not doing call in 3rd year

[efex101]

Are you kidding? there are many times that you have to practice good medicine with NO sleep....if not, who takes care of patients during the night? interns/residents/physicians that are working those hours on NO sleep. This is not only during residency but also once you are done. There are physicians working at night at every hospital in the country.

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[QofQuimica]

Are you kidding? there are many times that you have to practice good medicine with NO sleep....if not, who takes care of patients during the night? interns/residents/physicians that are working those hours on NO sleep. This is not only during residency but also once you are done. There are physicians working at night at every hospital in the country.

I reckon that will be the purview of the burgeoning subspecialty of nocturnists (nocturnal hospitalists). This is a real job description, at least at my school's hospital. I heard about it from one of my attendings, who nicknamed them "vampires."

 

[smq123]

Why is that so unreasonable? Practicing good medicine has nothing to do with the ability to function well on no sleep- doctors are humans too, and countless times we talk about how important good, proper, daily sleep is for a person's health, so why shouldn't that apply to us too?

LEARNING how to practice good medicine (which is what this student is supposedly trying to do) also involves learning how to function under the extremely stressful conditions that a resident will face.

If your first sleepless night on call is when you're an intern, you (and your patients) will be in serious trouble.

 

[efex101]

Yeah, but nocturnists are hard to find and not all hospitalist teams have this. The pay is excellent for those that can deal with the madness of working nights only....

 

[ShyRem]

Or for those like me who are natural night owls. I think any hour before about 11am or noon should be outlawed.

 

[Non-TradTulsa]

I think those accommodations sound reasonable: it hurts her health to work extended shifts, so the school allows her to avoid them but she has to stay until 9pm 2 extra nights so she still gets enough experience. Why is that so unreasonable? Practicing good medicine has nothing to do with the ability to function well on no sleep- doctors are humans too, and countless times we talk about how important good, proper, daily sleep is for a person's health, so why shouldn't that apply to us too?

You're missing a great deal of the point here (not surprising from a premed). I understand Dr. Bagel's mixed emotions. I, too, fear that we are delaying the inevitable for this poor student. The student in question does indeed have severe, crippling migraines. Someone with migraines of that severity is unlikely to have lack of sleep as the only trigger. I've never known a person that ill with migraines who couldn't be triggered by stress.

OK, let's suppose that in residency she is allowed to never work longer than a 16-hour shift. Two hours into a 16-hour shift, a patient of hers unexpectedly codes and dies. This incredibly stressful experience triggers a migraine - resident goes home. Now, suddenly, there's 10 patients with no coverage that the rest of the team has to try to pick-up. That's dangerous for the patients for coverage to be spread that thin - it would be tolerable if it were a once-a-year occurence - but if it's once a month, that's an ongoing problem that involves patient care and safety. Even in a discipline with less call requirement, like Psychiatry, she's going to be expected to come in for a late-night/early-morning admission while she's on home call. If this triggers a migraine, she may not be there for rounds the following morning. No residency team that I know of, in any discipline, could tolerate a team member who is that prone to absence.

The real question is, is this student ever going to be able to function well enough to get through residency? I really don't know. I do think that the school may just be postponing the inevitable by granting her too many accomodations. Lots of physicians have migraines - but her migraines are at a whole different level, and I fear that her HAs do constitute a handicap. A handicap that is not irrelevant.

I hear what you're saying, midwesterner, and I too support any reform that removes unnecessary malignancy from medical training. But, the truth is, accomodating physical disability in the medical profession has to be balanced against patient safety. There are times when it has to be patients first, self second. A person who has headaches so severe that she is totally physically incapacitated - that may come on without warning at any time - is just very hard to accomodate safely.

 

[caffeine37]

You're missing a great deal of the point here (not surprising from a premed). I understand Dr. Bagel's mixed emotions. I, too, fear that we are delaying the inevitable for this poor student. The student in question does indeed have severe, crippling migraines. Someone with migraines of that severity is unlikely to have lack of sleep as the only trigger. I've never known a person that ill with migraines who couldn't be triggered by stress.

OK, let's suppose that in residency she is allowed to never work longer than a 16-hour shift. Two hours into a 16-hour shift, a patient of hers unexpectedly codes and dies. This incredibly stressful experience triggers a migraine - resident goes home. Now, suddenly, there's 10 patients with no coverage that the rest of the team has to try to pick-up. That's dangerous for the patients for coverage to be spread that thin - it would be tolerable if it were a once-a-year occurence - but if it's once a month, that's an ongoing problem that involves patient care and safety. Even in a discipline with less call requirement, like Psychiatry, she's going to be expected to come in for a late-night/early-morning admission while she's on home call. If this triggers a migraine, she may not be there for rounds the following morning. No residency team that I know of, in any discipline, could tolerate a team member who is that prone to absence.

The real question is, is this student ever going to be able to function well enough to get through residency? I really don't know. I do think that the school may just be postponing the inevitable by granting her too many accomodations. Lots of physicians have migraines - but her migraines are at a whole different level, and I fear that her HAs do constitute a handicap. A handicap that is not irrelevant.

I hear what you're saying, midwesterner, and I too support any reform that removes unnecessary malignancy from medical training. But, the truth is, accomodating physical disability in the medical profession has to be balanced against patient safety. There are times when it has to be patients first, self second. A person who has headaches so severe that she is totally physically incapacitated - that may come on without warning at any time - is just very hard to accomodate safely.

that's not your problem to figure out though. there are medical students that have been through the system with limitations (missing an arm, blindness) they will find a way to contribute to the medical profession. as much as you want to complain, it's not your job as a fellow med student to determine that for them. the administration and the faculty will do that. i think the reason this strikes a nerve with everyone is that we are ALL sleep deprived, but i think her limitations are on a different scale.
i'm sure in her dean's letter there will be some mention of her inability to take call/work long shifts, so that will help sort her out from any programs or specialties that require it.

