Hospital Administration threatening to make cuts to program

[Winged Scapula]

Wondering what you'd suggest instead? If someone who is out ill has work that has to be done that day, then someone else needs to do it.

In my own clinical life, if I've got a day full of patients and cancel due to illness, anyone not critical gets bumped. But I have very minimal openings in my schedule -- so that means that I end up overbooking those patients over lunch, my admin time, or sometimes into the weekend to get them all seen.

In my program, we have "backup call". If you're on backup, and someone gets sick, then you get pulled to cover their shift if needed. Sometimes we can get away with not replacing the person (commonly, we can function without an intern on a team for a day). We don't mandate payback, we assume that, in general, the number of times any person calls in sick and the number of times they get pulled for backup for someone else will balance out. But it doesn't -- some people seem to call in sick more than others. Whether that's because they are "more ill" or because they "have a lower threshold to call in sick" is unclear. Or maybe it's just random. But having no payback creates some friction if you get called in quite a bit for someone else who doesn't "seem sick".

So interestingly enough, it works like the real world? Huh.

If you work at McDonald's and call in sick, someone else has to do the work, either come in early/stay late or come in when not scheduled. I'm not sure why some think residency training would be any different.

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[Raryn]

So interestingly enough, it works like the real world? Huh.

If you work at McDonald's and call in sick, someone else has to do the work, either come in early/stay late or come in when not scheduled. I'm not sure why some think residency training would be any different.

To be fair, if you work at McDonalds and someone has to cover for you, that someone will get paid for the extra day. Not so in residency (or any salaried gig). That's where the debate about the fairness of payback comes from: If I pick up an extra inpatient shift because intern X calls in sick, we're both now getting paid the same but I'm doing 2 extra days of inpatient. That isn't fair either.

 

[Ismet]

We are given week blocks off in certain rotations. My intern year, they gave me a week in July, a week in August, and a week in January. I was ready to kill someone by the end of the year.

My last vacation week was in March. My next one is November. I have 2 ICU months, 1 wards senior month (including night float), and 2 inpatient elective months between now and then. Here we go...

What happens if you take sick days?

Did the system in place make you second guess actually taking sick days when you were really sick?

Feels odd to me to create a system whereby taking a sick day penalizes your co residents in a sense that they then automatically have to take an additional shift. Sort of an odd ethical scenario there to have to be involved in when you are feeling sick.

We have a similar set-up as already described, a jeopardy system. Payback is not mandated at my program. It's not abused as far as I know. Gets a little worse in the winter, especially for our residents with kids who pick up whatever the bug du jour is. Really no ethical scenario involved. If you're so sick that you cannot get out of bed, you have a fever, or you can't go more than 20 minutes without running to the bathroom, no one will fault you for calling in sick and if necessary, will cover for the sick resident. For us, it's mainly for inpatient and ICU rotations, the electives have more leeway, so it's not an "automatic" additional shift. As said above, the work still has to get done, and I'm not sure how you recommend that gets done without having another resident do the coverage.

 

[mvenus929]

Did the system in place make you second guess actually taking sick days when you were really sick?

Feels odd to me to create a system whereby taking a sick day penalizes your co residents in a sense that they then automatically have to take an additional shift. Sort of an odd ethical scenario there to have to be involved in when you are feeling sick.

We have a culture that is fairly understanding. We've had multiple family emergencies during my time in residency, including leaving wards to attend funerals. People band together and help out where they can, mostly. And the ones who don't have a hard time finding people to accommodate trading shifts down the line.

That said, yes, I try not to call out unless I'm truly ill because I don't want to impose on my coresidents.

 

[Winged Scapula]

To be fair, if you work at McDonalds and someone has to cover for you, that someone will get paid for the extra day. Not so in residency (or any salaried gig). That's where the debate about the fairness of payback comes from: If I pick up an extra inpatient shift because intern X calls in sick, we're both now getting paid the same but I'm doing 2 extra days of inpatient. That isn't fair either.

Fair enough.

My point still stands that in the real world there is to be work to be done and when we aren't there either someone else does it, or someone suffers because you won't finish your work as soon as possible.

 

[VA Hopeful Dr]

To be fair, if you work at McDonalds and someone has to cover for you, that someone will get paid for the extra day. Not so in residency (or any salaried gig). That's where the debate about the fairness of payback comes from: If I pick up an extra inpatient shift because intern X calls in sick, we're both now getting paid the same but I'm doing 2 extra days of inpatient. That isn't fair either.

Perhaps not, but it's 2 days out of roughly 1000. Plus, odds are you'll be sick and have it even back out.

