my feelings of burnout are directly tied to the way in which my call is scheduled and the lack of control I have over my own life as a result.
The Professional Association of Residents of Ontario (PARO, the union that represents all residents in Ontario) mandates that call schedules be released 2-weeks before the start of a 4-week rotation, despite the fact that we know our clinical rotation schedules 13 months in advance.
The result of this PARO mandate and the fact that the call schedulers work to that deadline is that I never know more than 2 weeks in advance whether I can go to my brother’s wedding that was booked 1 year ahead, or to a dinner reservation with my friends that was booked 1 month before my rotation began. As residency is a time where many individuals (including myself) choose to have children, I can only imagine the call scheduling nightmare and challenges faced by a family with children whose parents are both doctors. It shouldn’t come as any surprise that residents have an alarmingly high rate of burnout when we find ourselves distanced from the social bonds that sustain us.
There are likely many different ways to improve call scheduling, and I lack the benefit of observing the evolution of the current scheduling system to help inform the solution. But the current system of resident working hours, including call, indicate that patient safety and resident education are suffering, and resident burnout isn’t necessarily changing. The knowledge that a lack of autonomy in personal scheduling contributes to overall resident burnout within this system signals that we clearly need a better system. What might that look like?
The development of a centralized software program that uses an algorithm to schedule resident call would be able to calculate the near infinite number of different possible combinations of resident scheduling in a matter of microseconds, thereby ensuring that as many resident requests for off-call are honoured and would relieve our overburdened call schedulers from their arduous and complicated task.
There could be an imposed deadline for residents to submit vacation and off-call requests (for example, 6 months ahead of time). Changes to this schedule would not be allowed unless accomplished on an individual basis between residents who would have to ensure availability in their own schedule. Unexpected events arise and may require a last minute change to the overall schedule. Again, the computing power of an algorithm designed to efficiently evaluate possible scheduling changes (and send out requests to those residents who would be affected) would allow for minimal disruption to the call structure.
In other words, I could say ‘yes’ to the invitation for my Mom’s surprise birthday party and not worry that I may have to miss it because I was put on call 2 weeks beforehand. And maybe, just maybe, it might help to keep me feeling less burned out when I am on my 26th-consecutive hour worked while on call.
The Resident’s Call Index
Average number of call shifts per year – 62
Average hours per call shift – 26-30
Call stipend per shift – $115
Call stipend after income tax – $86.92
Hourly call rate for a 30-hour call shift – $2.90
Price of a brewed coffee on call – $2.25
Percentage of residents who are married to another healthcare professional: 36.2
Percentage of residents who have children: 15.9
Maximum allowable hours for a medical resident to work consecutively in Ontario: 26
Maximum allowable hours for a surgical resident to work consecutively in Ontario: 30
Maximum allowable hours for a commercial truck driver or commercial pilot to operate a vehicle in Ontario: 14
Average number of patient consultations on a 26-hour call shift: 18-20
Average number of visits to the bathroom on a given 26-hour call shift: 1
Average number of meals eaten on a given 26-hour call shift: 0.5
Maximum flying time per year for a commercial pilot: 1200 hours
Average number of hours spent annually on call during residency: 1612 hours
Mean burnout rate for 1st year residents: 50%
Mean burnout rate for similarly aged individuals who have completed a college or university degree: 30%
Kieran Quinn is a medical resident at the University of Toronto.