 

[Doctor Bagel]

that's not your problem to figure out though. there are medical students that have been through the system with limitations (missing an arm, blindness) they will find a way to contribute to the medical profession. as much as you want to complain, it's not your job as a fellow med student to determine that for them. the administration and the faculty will do that. i think the reason this strikes a nerve with everyone is that we are ALL sleep deprived, but i think her limitations are on a different scale.
i'm sure in her dean's letter there will be some mention of her inability to take call/work long shifts, so that will help sort her out from any programs or specialties that require it.

Well, I think the bigger question is whether or not some limitations are so severe that you can't be a physician. I honestly don't know the answer to that one. Some limitations make it so you can't be in certain fields, but inability to deal with sleep deprivation pretty much rules out all fields during residency at least. I honestly doubt that it will pop up in the dean's letter, either, unless someone specifically wrote about it in her evals. My school is not known for having brutally honest dean's letters.

 

[lilnoelle]

Well, I think the bigger question is whether or not some limitations are so severe that you can't be a physician. I honestly don't know the answer to that one. Some limitations make it so you can't be in certain fields, but inability to deal with sleep deprivation pretty much rules out all fields during residency at least. I honestly doubt that it will pop up in the dean's letter, either, unless someone specifically wrote about it in her evals. My school is not known for having brutally honest dean's letters.

Not all schools require a huge amount of sleep deprivation in residency though. I've spoken to interns in both Psychiatry and Family Medicine and they only do overnight call once a week during intern year. (We have night float that covers during the week and interns do call on the weekend)

 

[Non-TradTulsa]

that's not your problem to figure out though. there are medical students that have been through the system with limitations (missing an arm, blindness) they will find a way to contribute to the medical profession. as much as you want to complain, it's not your job as a fellow med student to determine that for them. the administration and the faculty will do that. i think the reason this strikes a nerve with everyone is that we are ALL sleep deprived, but i think her limitations are on a different scale.
i'm sure in her dean's letter there will be some mention of her inability to take call/work long shifts, so that will help sort her out from any programs or specialties that require it.

This is an utterly asinine statement. I'm older than most of my attendings and have been in hospital administration for more than 20 years. I don't need to refer the issues to the "grown-ups" before I formulate an opinion. I'm stating my concerns and my conclusions for the sole purpose of having a discussion. This isn't a trial court.

I am not, in any way, shape, or form, opposed to people with irrelevant handicaps being in medicine - and I resent your implication that I would be opposed to a student or resident who has a handicap that he or she can overcome. I further resent the implication that I do not wish this particular student well through "complaining" - I do care, I like her, and I worry about her. I share some of Dr. Bagel's feelings that it may not be completely fair for a student to be excused from what I thought was a mandatory part of the medical student experience, but those feelings are in no way directed at the particular student involved.

A gentleman in the class ahead of mine is a fine physician although he is a paraplegic confined to a wheelchair. But I assure you, when he was needed in the ER at 3am, he got out of his callroom bed into his chair and wheeled himself down to ER in order to do his job. That's what I mean when I say his handicap is irrelevant - he was perfectly capable of compensating for it and doing his job, and did so. I salute his considerable accomplishments.

What my point was - this individual may not be able to compensate for her considerable disability if it strikes at unpredictable times - there's no way I can think of to compensate for that and still take on full responsibility for patients, which is required as an essential part of training as an intern. What residency are you proposing that she select if she can be completely and totally disabled by a migraine headache at any time?

You've seen fit to criticize the fact that I've merely formed an opinion, but you've not advanced the discussion by explaining how this student is going practice medicine safely while in residency. As hospital management, I would not have been comfortable having our patients entrusted to a person who was not physically capable of reliable performance and I wouldn't abrogate my judgement to anyone else, because my institution was ultimately as legally accountable as the medical staff was for providing a safe environment of care to the patients.

 

[caffeine37]

This is an utterly asinine statement. I'm older than most of my attendings and have been in hospital administration for more than 20 years. I don't need to refer the issues to the "grown-ups" before I formulate an opinion. I'm stating my concerns and my conclusions for the sole purpose of having a discussion. This isn't a trial court.

I am not, in any way, shape, or form, opposed to people with irrelevant handicaps being in medicine - and I resent your implication that I would be opposed to a student or resident who has a handicap that he or she can overcome. I further resent the implication that I do not wish this particular student well through "complaining" - I do care, I like her, and I worry about her. I share some of Dr. Bagel's feelings that it may not be completely fair for a student to be excused from what I thought was a mandatory part of the medical student experience, but those feelings are in no way directed at the particular student involved.

A gentleman in the class ahead of mine is a fine physician although he is a paraplegic confined to a wheelchair. But I assure you, when he was needed in the ER at 3am, he got out of his callroom bed into his chair and wheeled himself down to ER in order to do his job. That's what I mean when I say his handicap is irrelevant - he was perfectly capable of compensating for it and doing his job, and did so. I salute his considerable accomplishments.

What my point was - this individual may not be able to compensate for her considerable disability if it strikes at unpredictable times - there's no way I can think of to compensate for that and still take on full responsibility for patients, which is required as an essential part of training as an intern. What residency are you proposing that she select if she can be completely and totally disabled by a migraine headache at any time?

You've seen fit to criticize the fact that I've merely formed an opinion, but you've not advanced the discussion by explaining how this student is going practice medicine safely while in residency. As hospital management, I would not have been comfortable having our patients entrusted to a person who was not physically capable of reliable performance and I wouldn't abrogate my judgement to anyone else, because my institution was ultimately as legally accountable as the medical staff was for providing a safe environment of care to the patients.

that's not my point, if you have experience, age, wisdom, etc. is it YOUR JOB for determine this students ability to practice medicine? no, it's not. you are not in the administration. you are a student.
i think the dean should mention it in a letter, and they are doing a disservice to future program directors if not. personally, i don't see the point in getting all worked up on this. if i knew of a med student like this, i would think "wow, that sucks" and move on with my life. obviously, she will be limited in her career options, and few program directors will want a resident like that. is there a place for her in medicine? sure. but her options are limited. is it my problem to sort out, as a fellow med student? nope.

