Ob-Gyn Chair Thinks ‘Outside the Box’
Saying Good-bye to ‘On Call’ Brings Educational & Quality of Life Improvements
Dr. Tina Mason, chairman of the Department of Ob-Gyn at Brookdale University Hospital and Medical Center in Brooklyn, NY would be the first to admit that she left no stone unturned in her quest to bring her program into compliance with New York State resident work hour limits.
“We tried every traditional permutation we could think of – we tried 1 in 3, we tried short call and long call and we tried night float, and every time we came up with a schedule we had a problem with the 80 hours. Then, I woke up one morning and – you know how they say ‘sleep on it?’ Well, it came to me – ‘why not try this!”
“This,” was a decisive move away from any call whatsoever. Instead, Dr. Mason devised a day and night shift schedule for the department’s 16 residents that has brought the program under 80 hours, reduced almost all consecutive hours worked to a maximum of 14 hours, guaranteed one day off in seven and 10 hours off between shifts – all while dramatically improving resident education and resident quality of life. Sound impossible? Read on.
While Dr. Mason knew that this shift model was the answer to her problems, she also knew it wasn’t going to be a simple matter of printing up a new schedule. “I knew that if we did this, then there would need to be a paradigm shift in the whole department. I needed to talk to the OR and to the attendings, to nursing and the clinic staff – to make them all understand that this change would be to everyone’s benefit.
“For example,” she explained, “clinic used to start at 9 AM, but really it didn’t start until 9:15 or 9:30 because clinic staff didn’t arrive until 9 AM. Now we have conference every morning from 8 AM to 9:30 and when the residents get to clinic to start at 9:30, patients are all ready to be seen. Clinic still ends at the same time – and we still see the same number of patients.”
Asked what, to her mind, was best about the shift schedule, Dr. Mason replied that there were two big advantages. First: the daily educational conferences, which all residents attend, unless they are in the middle of a delivery or operative procedure. “Short protected time five days a week is much more useful than a longer period once a week, when residents fall asleep or just come and go,” says Dr. Mason. “It’s easier to get speakers too.”
The second advantage is that the residents are happy. “Now, they can truly have a life. They can say, “Mommy will be home at 7 PM,” and mean it. They can see a movie or do some reading. Ironically,” she reports, “the residents fought us tooth and nail when we first proposed it, but now that they’ve lived with it, they are happy and tell all the intern applicants. We’ve gotten calls from Ob-Gyn departments all over asking us for the schedule.”
Since the term ‘shift’ or ‘shift work’ is often seen as a dirty word in medicine, CIR News asked Dr. Mason how she overcame that bias. “We older attendings, who trained when it was routine to work 120 hours a week, we have to change our thinking. All of medicine has to change. My kids would say, ‘that’s old school.’ There’s such a thing as physical exhaustion – when you can’t give any more. After a certain amount of time you have to go home! It’s not in the best interest of our patients to have sleepy physicians.”
Brookdale Ob-Gyn Schedule Solves Hours & Educational Problems
As of July 2004, all Ob-Gyn rotations at Brookdale went on a shift schedule that allows for one day off in seven, never goes over 80 hours per week, reduces almost all consecutive hours worked to a maximum of 14 and guarantees 10 hours off between shifts. Here’s a summary of the schedule.
Day Shift = 6:30 AM – 8 PM, five days per week, Monday – Friday (Maximum hours worked 67.5).
Night Shift = 7:30 PM - 9:30 AM, five nights per week, Sunday – Thursday (Maximum hours worked 70). Residents do three non-consecutive months of night shift each year. On this shift, every weekend is free from Friday at 8 AM to Sunday at 7:30 PM.
Weekends = Covered by the Day Shift teams — Friday 7:30 PM -8 AM Saturday. Saturdays are split into 2 twelve-hour shifts. Sundays 7:30 AM - 8 PM (Maximum hours worked 79.5). Some residents may be scheduled for a Friday night shift of 24 hours, but that is the only scheduled shift that is longer than 14 hours and their total weekly hours are still under 80.
Educational Conference: 8 - 9:30 AM, Monday – Friday. This is protected time and all residents are usually able to attend.
OR and Ambulatory Clinics begin at 9:30 AM. Attendings and midwives cover Labor & Delivery so that residents are able to attend conference (unless they are in the middle of a delivery).
Residents Initially Resist, but then Jump on Board
What’s Best? No Surprises
“Yes, it’s true,” says Dr. Kelley Halstead, a PGY 4 Ob-Gyn resident and CIR member at Brookdale University Hospital and Medical Center, “at first we weren’t happy about the change.” Dr. Halstead, who had worked the first two years of her residency under the old call system, explained:
“We said 8 PM every night – that’s late! But then we realized the advantages. Most important – there are no surprises. Worst case scenario, you’re there from 6:30 AM to 8 PM and then you can definitely leave, baring an extreme emergency. There’s no new admission that you suddenly have to take. Under the old on-call system, we were often here that late anyway [on a non-call day]. And with this schedule, sometimes you can even leave early, say at 5:00 PM, if the service is quiet.”
As for resident education, “It’s great to have educational time built in to every day – no getting called away,” observes Dr. Halstead. “It’s a set thing each day, resident lecture or M&M or faculty lecture. And having it one and a half hours instead of just one hour is good too. It builds in extra time for questions and answers after a talk or to discuss a problem that’s come up.”
When asked if she thought of shifts in medicine as a negative, Dr. Halstead said, no. “Shifts? I don’t think of it that way. I think of continuity of care and it’s better with this system. We have the same team on days signing off to the same team on nights and everybody knows the patients.”
“Residency is hellish,” concludes Dr. Halstead, “and Ob and Surgery are more hellish than most because of the uncertainty – you never know what’s coming in the door. But this schedule is set. You can plan your life.”