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Overnight call and sleep deprivation


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I have a medical condition that seriously requires consistent and adequate sleep. My treating physician is advising me to submit an accommodation request through my school's disability office to have me exempted from overnight call, with the expectation that this time will be made up in other ways. I'm worried about what my peers and preceptors will think. I'm wondering if anybody has had to do this before? How did you approach the topic with your preceptors? Thanks!

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9 minutes ago, mew said:

I have a medical condition that seriously requires consistent and adequate sleep. My treating physician is advising me to submit an accommodation request through my school's disability office to have me exempted from overnight call, with the expectation that this time will be made up in other ways. I'm worried about what my peers and preceptors will think. I'm wondering if anybody has had to do this before? How did you approach the topic with your preceptors? Thanks!

Do what is best for you and your health.  

That said, I don't know how that will go during residency? I would think you would need to pretty much focus on Psychiatry, Pathology or Family Medicine as residency options, as they would be more likely to be flexible about it..  ?

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2 minutes ago, JohnGrisham said:

Do what is best for you and your health.  

That said, I don't know how that will go during residency? I would think you would need to pretty much focus on Psychiatry, Pathology or Family Medicine as residency options, as they would be more likely to be flexible about it..  ?

Yeah, I ruled out the call-intensive specialties like IM and all of surgery a while back for this reason

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13 minutes ago, mew said:

Yeah, I ruled out the call-intensive specialties like IM and all of surgery a while back for this reason

Fortunately, there is still lot of good medicine to be done within Family medicine/Psych/Pathology.    I would strongly look at the residency program structures for how much off-service rotations they have, and how strict they are about requirements(in your case call) if you have a medical condition etc.   Some Family medicine and psychiatry programs don't even have general surgery rotations these days in R1, so that would be a big help.

 

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I know that my program has supported this for residents in the past - we have some call sites that have an add-on resident who does call until 11 pm, and some sites that allow splitting of weekend shifts into day and night shifts, so some residents who are unable to work overnight have made up the points in that way.  Others have been required to do an extra block of emergency psychiatry out of their elective time to make up for the missed learning experience.  I am not aware of the details but this is what I have heard.  I am also not sure how this works for R1s when they are off service - when I was R1 we did do two blocks of GIM CTU with call, which was probably the heaviest and most resident dependent call schedule I was part of.

Your peers don't necessarily have to know.  Some will inevitably find out - some people may notice that you are not on the call schedule and ask awkward questions, for example - but it isn't exactly publicised and you can think in advance of what sort of vague answer you would feel comfortable giving.  Or detailed, I guess, but it's not really anybody's business.  The chief residents usually know a bit more.  There's a little bit of grumbling in my program about call accommodations, but it isn't clear to most residents who has them, so it's more general grumbling than anything.  For the most part people don't get specifically targeted.  So you can expect a bit of general grumbling that you have to just brush off, but in terms of frank retaliation, that doesn't seem to happen in my program.

Your preceptors also don't necessarily have to know, since the call schedule (at least in my program) tends to be a bit separate from the core rotation, though I could imagine this would be different depending on the program.

I have some accommodations and when people (preceptors or peers or whoever) have needed to know, I have typically just said "I have accommodations" and that's the end of the conversation usually.  Most people are reasonable enough not to ask further, whatever they might privately wonder or think.  For one thing, pregnant residents routinely come off call at a certain GA and some come off earlier if it's a complicated pregnancy.  There are lots of reasons someone might be off call.

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just FYI some pathology programs do require residents to do overnight call (likely home call). Although it's uncommon to get called in, it does happen for urgent cases like transplant. Also overnight you could get pages for which you have to call back, but doesn't have to physically go into the hospital. So there is a risk that your sleep will be disrupted more than once when on pathology call, hence you should clarify this with each program. Keep in mind pathology programs are small and they need residents to cover overnight issues, so it's unlikely you could go through the entire residency in pathology and expect other residents to cover for you (assuming call is required by your program).

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Glad someone brought this topic up. I am in the same boat as OP. Still unsure how to approach CaRMS. I am currently interested in IM/FM (leaning more towards internal). I know internal is more intensive than FM, but perhaps I could ask for accommodation? Even if I were to pursue FM, I would still have to do overnight call which would still be a problem.

I am also aware that different programs structure call differently. Perhaps there are sites that are more accommodating or that are less call-intensive than others? Not sure if that’s true.

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23 minutes ago, WLG said:

Glad someone brought this topic up. I am in the same boat as OP. Still unsure how to approach CaRMS. I am currently interested in IM/FM (leaning more towards internal). I know internal is more intensive than FM, but perhaps I could ask for accommodation? Even if I were to pursue FM, I would still have to do overnight call which would still be a problem.

I am also aware that different programs structure call differently. Perhaps there are sites that are more accommodating or that are less call-intensive than others? Not sure if that’s true.

Different sites can have very different call expectations, especially family Med. I have been discovering this in my research for CARMS, although sometimes it’s hard to tell from the program resources alone. I’ve learned a lot from talking to residents. Abbotsford family medicine in BC, for example, has no overnight call except obstetrics - you’re always off by 11 at the latest, the trade off being you have to work the next day if it’s a weekday. 