 

[Non-TradTulsa]

that's not my point, if you have experience, age, wisdom, etc. is it YOUR JOB for determine this students ability to practice medicine? no, it's not. you are not in the administration. you are a student.
i think the dean should mention it in a letter, and they are doing a disservice to future program directors if not. personally, i don't see the point in getting all worked up on this. if i knew of a med student like this, i would think "wow, that sucks" and move on with my life. obviously, she will be limited in her career options, and few program directors will want a resident like that. is there a place for her in medicine? sure. but her options are limited. is it my problem to sort out, as a fellow med student? nope.

Let's get back to the original point. We were discussing whether or not it was proper for a student to be excused from mandatory overnight call. Talking about what this student's future might hold was part of the discussion - a consideration in discussing whether she should be excused from student responsibilities when there are likely to be intern responsibilities that she can't be excused from. Nobody's worked-up over this - it's a discussion. It's an intellectual exercise. An exchange of viewpoints. If you feel that discussion of a student's being excused from overnight call involves personal judgements that you're not comfortable making - by all means, don't participate in the thread.

Your implication that it is somehow "wrong" to discuss a legitimate medical school issue is the only thing I'm a little worked-up over.

Incidentally, a "profession" by definition is a group of highly-trained individuals who have a collective power to regulate who may enter their profession. It won't be up to the "administration" to determine whether someone is safe to practice medicine. That's up to the state board, which is composed of ordinary physicians who are willing to form an opinion, albeit an uncomfortable one.

 

[caffeine37]

Let's get back to the original point. We were discussing whether or not it was proper for a student to be excused from mandatory overnight call. Talking about what this student's future might hold was part of the discussion - a consideration in discussing whether she should be excused from student responsibilities when there are likely to be intern responsibilities that she can't be excused from. Nobody's worked-up over this - it's a discussion. It's an intellectual exercise. An exchange of viewpoints. If you feel that discussion of a student's being excused from overnight call involves personal judgements that you're not comfortable making - by all means, don't participate in the thread.

Your implication that it is somehow "wrong" to discuss a legitimate medical school issue is the only thing I'm a little worked-up over.

Incidentally, a "profession" by definition is a group of highly-trained individuals who have a collective power to regulate who may enter their profession. It won't be up to the "administration" to determine whether someone is safe to practice medicine. That's up to the state board, which is composed of ordinary physicians who are willing to form an opinion, albeit an uncomfortable one.

obviously it's not "wrong" (and i don't think i ever used that word) to discuss something on a forum. i thought you were getting too worked up about my post. my point is, it's just not your job as a fellow student to determine if someone can practice medicine. you're not on the faculty, you're not in the hospital administration, you're not on the medical board yet. you can hear the story and make judgments but you can't be sure you have all the information, or are even in an impartial place (i.e. "and i've been on call three times this week!") to make that determination. that's why these committees exist and graduation from med school isn't determined by some mob rule of who the students themselves think will add to the profession.

just exchanging my viewpoint...

 

[MeowMix]

As a resident, I would be happy if the faculty made "special accommodations" for students who were unable to function effectively on call and would end up adding to my workload. It is easier for me to cover the service and do admissions myself, than to have a miserable student with a migraine or anything else, working slower than a snail and doing a bad job. In the end, the other students do more work but also learn more; nothing is being taken away from your education. And everything counts when it comes to evaluation time, do not fear.

I do think that a designated faculty member should be working with this student to assist them to get their medical issues under control, and to realistically assess their prospects for residency training.

 

[Non-TradTulsa]

I do think that a designated faculty member should be working with this student to assist them to get their medical issues under control, and to realistically assess their prospects for residency training.

There's a constructive suggestion.

No, I'm not the final decision-maker - thank God. Don't want to be. Nor do I have any illusion that any opinion I've ever had on SDN changed anything in real-life. But how my school treats students affects the school's reputation - which affects me. And as a student, I'm entitled to expect that no students receive special considerations that I do not receive unless there's a darn good reason for it - and that was the point here, "is this a good enough reason to be excused, or would some other action in this situation be more appropriate?"

Which made the issue worth discussing in my eyes, although - if Dr. Bagel agrees - it's probably time to put this thread to bed while we're all still on speaking terms.

 

[SoCuteMD]

As a resident, I would be happy if the faculty made "special accommodations" for students who were unable to function effectively on call and would end up adding to my workload. It is easier for me to cover the service and do admissions myself, than to have a miserable student with a migraine or anything else, working slower than a snail and doing a bad job. In the end, the other students do more work but also learn more; nothing is being taken away from your education. And everything counts when it comes to evaluation time, do not fear.

I do think that a designated faculty member should be working with this student to assist them to get their medical issues under control, and to realistically assess their prospects for residency training.

What about when that student is your co-resident? Or you are now supervising that student as an attending, only now s/he is a resident? Still happy to take on additional hours and additional calls so that someone else can rest 8 hours every night?

 

[SoCuteMD]

Well, I think the bigger question is whether or not some limitations are so severe that you can't be a physician. I honestly don't know the answer to that one. Some limitations make it so you can't be in certain fields, but inability to deal with sleep deprivation pretty much rules out all fields during residency at least. I honestly doubt that it will pop up in the dean's letter, either, unless someone specifically wrote about it in her evals. My school is not known for having brutally honest dean's letters.

