Call coverage issues and lack of resident rights

[Esebria1861]

Two residents in my program have been pulled off call due to poor performance. One has been free of call duties for over a YEAR while another was pulled more recently. Neither will be taking call until at least July 2016.

Because of this, the few of us remaining now have to take double the call (we still do 24hr shifts) while the two residents performing poorly get to sleep at home and enjoy quality family time, etc. We also apparently have to cover their holiday call in addition to our own.

The residents pulled off call are still projected to graduate on time. They will never "re-pay" us the shifts we are covering for them. Their "remediation" is a joke, and does not relieve or lighten any of the burden of those of us taking extra call.

Have any of you had this situation and what did you do? Would you refuse to take the extra shifts, possibly jeopardizing your relationship with attendings? As a group we already approached our attendings to negotiate and got no where; in fact a couple of them said that if we don't comply, we will be jeopardizing our future when an employer contacts them as a reference.

P.S. I'm not trying to get away with taking zero call, I'd just like to take the amount that would be expected if the other two were also in the call pool.

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[YankeeCandle1141]

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[22031 Alum]

First of all, I don't see how that isn't leading to duty hours violations. Secondly, the last thing that someone who is subpar needs is less work/experience. I've heard of people remediating with extra supervision on call, but never no calls.

You are really in a tough spot. Are you at a teaching institution with a GME office that oversees all the specialties? You may want to bring the matter to their attention, as your program should answer to them and they don't benefit from threatening you with poor references.

 

[Esebria1861]

Thanks. We are not quite violating duty hours yet. It's not as much the fact that I have to do so much call that bothers me (although I'll admit I really dislike 24hr shifts) as it is that I have to do double the call I would've had to do otherwise while these residents get to do NONE. I don't expect complete fairness in residency by any means, but this far beyond slightly unequal call distribution.

I have thought about bringing it to the attention of our GME dept but I'm a little nervous about how much protection I will have if a potential employer chooses to contact my program director/attendings directly when I list my residency program... But I think that may be the most reasonable option. I guess I just have to decide if it's worth the risk!

 

[IlDestriero]

Who do you think should cover their calls if not the other residents? Do you expect them to hire PAs or have the attendings do it?

 

[Esebria1861]

They already have a group hired that they use on nights when we are not available (we would violate duty hours without this as we are an extremely small program). That group could cover the extra shifts, but it would cost the group $. Alternatively, these residents could take call under our supervision, so that we have help on some shifts and this could also help prepare them to return to call. Actually, in my specialty at many non-residency program hospitals (the same size as ours) the attendings do work night shifts without residents, although I would never suggest to my attendings that they do this because I feel it would be out of line. We have thought of other options as well.

Regardless, I do not think an acceptable solution is to allow some residents to get away without taking call while requiring it of others.

 

[Arcan57]

Nothing about the OPs letter makes much sense. There are definitely specialties that I didn't interact with in residency, but I can't imagine a program who's response to a struggling resident is to give them a YEAR without call. Either it's a specialty that has super light call responsibilities (rad onc, maybe derm?) or the program is run by insane people. Or the OP invented the above scenario.

 

[j4pac]

I've seen similar situations...but it is usually due to a combination of factors such as a few residents pregnant, another on medical leave, another in remediation. Could be a perfect storm for disaster.

If the program isn't violating work hour restrictions then I don't have a huge problem with it. Think about it this way...there are likely residents who are working their butts off right up against work hours and IT'S THE EXPECTATION. If it is becoming a safety concern...then I would first go to the chief resident and give your concerns. If there is no attempt to improve things through the chief...I would consider going to the PD. The PD is also likely in a crap situation and realizes the coverage challenges. He/she may be behind the scenes trying to improve things and you just don't know about it. Or...maybe they are unaware of the issue on his/her wards and it needs to be brought to their attention.

 

[ThoracicGuy]

I just don't understand why your program would take residents that are doing badly off call and still keep them on track to finish. They are putting those grads out there with the program reputation behind them.

 

[Doctor Bagel]

I just don't understand why your program would take residents that are doing badly off call and still keep them on track to finish. They are putting those grads out there with the program reputation behind them.

Yeah, this. I'm wondering if there are more consequences for these residents than the op knows about. I suspect it's a pretty miserable experience for them, too, to be deemed so incompetent that they can't perform a major part of their job function. If I were them, I'd worry my contract wouldn't be renewed.

About resident rights, though, there aren't many aside from ACGME guidelines. One of the many reasons why residency sucks.

 

[Apollyon]

About resident rights, though, there aren't many aside from ACGME guidelines. One of the many reasons why residency sucks.

