Sunday, February 28, 2016

What Residency is Really Like: Schedule

A little over a year ago I wrote a post called "The Price of Residency."

It's completely accurate, completely true, and I have not changed my mind about anything I said in that post. Click the link above if you want to read it.

That said, it's been a year since I've written in general about residency, and now that I'm only a few months (!!) from being completely finished, I think I can give an accurate summary of what residency has been like, at least for me.

I may do a few different posts on this, and there are a hundred things I could write about so I'll divide them into topics.

The first one is going to be:

Journal J 2016: How I Keep My Life Together [that would be a whole other post]

You've seen me post hundreds of times about being on "a busy rotation" or "a more relaxed rotation" and you've heard me reference my shifts both day and night so I thought I'd break it down for people who want to know what it really looks like from day to day.

I realize this isn't the most fascinating topic for some of my audience, so read if you're interested and if not that's fine I'll see you at the next post.

For context, I'm in a Pediatrics Residency at a medium-sized program. I chose my electives so that I would be prepared for a General Pediatrics practice with mostly outpatient but some inpatient responsibilities and Newborn Nursery care.

A. The Block Schedule
Here is my real life block schedule for my entire residency.

If you read each column down, that's a year. Each block is 4 weeks, so there are 13 blocks in a year (with a 5 week block to end the year in June). We literally change responsibilities every 4 weeks for 3 years, but return to many of the core blocks multiple times.

Intern Year
Year 2
Year 3
Dermatology with Ward Cross
Genetics with Ward Cross
Infectious Disease with Ward Cross
Newborn Nursery
Cardiology with PICU Cross
Nephrology with PICU Cross
Adolescent with Ward Cross
Emergency Room
Integrative Medicine with Ward Cross
Development with Ward Cross
Child Abuse Response Team with Ward Cross
Rural Community in Los Alamos
Intermediate Care Nursery
Community Medicine with Clinic Cross
South America
NICU Resuscitation
Emergency Room
Emergency Room

All of the Intern blocks are required, but many of the other blocks in second and third year are "electives" that I've filled in with what I chose to do. Any time it says "cross" that means we work weekdays on our elective rotation and then usually have weekends or nights when we cover the other services. We also have jeopardy, which is our sick call system, on most of those electives as well. This means we could be pulled from our elective to cover for someone sick for the days that we're assigned jeopardy.

B. The Hours/Rules
So with the above schedule laid out, how much does a resident actually work?

We work usually 6 days a week between 9-13 hours per shift depending on the rotation. We have the occasional 24-28 hour shift, but they're fairly infrequent and on some rotations we might work only 5 days a week and have weekends - there are a couple of those in second year and a couple in third year.

There are rules put in place by the resident governing bodies that are supposed to be followed in terms of hours and days off. These were implemented in 2011 in an attempt to make medicine safer for both the residents and the patients they take care of by decreasing medical errors due to fatigue. The research as to whether these changes were effective is still ongoing.

- We're not allowed to work more than 80 hours a week, averaged over the month (so 90 one week and 70 the next is fine).

- We are to have 1 day off a week, averaged over the 4 weeks. We could work 14 days, have 2 days off, work another 12, as long as there's 4 in 4 weeks.

- We are supposed to have 8 hours (though preferably 10) between shifts. We are supposed to have 14 hours if we work 24 hours or more. But 23 - that's fine, then we only need the 8-10.

- We cannot be scheduled for night shift more than 6 nights in a row.

- Interns can't work more than 16 hours in a row, upper levels more than 24-28.

C. Examples. Below each example I've given an estimate of the hours per week, in which I included sign out time and the extra time sometimes spent for a late admit, finishing documentation etc. that occurs over the month. 