I absolutely think there are limitations so severe that one can't be a physician, especially when coupled with a student who is more than willing to just give up and go home.

Not all schools require a huge amount of sleep deprivation in residency though. I've spoken to interns in both Psychiatry and Family Medicine and they only do overnight call once a week during intern year. (We have night float that covers during the week and interns do call on the weekend)

Not all schools do, but many do. Our psych residents take call q4 while on medicine during their intern year. They commute an hour each way to a community hospital as well. Our FM interns take q4 call during their inpatient FM months. Certainly there are cush programs, but I'm not sure how realistic it is to limit yourself entirely to only ranking those programs, especially since many programs put up a MUCH better front on interview day than they do when you are a resident there.

 

[lilnoelle]

Certainly there are cush programs, but I'm not sure how realistic it is to limit yourself entirely to only ranking those programs, especially since many programs put up a MUCH better front on interview day than they do when you are a resident there.

It wouldn't be ideal to rank only those kind of programs, but to say this gal shouldn't be in medicine if she can't handle frequent sleep deprivation seems like a bit much to me.

Her options for residency are limited, of course, both in the field she chooses and the hospital she chooses to work at. But it seems a bit much that everyone seems to claim an individual with a medical reason to need a healthy sleep schedule shouldn't become a physician.

We are mere mortals after all.... and doesn't it seem strange to anyone else that we tell our patients to live healthy, balanced lives, but for some reason prohibit it within our own ranks?

I don't condone laziness, but I do think we should understand when there are those amongst us who are limited because of their health, and make reasonable accommodations. Technically, I believe residents have the same rights to FMLA as anyone else who meets the technical requirements.

I don't know what your experience with places of employment making accommodations for individuals with health issues, but my experience (with my patients) involves some employees requiring to work half time or less, (i.e. less than 20 hours a week), and it commonly costs their employers a considerable amount of money to accommodate for these individuals. Is that "fair" to everyone else? Would you recommend that these individuals be fired because they are not able to pull their part of the load?

I hope not. Why is it that we hold ourselves to a completely different standard than everyone else?

 

[SoCuteMD]

It wouldn't be ideal to rank only those kind of programs, but to say this gal shouldn't be in medicine if she can't handle frequent sleep deprivation seems like a bit much to me.

Her options for residency are limited, of course, both in the field she chooses and the hospital she chooses to work at. But it seems a bit much that everyone seems to claim an individual with a medical reason to need a healthy sleep schedule shouldn't become a physician.

We are mere mortals after all.... and doesn't it seem strange to anyone else that we tell our patients to live healthy, balanced lives, but for some reason prohibit it within our own ranks?

I don't condone laziness, but I do think we should understand when there are those amongst us who are limited because of their health, and make reasonable accommodations. Technically, I believe residents have the same rights to FMLA as anyone else who meets the technical requirements.

I don't know what your experience with places of employment making accommodations for individuals with health issues, but my experience (with my patients) involves some employees requiring to work half time or less, (i.e. less than 20 hours a week), and it commonly costs their employers a considerable amount of money to accommodate for these individuals. Is that "fair" to everyone else? Would you recommend that these individuals be fired because they are not able to pull their part of the load?

I hope not. Why is it that we hold ourselves to a completely different standard than everyone else?

Sorry, but I firmly believe that if you can't handle sleep deprivation you don't belong in medicine - plain and simple. The way the wards are structured, one resident shirking his/her duties means another overworked resident will be forced to pick up the slack. I don't know about you, but I'm perfectly happy to pick up the slack for a colleague with a temporary setback - high risk pregnancy, flu, surgery, whatever. However, to constantly be expected to do more just because someone else can't? No, not happening. I need my life, my sanity, and my free time just as much as the next person - I need my healthy, balanced life and I can't have that if I'm picking up someone else's slack. I "need" my healthy sleep schedule just as much as anyone else. However, I made a decision in my early 20s to pursue medicine and I accepted that my life was going to change. So, I guess what I'm saying is that if you make that choice you have two subsequent choices 1) do something else or 2) put on your big girl panties and deal with it. If you pick the right field, you can be free of call once you finish residency and then you can have your healthy sleep schedule and whatever else you desire. Until then, you have responsibilities to fulfill with respect to both patients and colleagues.

I think you are referring to the ADA, not FMLA. Simply put, it specifies that you must complete your work with "reasonable accomodations" (e.g. if you accept a night nursing position, you can't then insist that you can't work overnights and can only work days). IMO, not taking call is not a "reasonable accomodation." Taking call is a significant part of being in medicine, period. Medical school and residency make up the better part of a decade's work, and should not be completely ignored in this equation, either.

 

[lilnoelle]

I think you are referring to the ADA, not FMLA. Simply put, it specifies that you must complete your work with "reasonable accomodations" (e.g. if you accept a night nursing position, you can't then insist that you can't work overnights and can only work days). IMO, not taking call is not a "reasonable accomodation." Taking call is a significant part of being in medicine, period. Medical school and residency make up the better part of a decade's work, and should not be completely ignored in this equation, either.

Well, I was partially referring to both. I honestly don't have a huge amount of experience with ADA, but I have some with FMLA. In this particular situation, since the person in question has a medical problem that would require her taking some time off, I would assume that would fall under FMLA, rather than ADA (which would be more relevant to the individual who was deaf or missing a limb).

As long as the individual had a physician claiming the individual had a medical necessity to miss work, then its my understanding that the hospital will have to accommodate that need. (if all of the FMLA requirements are met).

Obviously its not right to make other individuals carry the residents load. It is my belief that this is a systems problem that should be dealt with. In my former place of employment, we had to bring on extra staff when an employee was pregnant, or had other medical issues. (I worked in a chemical lab, and being pregnant meant I was not only going to miss for 6 weeks after delivery, but that I was pretty much worthless to the lab during my entire pregnancy.)