Whenever I hear of something off the wall like this, my first thought is whether it is an AOA residency. Some of them seem like the Wild West.

 

[Kevin Baker]

Whenever I hear of something off the wall like this, my first thought is whether it is an AOA residency. Some of them seem like the Wild West.

We had something similar in the recent past at my program(ACGME). If a resident can't be trusted with the kind of indirect supervision and data gathering call entails, there's not much one can do apart from hiring more attendings to take call (expensive) or having residents pick up the slack. It's not a good situation for those punished and as already iterated, can be a sign of remediation, dismissal, or contract non renewal.

That said, I saw this in a malignant AOA residency on rotations so it happens there as well. But again, those kicked off call were eventually fired.

 

[Law2Doc]

Yeah, this. I'm wondering if there are more consequences for these residents than the op knows about. I suspect it's a pretty miserable experience for them, too, to be deemed so incompetent that they can't perform a major part of their job function. If I were them, I'd worry my contract wouldn't be renewed.

About resident rights, though, there aren't many aside from ACGME guidelines. One of the many reasons why residency sucks.

1. Yeah I agree those pulled off call are likely in much more jeopardy than OP is suggesting. When someone is pulled off service that's rarely a reward situation.
2. If OP isn't being asked to violate duty hours he really has no recourse and probably needs to just keep his head down. Lots of people in residency push the duty hour limit, and his program was "allowed" to do this even when they had more able bodies to work with. Odds are the people pulled off service will be lucky to graduate at all, as opposed to on time.

 

[Esebria1861]

The attendings do not take call in house with us and are not available to us overnight (although of course on paper there is an attending "available" by phone). There is only one resident on call at a time because we are such a small program. There is a lot of pressure from hospital admin on the attendings to come in house overnight during our call shifts, and they obviously do not want to do this. One of the residents has not taken call for 1.5 years but was supposed to start call this academic year. However, because things got "shaken up" and they were feeling heat due to the other resident performing poorly, the attendings pulled this second resident and decided not to risk trying to start the other resident on call because they are very close to being forced by admin to come in-house overnight.

These residents are not getting fired or worried about getting fired partially because we are such a small program and we need them to help share coverage during the days; we work at a few hospitals/sites and without them there would be too few residents to cover all the sites. There are other reasons they are not getting fired as well, but I am not going to go into that on a public forum. Rest assured, they won't be going anywhere and their training is not going to be delayed.

As far as these two residents having more consequences or responsibilities that I'm unaware of - well, this is just not the case. With only 5 of us, we know where we all are at all times and what we are each doing. In fact, we have seen data provided by one of our seniors that was obtained from electronic documentation/records that the three of us are consistently doing 3-5x the work during the days per month than the other 2 residents. We've never cared even though we have been aware of this, because we realize this will make us better physicians in the long run. But it is hard proof that these 2 residents are getting away without taking call and are not making up the work elsewhere. Very frustrating!

I'm just glad the 3 of us call takers have been able to stand together on this issue and remain a team despite the low morale in the department right now. I still hope we can find a way to improve our situation without compromising the reputations we've worked so hard to build...

 

[Esebria1861]

I know that there is no minimum call requirement and that there are regulations regarding maximum duty hours. I know that the program is not violating any rules or regulations by doing this. Technically they could tell one resident to take all the call and not make the others... The way things are written, there is no standard.

However, if there is no minimum, can't we refuse to work the extra shifts? We would not be violating any written rules or regulations by doing so. Our contract does not say that we are required to take at least X amount of call, it only says we can take up to X amount of call. Of course this would be damaging to our reputations and likely extremely unwise, but I'm just asking out of curiosity.

 

[ThoracicGuy]

Sounds like a bad program if all of that is the case...

There is a point when the attending has to pot his big boy pants on abd do what needs to be done. If they graduate these residents, they'll likely be bad doctors and will give your program a bad name...

 

[IlDestriero]

No, you can't refuse to cover call. You do what the PD tells you to do or you might as well pack your bags with the other guys. What kind of LOR do you think you'll get if you ask to be let out of call.

 

[Esebria1861]

The other guys aren't packing their bags, they are definitely not at risk of getting fired, so I don't think they could fire me - wouldn't that look like discrimination? I mean, how can you fire someone for refusing to do something you don't make others do? I would not be violating the terms of my contract... I don't think they could legally fire me for that??

However, they most definitely would hold it against me when it comes to future job applications as they've already stated to us. I'm doing a fellowship and I have connections in the field so I think I'd be fine, but I really don't like burning bridges. Which is why I haven't gone down this road and am trying to work things out.

 

[22031 Alum]

It's kind of sucky for you, but I recommend just keeping your head down, doing the work, and thanking your lucky stars you won't be as ill-prepared as your co-residents will be after graduation.