Let's take the start of my residency as an intern for example:

1. Heme-Onc: For 4 weeks I came in at 6:30 AM and signed out at 5:30 or 6 PM. I worked 16 hour shifts overnight with morning rounding both days of 2 of the weekends, and then had the other weekends as my 4 days off for the month.
Hours per week: 60 - 80

2. Clinic: In clinic I worked from 8 AM - 5 PM most days, and 8 AM - 9 PM about twice a week when I covered "late clinic." I also worked 2 Saturdays from 9-2. This is a nice rotation in that I had 6 whole days off in the month.
Hours per week: 55 - 60

3. PICU: On PICU I worked 6:30 AM to 5:30 PM (plus the time it takes for sign out) 6 days a week for 3 weeks, and then at night 5:30 PM to 6:30 AM for one week.
Hours per week: 70

Moving on to the senior years, here are some other examples:

4. Nephrology with PICU Cross: On this rotation I typically came in around 7 AM and stayed until around 5 PM, though it's flexible a little depending on the patient load, when the attending likes to start etc. PICU cross was a 24 hour shift every weekend. In order to have my one day off a week I usually took a weekday. 
Hours per week: about 65

5. Rural Community Rotation: For this one I got to work regular business hours for a whole month. We started around 8 and typically finished by 5:30 and I had all weekends free. I even usually had a lunch break. It was crazy.
Hours per week: 40

6. Wards: Wards as a senior is 2 weeks of 6:30 AM to 5:30 PM for 6 days each and 2 weeks of nights 5:30 PM to 6:30 AM for 5 shifts each.
Hours per week: about 70 - 80

D. Day to Night
It may be hard to tell from the description above, but we may change from working at night to day or day to night or work a 24 hour shift quite often.
Towards the beginning of my second year (that stretch from Wards through Nephrology with PICU cross of 16 weeks) I made about 12 switches from night to day or day to night (or worked 24 hrs). Sometimes though we may get to stay on days for a couple months in a row, it just depends on the rotation order.

E. Vacation
We get three weeks of vacation in addition to 5 days around the holidays that include either Christmas or New Years. I used a couple of my vacation days to take the third step of my Boards because I couldn't fit it in elsewhere, but for the most part vacation is an incredible time you look forward to months in advance.

F. What if you're sick or have an emergency?
If you're sick but not super sick, like if you have a cold, or you've only thrown up a couple times or you can still walk then people pretty much come to work. It's up to the resident to determine whether we're too sick to work or not. If you can't come in, then the Jeopardy call person gets called in to cover and you owe them. Later on when you have a chance you work a shift for them. At least that's what's supposed to happen. I've been called in for Jeopardy 4 times and gotten paid back once.

G. Eating
We don't have any lunch breaks exactly, but we're not surgeons - most of the time we get to eat. Lunch may not be until 3 PM sometimes when the day is busy, but eventually we get to it.

H. When Not At Work
There's research, quality improvement, reading, presentations, Board studying - a myriad of things to fill our time with as soon as the shift is over. I can't really quantify the time spent on these because it's different for everyone, but our day certainly doesn't end at sign out.

Summary: What does working this schedule actually feel like?

I suspect it feels better than it used to. Duty hour restrictions and a transition to more shift work have their merits and also their disadvantages. I much prefer working 24 hours straight in the PICU to 2 shifts of 12 hours because of the continuity. The multiple sign outs are something that everyone in medicine is working on improving, because if we're here less, then we're signing out our patients to someone else more. Then again, it's nice to go home, sleep, see our families etc.

There are some times when I literally don't do anything but eat, shower and sleep when I'm not at work. Mostly I feel that way when I'm working nights, but if the days are busy I may stay after or have to do documentation after sign out and by the time I finish and walk home from work, I'm only home about 10 hours before I go back.

I try to make the most of the time I spend not at work, but it's hard to feel like I have a life outside of work during a lot of these months.

Before residency, I definitely underestimated what it feels like to have only 1 day off (or sometimes no days off) each week, week after week. If the work doesn't energize you, that will make you feel drained all the time. That one day off a week is barely time to buy groceries, do a load of laundry, 409 your kitchen and put your feet up for a second, let alone keep up with hobbies you used to like or make you feel restored enough to face another 6 days.

Let's put it in another perspective though: I'm grateful for everything I've learned. A lot of what we need to know can't be learned any other way but being here at work.

If I wanted to work less days or hours during residency, it would take more years to learn what I need to know to be a decent doctor. I certainly don't know everything, but working like this means we know enough to be safe, and we know how to find out when we don't know the answer.

To summarize I'll say this: The schedule of a resident is not light. It is not easy and everyone at some point feels like it will never end. And then it does - and if it's the only thing you want to do with your life, it's worth it.

Do you have questions? Are there things I didn't cover? 
Let me know if you have a suggestion for something else you'd like to read in the "What Residency is Really Like" series.

Thanks for reading, see you soon.

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