 

[SoCuteMD]

Well, I was partially referring to both. I honestly don't have a huge amount of experience with ADA, but I have some with FMLA. In this particular situation, since the person in question has a medical problem that would require her taking some time off, I would assume that would fall under FMLA, rather than ADA (which would be more relevant to the individual who was deaf or missing a limb).

As long as the individual had a physician claiming the individual had a medical necessity to miss work, then its my understanding that the hospital will have to accommodate that need. (if all of the FMLA requirements are met).

Obviously its not right to make other individuals carry the residents load. It is my belief that this is a systems problem that should be dealt with. In my former place of employment, we had to bring on extra staff when an employee was pregnant, or had other medical issues. (I worked in a chemical lab, and being pregnant meant I was not only going to miss for 6 weeks after delivery, but that I was pretty much worthless to the lab during my entire pregnancy.)

FMLA guidelines wouldn't be met by this person for a few reasons. First, you have to have been at your company for at least 12 months before leave is requested. It doesn't seem that this person would meet that requirement, as internship is typically the most demanding year and would presumably require the most accomodation. I guess so-called "reduced schedule" FMLA leave would somehow accommodate this person's needs, but IIRC FMLA only allows for <500 hrs of leave. Assuming a q4 call schedule where call is 16 hours longer than a regular workday, the resident would run through a year's allotment of FMLA leave in a little over 4 months.

As far as hiring extra staff, it's a nice thought but not exactly practical. I suppose they could hire a locums attending to fill in, but that's extraordinarily expensive. It's not practical (or even possible) at many places to add a resident to a program simply to make up for another resident's deficiencies. With the # of residency spots currently capped by Medicare (for now) and hospitals already struggling for funding, I'm not sure where the extra 200k (approximate cost of a resident/yr) would come from.

 

[lilnoelle]

Yeah, I'd forgotten about the 12 month thing. Okay. You guys win. I'm still a little niave/idealistic though and don't particularly like the idea that we're expected to be "superheros" of sorts.
I have no doubt that I'll be fine in residency, but you can better bet that I'm going to let the amount of call nights expected affect how I rank my residency choices.

FMLA guidelines wouldn't be met by this person for a few reasons. First, you have to have been at your company for at least 12 months before leave is requested. It doesn't seem that this person would meet that requirement, as internship is typically the most demanding year and would presumably require the most accomodation. I guess so-called "reduced schedule" FMLA leave would somehow accommodate this person's needs, but IIRC FMLA only allows for <500 hrs of leave. Assuming a q4 call schedule where call is 16 hours longer than a regular workday, the resident would run through a year's allotment of FMLA leave in a little over 4 months.

As far as hiring extra staff, it's a nice thought but not exactly practical. I suppose they could hire a locums attending to fill in, but that's extraordinarily expensive. It's not practical (or even possible) at many places to add a resident to a program simply to make up for another resident's deficiencies. With the # of residency spots currently capped by Medicare (for now) and hospitals already struggling for funding, I'm not sure where the extra 200k (approximate cost of a resident/yr) would come from.

 

[MeowMix]

What about when that student is your co-resident?

Then you deal with it.

I bet $100 that you WILL, at some point, end up working with a co-resident who will have problems. Perhaps even you yourself.

Very competent people end up in residency with all kinds of health issues, and the other residents and everyone else have to accommodate them. The most common situation requiring everyone else to fill in is pregnancy. Yes, it sucks if 30% of the residents in your year get pregnant, if there's no good backup system when they end up on bed rest or maternity leave. Should there be a rule that no one should get pregnant? People have physical or emotional troubles, their parents get sick, people switch into other fields and leave programs, etc. If it becomes unworkable, they leave, which is more common than we realize as med students. I would say you should expect that 10% of your intern class will end up in some situation like this, and at some point you will have to fill the gap for someone else. It may not be fair, but it is the real world. What if your physician partner in practice gets called back to military duty? or gets pregnant, or sick, and goes out on leave for months?

Again, the student needs a lot of guidance in identifying realistic goals for residency selection and specific programs. He/she is responsible for being honest. The med school is responsible for accurately reporting his/her limitations in the Dean's letter.

 

[SoCuteMD]

Then you deal with it.

I bet $100 that you WILL, at some point, end up working with a co-resident who will have problems. Perhaps even you yourself.

Very competent people end up in residency with all kinds of health issues, and the other residents and everyone else have to accommodate them. The most common situation requiring everyone else to fill in is pregnancy. Yes, it sucks if 30% of the residents in your year get pregnant, if there's no good backup system when they end up on bed rest or maternity leave. Should there be a rule that no one should get pregnant? People have physical or emotional troubles, their parents get sick, people switch into other fields and leave programs, etc. If it becomes unworkable, they leave, which is more common than we realize as med students. I would say you should expect that 10% of your intern class will end up in some situation like this, and at some point you will have to fill the gap for someone else. It may not be fair, but it is the real world. What if your physician partner in practice gets called back to military duty? or gets pregnant, or sick, and goes out on leave for months?

Again, the student needs a lot of guidance in identifying realistic goals for residency selection and specific programs. He/she is responsible for being honest. The med school is responsible for accurately reporting his/her limitations in the Dean's letter.

If you read my other posts, you'd know that I said I have NO issues pinch-hitting for someone who has a temporary health condition. I specifically mentioned high risk pregnancy, flu, and surgery but there are many others I'd add to that list. I think there's a huge difference between filling a gap temporarily and being asked to do so indefinitely.

I'm actually going into EM, so if someone gets called up, gets pregnant or sick it's likely that the group will hire someone new or hire a locums. Or we'll all step up our game and earn some extra money for a few months while things get sorted out.