 

[Light at end of tunnel]

Thank you to all in this thread for the responses, really clarifies and puts things into perspective.

 

[Perrotfish]

Wondering what you'd suggest instead? If someone who is out ill has work that has to be done that day, then someone else needs to do it.

The issue is that Residents are so overworked that there is no slack built into the system for sick days. Attendings make sure there is room for sick days for themselves, but not for their residents. In Pediatrics, for example, the average attending works about 45 hours per week (per a survey published in Pediatrics). When a ward attending calls out sick someone else covers, but they're only working 15 days/month in any event so its easy to arrange coverage and, if you have a payback system in your group, its easy to pay back. Clinic attendings usually start their day with at least half of their appointments open for 'acute' visits, so when one attending calls out sick the scheduled patients just get distributed to everyone else's acutes and life goes on. Its the same concept as residency (someone else does the work when you call out) but because you aren't working people to death to begin with no one really feels significant stress when they need to briefly add your workload to theirs.

The abusive culture of residency, though, forces residents to both accept and remain at jobs that, for the sake of hospital profit margins and attending schedules, run so lean that when anyone call out sick there isn't any real plan B. Do you call in a resident who has almost no days off to start with, denying them what might be their one golden weekend for months? Do you double the patient load on the remaining resident, and hope that he can take care of 40 patients without killing someone?

BTW, I am aware that you can find attendings who work 80 hours/week and have no slack in their schedule at well. That is, however, a choice. No more than a handful of attendings are willing to work at jobs with so little slack that its a disaster when they call out sick, and the ones who do are doing it for a very specific reason (desirable location, partnership tract, way higher than average salary, or to compensate for multiple red flags on their record). Its not the same as a resident being forced into that kind of sweatshop.

 

[Siggy]

Perhaps not, but it's 2 days out of roughly 1000. Plus, odds are you'll be sick and have it even back out.

Not always. The last time I missed a day of work or school for illness was over a decade ago. I was in high school at the time.

 

[LucidSplash]

We don't have an official system. It's typically left to the residents to find someone to cover if they are really sick or have a family emergency. The culture here is supportive in that we take care of one another and typically don't ask unless there is a true need. I've covered call before for coresidents who's wife had a baby in the last couple of days and was scheduled to be on call the day baby and new mom came home. Baby had arrived earlier than expected so while this had been taken into account on the schedule around the scheduled due date, babies don't really like to follow call schedules. I didn't ask the guy to pay me back because it was one night and I was happy to do it and I know he would have done the same for me if I needed it. IMHO it all comes out in the wash.

The one time I've had to take time off for sickness was March. I had the flu, despite having the flu shot, and I can't recall the last time I felt so ill. It started with a mild cough and sore throat on a Monday and even though I honestly didn't feel very bad I nearly passed out while scrubbed in with my PD. I stayed home the next day and made a PCP appt for Wednesday. Tested positive, got TamiFlu even with questionable window of symptoms. Was out until Friday, tried to come back and was still woozy so went home. The other resident on the service covered all the consults that week and it was busy. We asked one of the research residents to help him out a couple days and they were happy to because it got them a few extra cases to scrub. I had to ask the CR fellow to cover one of my calls that week but I paid him back in April. But he was happy to do it as well because the culture is we take care of each other. I prefer our system which is an honors system. If there's a dispute, and there essentially never is, it would get kicked up to the Scheduling chief to deal with. I can't think of a time in my time here that it's had to go beyond that to the PD.

 

[Light at end of tunnel]

The issue is that Residents are so overworked that there is no slack built into the system for sick days. Attendings make sure there is room for sick days for themselves, but not for their residents. In Pediatrics, for example, the average attending works about 45 hours per week (per a survey published in Pediatrics). When a ward attending calls out sick someone else covers, but they're only working 15 days/month in any event so its easy to arrange coverage and, if you have a payback system in your group, its easy to pay back. Clinic attendings usually start their day with at least half of their appointments open for 'acute' visits, so when one attending calls out sick the scheduled patients just get distributed to everyone else's acutes and life goes on. Its the same concept as residency (someone else does the work when you call out) but because you aren't working people to death to begin with no one really feels significant stress when they need to briefly add your workload to theirs.

The abusive culture of residency, though, forces residents to both accept and remain at jobs that, for the sake of hospital profit margins and attending schedules, run so lean that when anyone call out sick there isn't any real plan B. Do you call in a resident who has almost no days off to start with, denying them what might be their one golden weekend for months? Do you double the patient load on the remaining resident, and hope that he can take care of 40 patients without killing someone?

