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Include at-home call in the 80-hour limit?

A research letter in the May issue of Academic Medicine suggests that “a change to current duty hours requirements may be in order to account for all hours worked, whether in-hospital or at-home, while allowing for flexible solutions from one specialty to the next.”

We asked the readers of the GME e-Letter their thoughts on this issue, and received the following comments.

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Count time sleeping as duty hours? Silly. Count hours you are required to go to the hospital while on at-home call. Better.

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There is no way to keep the work week below 80 hours for any resident taking at-home call if they count the time they are not working but are "on call." The hours actually worked (when the resident comes in) should be counted.

Our faculty take call for seven days in a row. Technically this amounts to 24/7 for an entire week (counting the regular workdays) for us. Will there ever be a limit to the amount of time we "work?" It makes no sense to do this.

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How will each program define the hours worked? Will the resident log minutes on the phone? As an attending, when I am on call on a weekend (60 hours), I do not get compensatory time off during the week. Call from home most accurately represents life as a physician; let's continue to teach residents to be competent, caring physicians.

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In my urology residency, we maintain home call, and at a very busy hospital. Most nights we are so busy triaging home calls, ER consults, and driving in for procedures, foleys, and to examine patients that I get about as much sleep as if I were in call. Most nights I stay in-house on my own accord in order to get more sleep and be rested for the next day. As a service we try to get the post-call resident home before evening rounds, but just as often we end up operating past five pm that day.

There is no way to standardize the busyness of home call to "count" it or "not count" it, but leaving that time out of the work hours is one way programs can get around the 80-hour limit. If you count all the time I am awake working—that means thinking, calling and planning for patients—home call is not much different that in-house call.

Should there be a second category for home call in the 80-hour tally? Should the 80 hour limit be expanded for those who take home call? Perhaps only home call with a primary pager should count. A senior resident does not field pages for the ward or patients—but the junior residents do.

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Short answer: Home call time should not be counted in duty hours except “time on task” (in which I would include phone calls, driving to and from the hospital, and any time spent in the hospital).

Longer answer: Home call is a very sticky wicket when counting duty hours. There is no question that this is a mechanism subject to abuse by programs to avoid counting hours that residents have worked. However, there is something very different and more restful about eating dinner at one’s own table, sleeping in one’s own bed, and showering in one’s own bathroom compared to spending the night in the hospital. And, if a service is slow enough that the patients can be well taken care of by an at-home resident, then home call is a win-win.

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Counting work done at home while on-call (what true work that is I’m not sure) will just perpetuate the “billable-hour” mentality that characterizes much of the legal profession. It’s a bad idea in concept and even worse in execution. When I get a phone call from a patient or a colleague I don’t start my timer running, and neither should our residents. 

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I believe home call should be included in the 80-hour work limit. For example, our program has home call for orthopedic surgery residents. The majority of times the residents are on call, however, they are in the hospital the entire night seeing patients and operating. The nights they do spend at home, they are paged incessantly with patient issues. Because their call is “home call,” they do not get the benefit of a post-call day after a rough night. On the other hand, as a pathology resident, I take home call one week at a time and am hardly paged. So maybe it should be specific to each specialty?