 

[aphistis]

If you read my other posts, you'd know that I said I have NO issues pinch-hitting for someone who has a temporary health condition. I specifically mentioned high risk pregnancy, flu, and surgery but there are many others I'd add to that list. I think there's a huge difference between filling a gap temporarily and being asked to do so indefinitely.

I'm actually going into EM, so if someone gets called up, gets pregnant or sick it's likely that the group will hire someone new or hire a locums. Or we'll all step up our game and earn some extra money for a few months while things get sorted out.

I find it odd that you include "high-risk pregnancy" in the list. Many times a woman will know ahead of time that her pregnancies will be at elevated risk. Even if not, however, becoming pregnant is completely within the resident's means to control, unlike the OP's migraines, and results in an extended period of continuously increased workload for her colleagues as opposed to just a day.

What makes one acceptable to you, but not the other?

 

[malpractician]

I bet $100 that you WILL, at some point, end up working with a co-resident who will have problems. Perhaps even you yourself.

Very competent people end up in residency with all kinds of health issues, and the other residents and everyone else have to accommodate them.

Amen. My experience in the military taught me a lot about the human element. I can imagine empathy goes out the door when a med student is on their 25th hour while a colleague calls out sick or doesn't show up at all.

Once my supervisor had been late/taking leave for nearly 2 weeks. People were gossiping and noticing it. Turns out his wife and son nearly died during pregnancy and he was stuck shuffling between the hospital and work.

A fellow coast guard friend of mine was stationed on a ship. She started missing duty and couldn't work, which is a big deal for the military. People were cynical and saying she was lazy. She was diagnosed with Crohn's disease and later discharged.

It's important to address malingering, but a good leader and colleague never forgets Maslow's hierarchy of needs.

 

[SoCuteMD]

I find it odd that you include "high-risk pregnancy" in the list. Many times a woman will know ahead of time that her pregnancies will be at elevated risk. Even if not, however, becoming pregnant is completely within the resident's means to control, unlike the OP's migraines, and results in an extended period of continuously increased workload for her colleagues as opposed to just a day.

What makes one acceptable to you, but not the other?

Women KNOW they are going to have a high risk pregnancy? I'd like to see you tell that to my mom, who was on unexpectedly on bedrest for 4 months of her 7 months of pregnancy with my sister. While some women may know that they are at increased risk, many high risk pregnancies are completely unanticipated as such.

The biggest distinction is that pregnancy is temporary. My colleague will be out sick and then, after a few months will return to work. The "sleep deprivation migraines" are permanent. I am going to be pinch-hitting for this colleague for the duration.

I'm really not going to address the whole "pregnancy is an option" thing in this thread because it's not pertinent to my take on the issue or to the discussion.

 

[platon20]

Maybe this person will go into path if she can't handle call.

She only hurts herself if she doesn't experience call like residents sometime during medical school. She needs to know what it's really like so that she can make a better decision about which residency to go into. Residencies won't be so accommodating for her sleep schedule. I can only think of path as the only specialty where she can avoid call completely during residency.

Is path really no-call? Who handles all the late night intra-operative surgical path?

 

[yaah]

I think it's an interesting discussion because it's kind of a slippery slope - at some point we have to draw the line in medical training about what is or is not acceptable. Anyone who has gone through residency knows that there are some residents or med students who are "out sick" much more often than others. Some of them have legitimate health issues, some have issues that others would just deal with. For some, it compromises their training and the training of others.

At some point it has to stop being about how the med school accomodates the student (or resident) and about patient safety and work getting done. At some point you have to stop saying, "I can't do this because of my health concerns," if you want to stay in medicine - because the patients certainly don't stop. If it's something you can't handle, then you can't handle it. I don't know of anyone who advocates harsh treatment of anyone who ever begs off of work because of illness. And to be honest, most chronically late or absent residents end up getting away with it because it is just too much work and effort to fight it. And yes, you can argue that the parts of med school that are problematic may not be relevant to the future career - but that's what med school is. I went into pathology. I didn't want to spend 12 weeks on surgery dealing with hemostasis and wound infections, but I did.

Is path really no-call? Who handles all the late night intra-operative surgical path?

Path has call. In some programs you are on call for a week at a time, at most I think it is structured by daily call. There are calls at all hours of the day - many are related to frozen sections, yes, but most are clinical pathology related (blood bank transfusion issues, mislabeled specimens, acute need for apheresis, critical values that no clinician responds to, etc). There were many nights where I got very little sleep but had to put in a full day the next day. It's nice that it is generally home call (except when you have to come back in for a frozen or whatever), but not good for someone who "needs" 8 hours of sleep to function. In addition, many of our days are very long (pathology is not 9-5) and our days require a lot of outside reading and independent study.

 

[aphistis]

Did I say all the time? Did I? Or did I explicitly address the times when it happens unexpectedly? Your personal story is not pertinent here, and I'm not interested in hearing your sister's perinatal biography. You still have a real problem with cherry-picking other people's arguments when you're not outright distorting them.

As for the parts of your response that *are* relevant to the original discussion, however, I respect your opinion as you've presented it here.

Women KNOW they are going to have a high risk pregnancy? I'd like to see you tell that to my mom, who was on unexpectedly on bedrest for 4 months of her 7 months of pregnancy with my sister. While some women may know that they are at increased risk, many high risk pregnancies are completely unanticipated as such.

The biggest distinction is that pregnancy is temporary. My colleague will be out sick and then, after a few months will return to work. The "sleep deprivation migraines" are permanent. I am going to be pinch-hitting for this colleague for the duration.

I'm really not going to address the whole "pregnancy is an option" thing in this thread because it's not pertinent to my take on the issue or to the discussion.

 

[SoCuteMD]

Did I say ALL THE TIME? Did I? Or did I explicitly address the times when it happens unexpectedly? Your personal story is not pertinent here, and I'm not interested in hearing your sister's perinatal biography. You still have a real problem with cherry-picking other people's arguments when you're not outright distorting them.