BTW, I am aware that you can find attendings who work 80 hours/week and have no slack in their schedule at well. That is, however, a choice. No more than a handful of attendings are willing to work at jobs with so little slack that its a disaster when they call out sick, and the ones who do are doing it for a very specific reason (desirable location, partnership tract, way higher than average salary, or to compensate for multiple red flags on their record). Its not the same as a resident being forced into that kind of sweatshop.

I've heard stories of and also witnessed surgery residents rounding with IV fluids hanging by their side. I can appreciate that its important to be a teamplayer and that there may not in fact be viable alternatives to the systems currently in place (except maybe having more attending coverage available in such scenarios) and that the work has to get done, but one has to wonder if the system sometimes unnecesarily pushes a resident to put their own health at stake.

 

[Apollyon]

I had the flu, despite having the flu shot

1 in 4 people that get that vax still get the flu. That ain't good odds.

 

[VA Hopeful Dr]

Not always. The last time I missed a day of work or school for illness was over a decade ago. I was in high school at the time.

That's why I said "odds are" not "it's a certainty"

 

[VA Hopeful Dr]

I've heard stories of and also witnessed surgery residents rounding with IV fluids hanging by their side. I can appreciate that its important to be a teamplayer and that there may not in fact be viable alternatives to the systems currently in place (except maybe having more attending coverage available in such scenarios) and that the work has to get done, but one has to wonder if the system sometimes unnecesarily pushes a resident to put their own health at stake.

The system does that to attendings too. I've worked sicker since I left residency than I did while a resident. Patients have to get seen and in residency you have a larger pool of folks to pick up the slack than most attendings do.

Sick people often can't wait so you do what you have to do

 

[kchan99]

When I was in residency, it was up to the chiefs to find the jeopardy resident to come in to cover a resident. If it were a senior resident who was sick, then it would be another senior resident from the same program who can cover. If a junior neurology resident got sick, then it would be another neurology junior or an intern.

 

[VA Hopeful Dr]

The issue is that Residents are so overworked that there is no slack built into the system for sick days. Attendings make sure there is room for sick days for themselves, but not for their residents. In Pediatrics, for example, the average attending works about 45 hours per week (per a survey published in Pediatrics). When a ward attending calls out sick someone else covers, but they're only working 15 days/month in any event so its easy to arrange coverage and, if you have a payback system in your group, its easy to pay back. Clinic attendings usually start their day with at least half of their appointments open for 'acute' visits, so when one attending calls out sick the scheduled patients just get distributed to everyone else's acutes and life goes on. Its the same concept as residency (someone else does the work when you call out) but because you aren't working people to death to begin with no one really feels significant stress when they need to briefly add your workload to theirs.

The abusive culture of residency, though, forces residents to both accept and remain at jobs that, for the sake of hospital profit margins and attending schedules, run so lean that when anyone call out sick there isn't any real plan B. Do you call in a resident who has almost no days off to start with, denying them what might be their one golden weekend for months? Do you double the patient load on the remaining resident, and hope that he can take care of 40 patients without killing someone?

BTW, I am aware that you can find attendings who work 80 hours/week and have no slack in their schedule at well. That is, however, a choice. No more than a handful of attendings are willing to work at jobs with so little slack that its a disaster when they call out sick, and the ones who do are doing it for a very specific reason (desirable location, partnership tract, way higher than average salary, or to compensate for multiple red flags on their record). Its not the same as a resident being forced into that kind of sweatshop.

I think its cute how you assume that most attendings have more back up available than most residents or that our days start out so underbooked that if we don't show up our partners can easily cover for us.

In family medicine, the median practice size is still only 3 doctors. That's not much back up should you be sick.

 

[Raryn]

It is truly specialty dependent, and in a lot of fields it is a lot easier to find a resident to pull than too much slack in the attending schedules. In IM, there's enough elective time built in to the residency schedule that you can typically pull someone from Derm/Endocrine/Rheumatology elective to cover a call shift if there's an illness. Try pulling one of the attending Endocrinologists to cover the general medicine wards. I mean yes, attendings in almost every field have more days off than residents do (very few attendings work 24/28 days routinely more than a month here and there), so you might be able to pull an attending on their day off... but that's also an issue.

 

[azmang108]

Not always. The last time I missed a day of work or school for illness was over a decade ago. I was in high school at the time.

Siggy, Strong like bull

 

[Perrotfish]

I think its cute how you assume that most attendings have more back up available than most residents or that our days start out so underbooked that if we don't show up our partners can easily cover for us.