 

[Crayola227]

The program may be doing you a favor, actually.

What if one of these residents has a legit reason to bail on the program entirely, and this is the negotiated solution that is keeping these residents doing shifts at all?

And maybe taking less call and being home asleep is what is letting them stay in the game.

You're pissed about the extra call but think of how much more pissed if those guys up and quit. I've seen if happen amd the rest of the residents left were mssing all their electives and associated golden weekends goodbye to do extra ICU and wards and nightfloat months instead. And replacements hired midyear and ****e like that.

You don't know what will happen to those guys next year, even keeping them on to graduate on time, and frankly, there's a minimum requirement for stuff for GME but programs can be structured to have more of this or that than absolutely necessary.

As far as discrimination, if the program is accommodating these guys for certain reasons, then ina like a court situation they can legit defend why those guys are doing less than you.

And even if these are douche residents holding the program hostage in some way, going into the PD's office whining about covering these guys may just be putting yourself in the same league as far as the program is concerned.

Buckling down and "gladly" filling in here (as long as it isn't breaking ACGME rules or compromising care) is going to make you a helluva a lot more friends than anything you might try to do to shift work, God, especially onto attendings, especially if you succeeded.

Your comment about supposedly being "linked" in for fellowship and thinking that's going to save you if you alienate yourself your program is just delusional. They can hurt you tank you get back at you in all sorts of ways you've probably never even dreamed of.

Quit worrying about those guys' career of whom I'm guessing you know tip of iceberg on situation and just focus on your own.

 

[dozitgetchahi]

1. Yeah I agree those pulled off call are likely in much more jeopardy than OP is suggesting. When someone is pulled off service that's rarely a reward situation.
2. If OP isn't being asked to violate duty hours he really has no recourse and probably needs to just keep his head down. Lots of people in residency push the duty hour limit, and his program was "allowed" to do this even when they had more able bodies to work with. Odds are the people pulled off service will be lucky to graduate at all, as opposed to on time.

This was my exact thought.

OP, the situation definitely sucks. You'll get a lot of 'hard ass' advice from the academic types on this forum ('who else do you think should take call?', 'don't be lazy' etc), but there's no question that this is unpleasant. It's made worse by the fact that the residents pulled off call are probably on the way out, and thus you guys will likely be taking this level of call for the rest of your time as residents. Unfortunately, the best advice in these situations is almost always to shut up, keep your head down and get through it. This program has already shown it isn't shy about punishing people - don't stick your neck out.

 

[Law2Doc]

Also lost in this discussion is the fact that as you get further into residency, you are going to realize it is actually pretty valuable training, not just some gauntlet you are forced to run through 80 hours a week. By your later residency years you'll have started getting stressed that you haven done enough of X or seen enough of Y to be comfortable when it's your name on the malpractice coverage. So although you don't believe it now, working more hours is actually a benefit to you. Every new encounter or stress you make it through while on call is another notch on your belt that will help you in later years. Even if it's just dealing with yet another difficult consult or admission, or a colleague giving you a crummy sign out, that's going to be something you'll learn from, or that will shape you. I learned a ton while on call, and although I wouldn't go volunteer for more, I won't pretend that if forced on me it wouldn't give me some learning opportunities. You'll see this later on in your training. Or maybe notice it when looking at people from different specialty training programs -- don't the third year surgical residents who have worked 80+ hours a week for three years seem a bit less flappable than some of the other specialties who have logged many fewer hours a year? When you do something every waking hour, you can't help but get comfortable. It's very much like aviation -- the more time you have logged in the cockpit, the better qualified you are to be a pilot. Your friends who were pulled off call may still be making bad rookie mistakes when it's their neck in the medmal noose. I wouldn't wish for their fate.

But I'm still not buying that they were "rewarded" a cushier schedule by virtue of being bad residents. My experience is that getting pulled from call is usually a prequel to being asked to repeat the year, or having ones contract non renewed. You get some probation period to remediate things, because programs feel they have to do this, but they aren't going to change perceptions. They might "not be packing their bags" yet, but they may still be as oblivious as the turkey who is getting fattened up in early November. I wouldn't trade places with them.

 

[Gastrapathy]

This is really 3 separate issues.

1. Can they make you take call up to the maximum allowed by the ACGME? Answer Yes.

2. Can they treat residents differently without consequences? Maybe. If they fired a call taking resident and were sued, They might lose. But, that's not a path worth taking for you. Just assassinate the program on the survey. Just have one of you do it so you can all deny it.

3. Are they graduating doctors who can't practice? Maybe. But not your problem.