As for the parts of your response that *are* relevant to the original discussion, however, I respect your opinion as you've presented it here.

Dude, you don't have to yell. I thought it was an interesting counterpoint. IME (having done an ob/gyn rotation, which you haven't) most women have no warning that they are going to have a difficult pregnancy until they do. Now chill. It's summer (almost), it's Sunday, and there's no need to yell on the Internet or in real life.

 

[aphistis]

Dude, you don't have to yell. I thought it was an interesting counterpoint. IME (having done an ob/gyn rotation, which you haven't) most women have no warning that they are going to have a difficult pregnancy until they do. Now chill. It's summer (almost), it's Sunday, and there's no need to yell on the Internet or in real life.

Fair enough. The caps were meant to be emphasis, not shouting, but I can see how you'd interpret it that way. Fixed, and I stand by the corrected version.

 

[midwesterner]

The purpose of residency is primarily to prepare someone for practicing medicine, right? So, the main question at stake should be whether this person can still be a good doctor even if she absolutely needs 6 hours of sleep every night. My thought on this is a resounding YES, in some specialties.

Not every field of medicine requires sleep deprivation once in practice. I think a person who needs even 8 hours a night can still be a great doctor in these fields. I know many who get regular sleep every night and say they don't get many calls waking them up. Most are in primary care, some in IM-subspecialties, and one is a corporate doctor. Personally, I think someone who gets regular sleep and has a healthy home life is probably a more nurturing doctor, which is pretty important in primary care especially.

For all the points about how she wouldn't be able to get through residency, or how it would cause an unfair burden to other residents who have to take more call...that's because of our system of medicine. Anything man-created can be changed if there's a strong enough push to do it. Shoudn't medicine select for the most intelligent, most compassionate people? Not necessarily the ones with the toughest bodies?

 

[Doctor Bagel]

The purpose of residency is primarily to prepare someone for practicing medicine, right? So, the main question at stake should be whether this person can still be a good doctor even if she absolutely needs 6 hours of sleep every night. My thought on this is a resounding YES, in some specialties.

Not every field of medicine requires sleep deprivation once in practice. I think a person who needs even 8 hours a night can still be a great doctor in these fields. I know many who get regular sleep every night and say they don't get many calls waking them up. Most are in primary care, some in IM-subspecialties, and one is a corporate doctor. Personally, I think someone who gets regular sleep and has a healthy home life is probably a more nurturing doctor, which is pretty important in primary care especially.

For all the points about how she wouldn't be able to get through residency, or how it would cause an unfair burden to other residents who have to take more call...that's because of our system of medicine. Anything man-created can be changed if there's a strong enough push to do it. Shoudn't medicine select for the most intelligent, most compassionate people? Not necessarily the ones with the toughest bodies?

You know, I don't disagree with you and would like to see a future medical world where we don't have sleep deprivation as a big part of our training model. I got all of 2 hours of sleep a few nights ago due to being on call while the residents got none, and yeah, I don't think any of us would provide as good of medical care as we would have had we been well-rested. As mentioned above, some programs are trying to move away from 30 hour calls and replace them with more night float, but most programs are still stuck having residents forgo sleep just because of current structural limitations. So yeah, change in the future will be good, but it's going to take a while to get there.

 

[lilnoelle]

The purpose of residency is primarily to prepare someone for practicing medicine, right? So, the main question at stake should be whether this person can still be a good doctor even if she absolutely needs 6 hours of sleep every night. My thought on this is a resounding YES, in some specialties.

Not every field of medicine requires sleep deprivation once in practice. I think a person who needs even 8 hours a night can still be a great doctor in these fields. I know many who get regular sleep every night and say they don't get many calls waking them up. Most are in primary care, some in IM-subspecialties, and one is a corporate doctor. Personally, I think someone who gets regular sleep and has a healthy home life is probably a more nurturing doctor, which is pretty important in primary care especially.

For all the points about how she wouldn't be able to get through residency, or how it would cause an unfair burden to other residents who have to take more call...that's because of our system of medicine. Anything man-created can be changed if there's a strong enough push to do it. Shoudn't medicine select for the most intelligent, most compassionate people? Not necessarily the ones with the toughest bodies?

Amen. Beautiful.

 

[Rendar5]

Amen. Beautiful.

Maybe it's because I'm going into a shift-work field, but personally, I never understood the point of doing overnight calls (not talking overnight shifts), or hell, the concept of call in the first place. Just have a steady stream of patients on all days evenly distributed among teams, and a steady night float system where all residents are required to spend significant times on an alternate sleep schedule at different points of the year. Seriously, what's the point of having a system where you get massive spikes in workload every 3-4 days. I can only see a couple cases where that can't work, like trauma surg. The rest is "omg, that's so radical it's dumb and can't possibly work because that's not how it's done and I like it the way it is"

As for the person with migraines, if she really can't go less than 6 hours, meh. She better be picking up other people's slack regularly since they're picking up hers.

 

[JeffLebowski]

The purpose of residency is primarily to prepare someone for practicing medicine, right? So, the main question at stake should be whether this person can still be a good doctor even if she absolutely needs 6 hours of sleep every night. My thought on this is a resounding YES, in some specialties.

Not every field of medicine requires sleep deprivation once in practice. I think a person who needs even 8 hours a night can still be a great doctor in these fields. I know many who get regular sleep every night and say they don't get many calls waking them up. Most are in primary care, some in IM-subspecialties, and one is a corporate doctor. Personally, I think someone who gets regular sleep and has a healthy home life is probably a more nurturing doctor, which is pretty important in primary care especially.

For all the points about how she wouldn't be able to get through residency, or how it would cause an unfair burden to other residents who have to take more call...that's because of our system of medicine. Anything man-created can be changed if there's a strong enough push to do it. Shoudn't medicine select for the most intelligent, most compassionate people? Not necessarily the ones with the toughest bodies?

