What is your Experience with At-Home Call?
In the August issue of the GME e-Letter, we asked residents/fellows, "What is your experience with at-home call?"
There has been concern that some residency/fellowship programs have been misusing at-home call to circumvent the intent of the ACGME duty hour restrictions. For trainees in some specialties, however, increased use of at-home call has been appreciated and well accepted.
The AMA Council on Medical Education is drafting a report on at-home call, for consideration at the AMA’s 2008 Interim meeting. Some of the responses below were excerpted for inclusion in the report.
In the interest of confidentiality, each respondent's identifying information has been removed.
I am a general surgeon who completed my residency in 2007. From 2005 to 2007 I was a chief resident on q2 home call. The GY4 chief was bestowed upon me because a resident left the program. Initially this was a great honor for my hard work and medical/surgical acumen, but in the final analysis it was just too tiring, especially without supporting help.
At-home call is an abuse of the 80-hour work week. It is good for experience, maturity, continuity of care, and responsibility, but the interrupted sleep and long work hours can easily violate the basic premises of the duty hour limits.
I support limited use of at-home call, especially q2. Program directors know the pros and cons of home call and are in a bind. The only problem will be how hospitals will fill the void in the workload. Undoubtedly academic and affiliated-private attendings have been doing more work for the past five years. At the same time, not every hospital system can afford additional providers, such as nurse practitioners, physician assistants, or preliminary residents.
Note Bene: My surgery program was rather busy—an open ER, county hospital, and a de facto trauma center (no trauma system set up in the county yet—paramedics knew to bring the “knife and gun club” to the county hospital). Now, as an attending for the Veterans Affairs department at an academic medical center, with a closed ER (VA patients only) and no trauma, this set-up would appear to allow better hours for the resident at-home q2 call.
So ultimately the frequency and duration of work at night will determine whether a hospital or residency can successfully implement an at-home call system.
My orthopedic surgery program has an at-home call policy for all levels of training. We employ a two-person call system—that is, a junior resident (GY2 or 3) paired with a senior resident (GY 4 or 5). At any time the residents may leave the hospital and take call from home, provided that they can reach the hospital within an acceptable time frame. The nature of our hospital as a tertiary referral center means that the junior resident very infrequently has the opportunity to leave the hospital. The senior resident comes in for operative cases and assists the junior in the ED as needed. Due to the variability in night-to-night experiences, we have determined that the entire night counts toward duty hours, even if you have a "good night." Thus, the call team goes off call 24 hours after starting, and leaves the hospital 30 hours or earlier after their shift started (regardless of how the night went).
This system has been very satisfying. There are no duty hour violations and the design is actually in favor of the residents being under work hours (ie, hours that they may have worked at-home are considered as work hours). This makes the following day run more smoothly as well as we have a regular schedule. The chief residents can plan operative coverage each day, knowing that the call team will be leaving by mid-day. I would encourage other programs that have enough residents to adopt a similar policy.
I am a pediatric subspecialty fellow. Our call schedule mandates one weeknight a week and one weekend a month for a total of seven nights/month. The weekend is counted as Friday afternoon till Monday morning. The weeknight call is taken from home. We are expected to come in to the hospital in the event of an emergency. On the weekend we round on both services in the hospital on Saturday and Sunday from 8-6 on average, depending on the patient load. We are also on pager call the entire 64 hours of the weekend. Our attendings claim the pages through our answering services are supposed to be routed to them between the hours of 9 a.m. and 1 p.m. on Saturday and Sunday so that we may round, but I can tell you that this has occurred at most 25 percent of the time despite my bringing it up repeatedly.
Our pages include calls from outside pediatricians, parents, the ER, new inpatient consults, and various labs reporting results. On some of my call nights I have received 25-30 pages. On an average weekend (Friday afternoon to Monday morning), I sleep approximately 10-12 hours uninterrupted total. I can also tell you there are weekends when I have slept less than five.
Our program insists that this is in compliance with the work hours guidelines and according to the letter of the law, I suppose it is. I don't know if there is a "spirit of the law" but if there is, I imagine this can't be in it.
There has recently been talk that we are not taking enough call and they have considered splitting our weekends into covering one service or the other. In that case we would be on call two weekends a month. If this were ever to come to pass, I would have to think about quitting.
There needs to be some imposition of guidelines to programs to regulate the usage of at-home call. In certain subspecialties, I imagine that home call is not a particularly draining experience, but when I am covering 30-40 inpatients, many of whom are in the ICU, I can promise that it is.
My general surgery program went to at-home call for chief residents (R4 and R5) earlier this year. This enables chief residents to go home when their day is done and return only for very sick patients or for patients taken to the OR.
Unfortunately, there are some very concerning things that are happening. Once a chief is called back in to the hospital, he pretty much stays there. To be honest, it is too tiring to drive back and forth more than once a night. In addition, with the cost of gas, it is not very frugal.
If, on the other hand, the chiefs stay home most of the night, this leaves a large potential for very inexperienced housestaff to be responsible for every surgical patient in the hospital. We had a big issue recently where a patient had a postop MI, and the severity of the situation was not appreciated by the R2, thus not communicated to the chief at home, who relies on the R2 to give an accurate picture.
I feel at-home call can work for services that do not get consults every night or rarely have emergencies. For services such as transplant, trauma, or general surgery, or for very busy academic centers, this is just not a realistic application of the at-home call rule.
FYI: My program is already on probation from the RRC for duty hour violations (thus the switch to home call to attempt to alleviate the problem).
At times I believe at-home call is a way to get out of duty hour trouble while really not changing the amount you work. There should be limitations on what can be called at-home call. If you stay at the hospital more than 80% of your time on call anyway, then it shouldn't be called at-home call. The 1.5 hours they can subtract from the total were likely spent driving back and forth to the hospital or answering pages from your home...so you are working, just not able to document that time.
Other rotations should be at-home call. It just needs regulation and inclusion criteria.
My internal medicine program misuses at-home call, especially on elective subspecialty services (eg, hematology/oncology, nephrology, pulmonology). The residents on those services have been used as the primary team to admit patients and discharge them. At-home call is every three days, and every call the resident is called to the hospital to admit patients. Many times that could take from 9 p.m. to after midnight. The day after call is not considered post-call, and the resident has to stay until 5 p.m.
The duty hours exceed 80 per week when on subspecialty services, but the program does not report the call-in hours as duty hours.
On the pulmonary and nephrology services there are over 50 patients distributed across three residents. The resident has to take care of all his patients as a primary (admit, dictate, discharge, and answer pages all night).
On hem/onc the call is every third day, and every call the resident has to stay to see three or four new consults after 5 p.m., which usually takes until after 10 p.m.
My concern is that the subspecialty rotation does not serve the purpose of teaching the specific area of medicine. For example, when on call for nephrology, the resident is called to the hospital to admit the nephrologist's patient, who may be admitted for a headache.