In family medicine, the median practice size is still only 3 doctors. That's not much back up should you be sick.

I am one of three Pediatricians in a clinic with a call schedule, and it's always been enough coverage for us to take sick days. The sick ones get rescheduled that day, while a few of the healthier ones might be moved later into the week

The absolute worst case scenario is that you have to schedule the remaining providers a few lunchtime or late patients, which still isn't that bad. When you usually go home at a reasonable hour and have the weekends off except for some nursery call taking a few extra hours once in a blue moon so that your colleague doesn't have to come in vomiting is common sense.

On the other hand when a resident forces someone to give up what might be their only weekend off for months, it can make them a parish.

 

[VA Hopeful Dr]

I am one of three Pediatricians in a clinic with a call schedule, and it's always been enough coverage for us to take sick days. The sick ones get rescheduled that day, while a few of the healthier ones might be moved later into the week

The absolute worst case scenario is that you have to schedule the remaining providers a few lunchtime or late patients, which still isn't that bad. When you usually go home at a reasonable hour and have the weekends off except for some nursery call taking a few extra hours once in a blue moon so that your colleague doesn't have to come in vomiting is common sense.

On the other hand when a resident forces someone to give up what might be their only weekend off for months, it can make them a parish.

I don't remember anyone in residency being made to feel bad if they had to take a day off for illness. I got pulled into 2 days of weekend night float for a classmate that got the flu. I won't say I enjoyed it, but I didn't hold a grudge or treat them badly because of it. Similarly, someone had to be called in for me when I had a kidney stone. They didn't complain or give me a hard time about it.

Outpatient practices are much easier to deal with sick days as a general rule (although those of us in solo practice or in groups of 2 docs have a tough time of it). Talk to your hospitalists, surgeons, or ER doctors about how easy it is to get someone to cover when they're sick. My wife is one of that first group, and it was easier for her to get coverage when sick in residency than it is now.

 

[Perrotfish]

I don't remember anyone in residency being made to feel bad if they had to take a day off for illness.

I do. YMMV but it is the culture at a lot of programs.

Outpatient practices are much easier to deal with sick days as a general rule (although those of us in solo practice or in groups of 2 docs have a tough time of it). Talk to your hospitalists, surgeons, or ER doctors about how easy it is to get someone to cover when they're sick. My wife is one of that first group, and it was easier for her to get coverage when sick in residency than it is now.

I don't get this. Does her inpatient group work more than 20 shifts per month per doc? Is there really no one who is off who can cover when she gets sick? I cover inpatient call and when we call in sick we are basically just trading days off. I got the flu on a weekend once, so the other Pediatrician covered it, and then I made it up a week later.

The only time I ever had trouble getting coverage was in residency, because they schedule everyone to work every day. Not that I was ever suicidal enough to try to take a sick day, of course.

 

[VA Hopeful Dr]

I do. YMMV but it is the culture at a lot of programs.



I don't get this. Does her inpatient group work more than 20 shifts per month per doc? Is there really no one who is off who can cover when she gets sick? I cover inpatient call and when we call in sick we are basically just trading days off. I got the flu on a weekend once, so the other Pediatrician covered it, and then I made it up a week later.

The only time I ever had trouble getting coverage was in residency, because they schedule everyone to work every day. Not that I was ever suicidal enough to try to take a sick day, of course.

People go into hospital medicine because they want lots of days off. If that's one of your motivations, why would you want to work more days? Or just work one random day where you don't know the patients and know that tomorrow they won't be yours again.

Yeah in residency people work every day. but you pull people off of electives to cover - or at least that's how its been everywhere I've been that had residents. No one likes missing a cushy GI clinic day to take inpatient call, but unless you're doing it multiple times per elective its really not a big deal.

 

[Raryn]

People go into hospital medicine because they want lots of days off. If that's one of your motivations, why would you want to work more days? Or just work one random day where you don't know the patients and know that tomorrow they won't be yours again.

Yeah in residency people work every day. but you pull people off of electives to cover - or at least that's how its been everywhere I've been that had residents. No one likes missing a cushy GI clinic day to take inpatient call, but unless you're doing it multiple times per elective its really not a big deal.

The problem ends up being bigger in specialties where people really don't have true "easy" electives. The surgeons for example are almost always on some kind of heavy duty service, so there's very little slack in the program. Especially given it's much smaller than your typical medicine program.

 

[VA Hopeful Dr]

The problem ends up being bigger in specialties where people really don't have true "easy" electives. The surgeons for example are almost always on some kind of heavy duty service, so there's very little slack in the program. Especially given it's much smaller than your typical medicine program.

