During residency and fellowship training, the schedule can be intense. But what happens when the immovable object—in this case, high-stakes medical training—comes up against an unstoppable force—like, say, you come down with the flu.
That’s where backup call comes into play, and physicians in training may feel less stigma than in years past about caring for their health. But the situation remains complex when the demands of patient care, educational performance and personal well-being clash.
“I sometimes tell them [residents] that back in my day, no one ever called in the backup. But now people are calling it in,” said Emily Lisco, MD, a psychiatrist and director of the emotional health and wellness program for house staff at Philadelphia-based Jefferson Health. “It was so stressful on the residents to have to ask for time and then for the other residents to cover.”
Jefferson Health is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Dr. Lisco and other physicians say that though it is never an easy situation, taking time off is not as verboten as it once may have been, and some training programs are adopting new strategies intended to preserve physician well-being.
“Having a system in place so it's less chaotic and so that residents have more permission to be human and to need time away from work is really important,” Dr. Lisco said.
The state of backup call
Sometimes referred to as jeopardy duty, backup call provides for situations in which a resident or fellow is unable to work due to illness, duty-hour issues, family emergencies and other absences that require coverage without much notice.
The rules for backup call, though, vary by residency training program. They likely differ on how quickly a backup needs to report, where you need to be when you are the backup and how often you might be assigned to the duty, for example.
“Every program approaches it differently, but, really, it's about trust in your colleagues,” said Christopher Wong, MD, MSc, a fourth-year resident in a combined internal medicine and pediatrics program in Texas.
“If you trust that they are calling out for a quote-unquote good reason—taking care of their personal health, taking care of a family member, for important events in their life—then you would hope that they would do the same for you.”
Training programs use different structures for backup-call systems, which can be formal or informal, and some use “specific rotations for coverage for when people need to be out at the last minute,” Dr. Lisco said.
There are also options, said Dr. Wong, who is also a delegate for the AMA Resident and Fellow Section, in which residents don’t have to rely on calling in someone who otherwise would have a much-needed day off.
“If the service you're on doesn't necessarily need you, if the attending or fellow can cover, if that resident talks directly to chiefs, sometimes things can be worked out or you can swap shifts and you can get that day off that you need to,” he said. “There are a lot of ways that you can troubleshoot prioritizing that time off for wellness.”
Sick time versus well-being time
Dr. Lisco noted that the discussion in residency is about more than sick days, in some cases.
The Accreditation Council for Graduate Medical Education requires, and AMA policy is in agreement, that training programs should give residents and fellows time off to visit their own physicians. Providing flexibility in scheduling time off can increase well-being and reduce stress. Dr. Lisco said that Thomas Jefferson University Hospital's internal medicine residency program allows residents a half-day roughly every six weeks during their elective rotation to schedule needed check-ups and other appointments.
Time-off structures “that increase resident autonomy can be really helpful,” she said. From being able to take a bit of time to bring a car into the shop when it breaks down to being able to take a larger percentage of your vacation time at once, training programs have “gotten more flexible and been more understanding of things like that.”
Find out more with the AMA STEPS Forward® playbook, "The Value of Feeling Valued: How Organizations Can Support Individual Physicians." It is enduring material and designated by the AMA for a maximum of 0.75 AMA PRA Category 1 Credit ™.
A give and take
Relationships matter when it comes to backup call.
“I’m fortunate that I feel like I trust my colleagues to call out for reasonable things,” Dr. Wong said. “And I think that mental health is a very big and very reasonable concern.”
Though he said there may be less stigma in residency to needing a day off, there hasn’t been a complete sea change.
“There is a big mental block with the idea of calling out. A lot of people will work through minor illnesses,” he said. “The culture is slowly changing, but there is still a lot of that self-responsibility and that feeling of empathy. After having been called in, you definitely think twice before you call out the next time.”
Some challenges for jeopardy
While the circumstances of backup-call systems vary, there are some commonalities. Chiefly, there is the understanding that residents need—and should be able—to take time off when they are sick or dealing with an emergency.
“Residency shouldn't raise expectations for your participation that leads you to make the wrong decision about your own well-being,” said John Andrews, MD, the AMA’s vice president for medical education and professional development.
Dr. Andrews noted, however, that residency training programs must meet their service demands. When residents and fellows are called away from rotations that are regular parts of their curriculum to work backup shifts, there can be a tension between competing interests.
“There’s a long and ongoing debate about the balance between what we call service and education,” he said, adding that there is value in a culture in which physicians prioritize—to an extent that is reasonable—the collective needs of patients and colleagues. At the same time, unrealistic expectations that a resident will never get sick or unexpectedly need a day off are deservedly becoming anachronisms.
“Around the culture of a residency program, there has to be some give in the system to accommodate personal circumstances,” Dr. Andrews said.
Explore this topic further with the AMA STEPS Forward toolkit, “Resident and Fellow Well-Being: Optimize Well-Being at Work for Physician Learners."
