Some residency programs allow their physicians to take call at home. Others have their residents take call in house, staying overnight in the hospital. There is some concern that working in the hospital puts an extra burden on the residents that may add to burnout or mistakes from loss of sleep. Others worry that being at home may result in missing surgical cases they would participate in if they were already at the hospital.
“The concern with call is that it is disruptive to sleep,” said Stacey Gray, MD, vice chair of education for the otolaryngology department at Harvard Medical School. “If residents are on call and extremely busy, they might not get enough sleep and rest to be truly productive the following day.”
Call Can Disrupt Sleep
Research tends to support those concerns. Andrew M. Nida, MD, and colleagues from the University of Mississippi School of Medicine in Jackson undertook a web-based survey of otolaryngology residents at their institutions. Results revealed a mean Epworth Sleep Scale (ESS) score of 9.9 ± 5.1, indicating that a significant number of residents were excessively sleepy (Am J Otolaryngol. 2016;37:210-216).
But does taking call from home make any difference? The Mississippi group indicates that the answer may be yes. They noted that residents taking in-hospital call had statistically significant fewer hours of sleep when compared with those taking call at home. And the amount of sleep residents get can directly impact the safety of these physicians, according to this survey. Residents who reported no needle stick injuries and no near-miss motor vehicle accidents also had more sleep as measured by significantly lower mean ESS scores.
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While the place of call is important, another noteworthy consideration is the volume of calls and their timing. Research reported in the Journal of Graduate Medical Education showed that urology residents slept an average of 408 minutes per night, as measured by a Fitbit device, when off call. On in-home call, the average fell to 368 minutes per night for those who were not fatigued the next day and 181 per night when on call and self-reporting fatigue. Each page was associated with 4.71 minutes less sleep (J Grad Med Educ. 2018;10:591-595).
At-Home Call Different?
The rise of in-home call can be partly attributed to resident work-time requirements from the Accreditation Council for Graduate Medical Education (ACGME). Restricting the number of hours a resident can work is related to concerns about sleep deprivation resulting in medical mistakes. Because of this requirement, if a program uses in-hospital call, the resident has to be given the following day off.
The ACGME doesn’t require residents taking call from home to take off work the next day. Dr. Gray thinks that requiring a post-call day off is another driver of at-home vs.in-hospital call. Their program was concerned about a training impact because the residents missed educational opportunities while on their mandated time off.
Variables in Residency Call Success
Making coverage fit in with the workflow of the specific program is an important variable in success.
“The type of call that works best depends on the program,” Dr. Gray said. “How many residents share the call schedule, how many services are covered, and how busy call really is, are all important considerations. Busy tertiary hospitals with [a] high volume of operative patients and a large inpatient service are potentially different from a smaller hospital where the service covered is smaller.”
Dr. Gray explained that at Harvard, residents cover several different hospitals, including an otolaryngology subspecialty hospital with an otolaryngology-specific emergency room. “Because of this, our residents are needed quite frequently in the hospital, and call is generally busy, so they need to be immediately available in the hospital.”
Type and Locations of Hospitals Covered
The needs of general tertiary hospitals or hospitals with geographic concentration may accommodate an in-home model. Consolidation may change this situation going forward, so programs should review their systems every few years. Busy hospitals may want to put a resident in each. In situations where the resident fields only a call or two a night, one resident may be able to cover more than one hospital from home.
“I think as we go further into academic hospitals buying other providers in their community, there are going to be more programs that cover more than one hospital and a greater geographic region,” said Cristina Cabrera-Muffly, MD, associate residency program director in the department of otolaryngology-head and neck surgery at the University of Colorado Anschutz Medical Campus. “During my residency, we covered five hospitals and home call was a requirement. Another program had only one hospital they had to staff, so in-hospital call was a good fit.”
As a resident, my goal is to see as many patients and cases as I can. Sometimes there are no calls overnight and other times very interesting ones come through. I don’t miss good operative cases having to sit out a post-call day. —Hannah Kavookjian, MD
Number of Residents
The number of available residents should also be taken into account. The more bodies are available, the less each individual has to take call.
“One of the concerns about residents going home post call is missing the clinical or operative experience they would have been exposed to that day,” Dr. Gray said. “If you have a program with a small number of residents, it makes the call burden higher, and with each post call day, the residents miss a large part of the clinical experience of that rotation.”
Residents Like the Call Program They Are Using
Hannah Kavookjian, MD, is a PGY4 resident at the University of Kansas in Kansas City, which utilizes at-home call.
“I don’t think I have missed anything from an educational standpoint [from at-home call],” she said. “As a resident, my goal is to see as many patients and cases as I can. Sometimes there are no calls overnight and other times very interesting ones come through. I don’t miss good operative cases having to sit out a post-call day.”
Dr. Cabrera-Muffly said that there was some concern that at-home call might mean residents miss out on educational opportunities as others cover emergency interventions. One example is transfer of emergency airway management to trauma or other services that are immediately available. But she says her experience suggests this is not much of an issue because the residents have been able to gain experiences over-night while still being able to take part in educational activities during the day.
David Lee, MD,’s experience with call as chief resident at the University of Cincinnati has been a positive. The Cincinnati program has a month of weekday night call in the hospital starting at 5:30 pm. For those four to five weeks, the resident is off during the day.
“We do one month of night float a year for our second, third, and fourth years, so in a three-year span, we spend three months on nights,” he said. “I think people generally feel that their operative skills may be a little ‘rusty’ coming off of nights. But we do get three to four operative cases a week on call.”
In addition, the experience is very challenging, with a heavy workload. Dr. Lee said he believes residents come out of the call rotation more confident in their decision making.
Lessen Burnout?
The ACGME guidelines were also put in place to lessen burnout and address quality of life issues. Some suggest that in-home call is better because residents can go out and do things as long as they realize they may be called in. Others note that in-hospital call means having the next day to attend to personal business, and fewer days on call.
“Home call definitely gives me more flexibility, as I can go home for a bit and structure my evenings to the best of my ability, granted that some emergent problems can arise,” Dr. Kavookjian said. “Even then, you can go in, see a few patients at once, and go home again.”
Dr. Lee finds it is easy to plan around the night float month-long call, especially since it happens only once a year. He knows when he will be responsible for nighttime coverage a few months out, which can help him schedule family outings and activities. In addition, during the month, he knows he will have the entire weekend off.
Pros and Cons for Both
The big picture is that there are pros and cons for each of the systems. The major concerns are educating the resident and caring for patients.
“Call is a necessary evil in order to really learn, and many of my important learning experiences took place then,” Dr. Kavookjian said. “Ultimately it doesn’t matter if I was in house or at home. When you are taking call, you are the first person to care for these patients, and you are getting an opportunity to take ownership of your work. To me, this is the biggest takeaway from call.”
Kurt Ullman is a freelance medical writer based in Indiana.