And yet interestingly the surgeons in this thread are the ones that had systems that worked fairly well without a huge amount of complaining

 

[Light at end of tunnel]

And yet interestingly the surgeons in this thread are the ones that had systems that worked fairly well without a huge amount of complaining

Complaining, because he/she has a valid counterpoint? Or is it perhaps some denial on someone else's part?

There is a point alluded to but not explicitly stated here: in residency, there are unspoken rules (often times met with passive aggressive retaliation if violated) one of which includes do not take sick days, i.e. create extra work that your attending may have to pick up.

The word "suicide" may be on the extreme end, but I don't think Raryn is using it lightly. In the real attending world, you don't come 1 step closer to probation and termination if you are indeed sick and have to end up taking a sick day (or heaven forbid you develop pneumonia and need 2 days off). Often times in residency your "performance" changes with the wind depending on how your evaluators are feeling about you; residents know better than to piss them off.

When is the last time you saw an attending colleague of yours see patients with an IV bag hanging from their side?

 

[VA Hopeful Dr]

Complaining, because he/she has a valid counterpoint? Or is it perhaps some denial on someone else's part?

There is a point alluded to but not explicitly stated here: in residency, there are unspoken rules (often times met with passive aggressive retaliation) one of which includes do not take sick days, i.e. create extra work that your attending may have to pick up.

The word "suicide" may be on the extreme end, but I don't think Raryn is using it lightly. In the real attending world, you don't come 1 step closer to probation and termination if you are indeed sick and have to end up taking a sick day. Often times in residency your "performance" changes with the wind depending on how your evaluators are feeling about you; residents know better than to piss them off.

When is the last time you saw an attending colleague of yours see patients with an IV bag hanging from their side?

The bold is untrue at the vast majority of places that I know of, so long as its a sick day for something reasonable. Taking a day for a cold, that's no good. Kidney stones, flu, appendicitis are OK.

And I think you vastly overestimate most attending physicians. Contrary to SDN belief, you're not going to have your career tanked over a single attending that doesn't like you. Every poster that I can recall in that last 5 years that said that turned out to have been leaving out significant details.

But since you asked, I've seen attendings stay through some pretty horrific things. A call partner of my father-in-law had an MI mid-hysterectomy. He stopped actively operating but did not leave the OR until someone came to replace him. One of my wife's partners had a CVA mid-night shift. He had to stay in-house until back up came because otherwise if a code or something serious happened there was no doctor to handle it. I've worked with truly epic GI bugs. I didn't do fluids because I refused them, but we're talking bathroom breaks every 15 minutes or so.

 

[Perrotfish]

And yet interestingly the surgeons in this thread are the ones that had systems that worked fairly well without a huge amount of complaining

Lazier attendings do throw the abusive practices of residency into much sharper relief. If I had the exact same experiences, but my attendings were 80 hour/week surgeons rather than 40 hour/week Pediatricians, I probably would have been much less annoyed by our work hours.

 

[Raryn]

And yet interestingly the surgeons in this thread are the ones that had systems that worked fairly well without a huge amount of complaining

Medicine programs have systems that typically work quite well. Jeopardy set up, clear guidelines on what shifts need to be covered (and which can be left uncovered), etc.

Just because we bitch about it doesn't mean it doesn't work.

 

[Raryn]

Complaining, because he/she has a valid counterpoint? Or is it perhaps some denial on someone else's part?

There is a point alluded to but not explicitly stated here: in residency, there are unspoken rules (often times met with passive aggressive retaliation if violated) one of which includes do not take sick days, i.e. create extra work that your attending may have to pick up.

The word "suicide" may be on the extreme end, but I don't think Raryn is using it lightly. In the real attending world, you don't come 1 step closer to probation and termination if you are indeed sick and have to end up taking a sick day (or heaven forbid you develop pneumonia and need 2 days off). Often times in residency your "performance" changes with the wind depending on how your evaluators are feeling about you; residents know better than to piss them off.

When is the last time you saw an attending colleague of yours see patients with an IV bag hanging from their side?

Suicide wasn't my word. As opposed to Perrotfish that used it, I called in sick a few times over the course of residency. Only one day ever required coverage from a coresident (my threshold on an inpatient service was much higher), and I paid him back. No big deal. We might gossip over someone who had a lower threshold for calling in sick, but we all understood the vast majority of the time, and we always did our work (except for one guy who refused to come in when he was called in on jeopardy because it was his kids birthday party. He got ripped a new one later on, because he knew well ahead of time that he was on jeopardy that week and could have always switched ahead of time if needed).