Eh, like Bagel, I agree with most of what you said.

However:
1) I really don't think taking an occasional call selects out the "toughest bodies". Come on, that's being dramatic. And like it or not, there is a physical component to medicine. You have to be able to hustle. You have to be able to rouse yourself when you're needed. You have to be able to physically perform your job. I don't like this constant stream of blind accommodation - it feels like no matter the "disability", there's a group out there who expects it to be accommodated. There's limits to reason here. Migraines is not a legitimate excuse (and this is coming from a person with a long history of severe migraines). Take meds, take naps, avoid foods, and even tell your residents on a case-by-case basis if you happen to get one and need to rest, but calling it a medical condition that requires preemptive accommodation is ludicrous.

2) Just because "not every field of medicine requires 'sleep deprivation' ", does not mean that students shouldn't be expected to experience it during medical school. This is not podiatry school or dental school, we get a broad-based education in medicine and we should be proud of that. It's a very good thing that we don't pick our specialties on day 1 and lock ourselves in from then on out. I get concerned by these "gosh, I'm going into derm, why do I have to do surgery call?" complaints - you need to do it because it was determined by people much smarter and more experienced in medical education than yourself that it's important. Not to mention, what happens if you change your mind and want to do surgery? All of a sudden you've done yourself a disservice because you don't know what call's like, you haven't learned as much, and you may not have a realistic experience of what the field is like.

Do I think call is a good thing? No, not necessarily, like Bagel I think call is probably something we could/should reduce and avoid overall, and the IOM seems to agree, and that's the direction medical training appears to be moving. But if there's a change, it should happen from the top down (i.e. if residents take less call, medical students should follow suit), because we are being trained to be residents.

 

[45408]

Speaking of call, I've got to post this - http://drgrumpyinthehouse.blogspot.com/2009/06/gimme-some-sarcasma.html

The story is good, but this comment just killed me:

3:00 AM
Nurse: Do you set up the PCA [for the post-surgical patient in pain]?
Me: No.
Nurse: But I'm going on break, and I don't know how to set it up.
Me: Then maybe the nurse covering you on break can set it up.
Nurse: Can't you write for something simpler?
Me: Okay. Here are some nursing boluses of hydromorphone. In the meantime, find another nurse who can help you with the PCA.

3:30 AM--Pager beeps
Nurse: Did you want 0.2mg of hydromorphone at a time, or 2mg?
Me: What did I write?
Nurse: You wrote 0.2mg.
Me: Then that's what I want.
Nurse: But it comes in 2mg ampules.

 

[SoCuteMD]

nm.

 

[eforest]

My school places a lot of value on the "technical standards" one must meet in order to become a doctor. There are certain accomodations one may get, including extra time on exams, tutoring, etc, but when it comes to clinical work, there is very little leeway. I have Bipolar Disorder and lack of sleep puts me in danger of having an exacerbation. However, it is really important that I learn to cope during medical school so that I can be a successful doctor eventually. Giving people too many breaks is not always advantageous in the long run.

 

[Doctor Bagel]

So now this person is actually missing days of the rotation even with the accommodations. It makes me think that maybe the school is delaying the inevitable for her, especially considering that she's interested in a field with a fairly hard residency.

It's also created some general disharmonious feelings among the rest of the students on the rotation, which maybe isn't great but probably natural. For example, she told an attending about how she stayed "post-call" once to scrub a case. Well, she went home at 10 pm that night and stayed until about 9 am the next day to scrub this case.

 

[smq123]

So now this person is actually missing days of the rotation even with the accommodations. It makes me think that maybe the school is delaying the inevitable for her, especially considering that she's interested in a field with a fairly hard residency.

Uh-huh.

 

[efex101]

The problems here is on the shoulders of the no balls attending, NOT the lazy medical student. This person is getting away with it because someone is allowing it period. This also happens in residency unfortunately so may as well get used to it.

 

[Conky]

My school places a lot of value on the "technical standards" one must meet in order to become a doctor. There are certain accomodations one may get, including extra time on exams, tutoring, etc, but when it comes to clinical work, there is very little leeway. I have Bipolar Disorder and lack of sleep puts me in danger of having an exacerbation. However, it is really important that I learn to cope during medical school so that I can be a successful doctor eventually. Giving people too many breaks is not always advantageous in the long run.

Some schools provide an incredible amount of leeway when considering accommodations for disabled students.

Read about this guy if you haven't already.

http://forums.studentdoctor.net/showthread.php?t=529637&highlight=walderness

 

[Mayhem]

I have a small problem with this student getting out of call. But my real problem is the unfairness of it all. If the admin decide that she can receive adequate training without doing call then why do the rest of you need to do call. I happen to like call and support the idea of it but it's the principle of the matter that's at stake here.

 

[GMDMD]

Sure you learn a lot on call. But you learn a lot every day. At some point, enough is enough. Maybe one night per rotation is fine. But call (outside of very specific rotations like trauma) is so low yield it's ridiculous. Following around your resident/intern like a puppy, who like to keep you around for conversation and scutwork because they forgot what it was like to be a 3rd year trying to maintain a semblance of a life while juggling shelf exams and trying to figure out your future.

There is enough going on during the 12 hour days to learn from. There is no education in sleeping in craptastic callrooms and being woken up at random hours of the night. We'll get through internship hell just fine without it, thank you very much.

Honestly I think it is unnecessary misery like this that discourages people from going into certain fields. Your job is to be a student. Intern and residency hell will come and a few extra hours here and there during 3rd year clerkships is like a drop in the bucket. Especially when those hours come at the expense of you being able to do well on your shelf exams (or just your general happiness) and deters you from getting into the field/location you want to get into.