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%
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A few years late to this post, thought you’d be interested though.
“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…”
I’ve made something that does this for my fellow residents in Edmonton. Not exactly centralized, but saves a lot of time
papermd.com
More people should consider specialties with good call schedules that are easy to get into, like PMR, pathology and psych.
The reason it doesn’t change is because people still sign up for this bull.
Vote with your feet.
Thanks for the post. I’m so happy to be a resident in an era when family time is valued and no longer a gendered issue.
I often wonder how residencies would be structured if we started from scratch and created a system aimed at maximizing patient care, residency education, and optimal use of resources. Interestingly, advancing the use of existing technologies (particularly EHRs) is a solution that comes to my mind as well.
Hi Kieran,
Can you please tell us where the numbers from the Resident’s Call Index came from? Several residents have been asking after your article was shared with them.
Hi Tabi,
The stats are from various sources that I have compiled. The physicians survey holsters a majority of the stats. Some of the published references linked in the article have some of the others. The Ministry of Transportation details the work limits for aeronautical and transportation. Coffee prices are an average of Tim Horton’s, Second Cup and Starbucks variety of drinks people may choose to have.
Hope that helps!
Yes thanks!! Everyone was just stunned by the numbers but I think they are just a harsh reality of the career we have chosen.
Very interesting article Kieran – I come from a specialty which advocates very strongly for patient safety and borrows heavily from the aviation industry – hence most anesthesia groups in the downtown core have a 16-24 hour resident call with a fairly strict morning handover time. The quality of resident life is much better and I truly feel the patient care experience is safer compared with the time I spent off-service.
That being said, I think a lot of the difficulties you are facing with the call schedule are specific to certain specialties. Most of my chiefs have been very accommodating and making important events has not been a big deal the same way it was while I was off-service. It can become a rigid, unforgiving system enforced by people who are themselves burnt out and not willing or able to put in the time to re-work call schedules. Then you have colleagues who aren’t accommodating even when it costs them nothing, and quite frankly don’t care about anyone around them because they’re just too exhausted.
A culture of collegiality and mutual support goes a long way towards the call schedule difficulties you mention, and that culture just doesn’t exist in some specialties because people don’t have time to look after themselves. This is not an argument about how we should be working less, it’s about confronting the nature of the work we do today. A steadily growing proportion is administrative and EPR-order nonesense. Working longer hours doesn’t mean we will be gaining useful clinical experience, usually it means more faxes will be sent and more discharge summaries written. I believe I read somewhere that on a per hour basis, residents today spend less time with patients than ever before – and more time in front of computers and EPRs. That in itself will influence how meaningful and satisfying your day feels, and how quickly you burn out.
It’s much more than just a computer algorithm, although I do find it interesting that you are leaning towards a solution that depersonalizes the system even more to solve the problem. I don’t think that’s the answer personally. Best regards and thanks for a thoughtful article.
Thank you for your insightful opinions Justyna.
My only concerns with some of the points you raise are that current evidence does not support the idea that resident duty limits improve patient safety or resident education – in fact they may be causing more harm than good.
You are right in pointing out that it is not the number of hours we work, but the type of work we do, the environment in which we work and the sense of personal control over our work and its scheduling that contribute to burnout.
I agree that the human touch in a sterile and inflexible system is of utmost importance! However, until we truly address a systemic culture of burnout, both in residents and those responsible for their call scheduling, perhaps a computer that is incapable of burnout, alongside the oversight of an empathetic human may be the solution.
I’ve since learned that this field is known as “Operations Research”, and below is a link to a great piece about how to apply it to resident call scheduling that a colleague of mine shared with me after writing this article:
http://www.jgme.org/doi/full/10.4300/JGME-D-14-00581.1
Kieran
Balancing the need for learning through concentrated experience with having a reasonable personal life is a worthwhile expectation.
One statistic that I have always wondered about is the percentage of Residents who moonlight at other hospitals concurrently with their residency training. Do you have that statistic?
Hi Tom,
Thanks for your interest! Unfortunately I don’t have the info you are looking for, but if you contacted the Ministry of Health and Long Term Care, they should have the number of residents who have registered for the “restricted registration” license that allows for moonlighting. It doesn’t necessarily reflect those who actually moonlight however.
Tom:
I can give a crack at answering. As part of the Pan-Canadian Consensus process, we did a national survey of resident, program directors and PG deans and we asked about moonlighting. The rate was 8.5% and most of those who answered yes, reported doing fewer than 11 mrs per month. Residents who did report moonlighting enjoyed it, found it helpful and did not report more burnout.
This has the limitation of being self reported data, but the number was comparable to the estimation of the PDs. I hope this helps. It would be great to get harder data, but is difficult as definitions of moonlighting and restricted registration processes differ by province and residents with an independent license don’t have to register.
The bottom line is that it is not likely a major contribution to resident workload/burn out and may have an upside. I hope this helps
Kevin
Hi Kevin,
Thank you for providing this important information. I wonder if a resident’s control over the scheduling of their moonlighting (in that they retain full autonomy to choose moonlight shifts) and are paid a significant proportion more than the standard call stipend (see my article on incentives and burnout: http://healthydebate.ca/opinions/burnout-resident-physicians-educational-incentive-not-enough) are part of the reason these shift don’t contribute to increased rates of burnout – they are doing work they have voluntarily signed up for and are being compensated more appropriately for it.