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I’m an FM resident in a program that has overnight call in only one rotation (OB/Gyn.) We were required to do four night shifts per emerg block, but I would imagine - not speaking for my program here but just my own impression of how wonderful they tend to be - that sort of thing is likely to be able to be accommodated. We do have home call when on our core family rotations but I’ve literally never been called. And we also do call until 11pm on other rotations, but because there’s no post-call day it ends up being as many hours as if you had done overnight call, it just allows for a solid amount of sleep in between. 
 

I feel like most non-rural FM programs can likely be modified in such a way as to accommodate your needs. I have an autoimmune disease and deal with pretty significant fatigue as a result. Hasn’t been much of an issue. 

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On 6/9/2020 at 2:44 AM, bearded frog said:

I think you could get by in a FM residency with accommodations, really not sure how an IM residency would go since call is an important part of it, no idea what the policies are.

Would really love to know whether an accommodation would be possible in IM or not. The problem is the only way to know is to ask, which means I have to disclose my diagnosis, which can then exclude me from the program. Frustrating.

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Yeah that is a hard case - one thing to consider might be contacting Disability Services at your home medical school because they may be able to tell you in broad terms what has been possible for other residents they have worked with.  They usually have the most experience advocating for accommodations.

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Responding to a couple different posters on this thread, but the comments apply broadly.

5 hours ago, WLG said:

Would really love to know whether an accommodation would be possible in IM or not. The problem is the only way to know is to ask, which means I have to disclose my diagnosis, which can then exclude me from the program. Frustrating.

I do not see why you would ever have to disclose your diagnosis to anyone (unless you want to). I'm fairly confident your doctor could write a letter for detailing the accommodations required to support your health without specifically saying the diagnosis.

 

On 6/3/2020 at 11:04 AM, mew said:

I have a medical condition that seriously requires consistent and adequate sleep. My treating physician is advising me to submit an accommodation request through my school's disability office to have me exempted from overnight call, with the expectation that this time will be made up in other ways. I'm worried about what my peers and preceptors will think. I'm wondering if anybody has had to do this before? How did you approach the topic with your preceptors? Thanks!

I'm worried about what my peers and preceptors will think. Who cares what they think. I know that's easy for me to say, but if people think less of you for prioritizing your own well-being then these aren't the people you want to be working with as a future physician anyways.  Unfortunately healthcare professionals often fail to extend the compassion they have for their patients to their colleagues. Just my 2 cents, but the 'old school' of medicine with infallible, near god-status physicians is falling away, we're all human here. You don't want to end up matching, training, or practicing somewhere with physicians that don't prioritize well-being. Ironic that we're a profession of healers but struggle to support our own colleagues eh?

I'm wondering if anybody has had to do this before? I have multiple friends that have received accommodations throughout their medical education. I would highly recommend speaking with your school's OSA (Office of Student Affairs) for guidance through the process. You won't be the first student to request this, they will be able to provide guidance. If you prefer to maintain a distance from your college of medicine, another option is to contact your provincial medical association's physician health program.

How did you approach the topic with your preceptors? They don't have a right to know what your accommodations are. For the most part, staff don't know students' schedules, so you can just tell them what your shift is and hit the road when you're done.

A Couple other thoughts:

This thread seemed to take a dive towards residency really quick. My advice would be focus on one thing at a time, clerkship first then residency. It is definitely a good idea to think about career paths that promote your well-being. If you're passionate about IM but hesitant about the residency, you should consider a family med - hospitalist rotation in clerkship. It is honestly fantastic, you essentially function as a GIM but with all the lifestyle freedom being a fam doc provides (and only a 2 year residency). It compensates extremely well to boot.

$$$$$$ - Having a disability can qualify individuals for additional financial support from their university, increase the amount of grants you receive on student loans, have beneficial tax implications with the CRA, and even get you an extra $750/mo on CESB. These programs exist for a reason, utilize them!

At the end of the day it's your life and your health. Don't worry about what your colleagues think, do what is best for you.

 

 

 

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It's easy to say "who cares what they think?" but in practice it can become a really big issue.  In residency you don't actually have the option of not working with people who will judge you and think less of you.  Preceptors who interpret your behaviour as "lazy" or "not hard working" have the potential to come after you on your evaluations or otherwise treat you poorly.  Similarly, it can cause friction with other residents - in my experience people do scrutinize the call schedule and comment if someone is doing more or less call than other people, either to their face or behind their back.  At times people will bring it up and ask for an explanation, or you will have to let people know.  Something as simple as a preceptor asking you "when will you be post call in this block?" requires you to disclose that you are not on call, and you need to have some sort of language for conveying that to people, even if it's as simple as "I am not taking call this block."  Some people will be nosy and ask inappropriate questions.  It's impossible to completely avoid the questions and conversations, both with co-residents and with preceptors, or at least I have found it to be so, and my call accommodations are pretty minimal.

The issue around disclosure is that in order to ask questions about what accommodations are possible, you have to flag for a potential program that you may need them - and that can result in judgment and stigma that can impact your ability to match.  Again, it's easy to say "then those aren't people you want to work with," but at the same time, you don't want to finish four years of medical school and not match, either, especially with the match as tight as it is.  And stigma is unfortunately so widespread and insidious that in some specialties, it isn't just about throwing out one or two programs.

It is really true and valid that if you are a person with a disability, you need to find subtle ways of figuring out which programs will accommodate you, and comfortable/safe ways of responding to the questions, comments, and challenges that will happen.  Even if you have an invisible disability, it will come up.  You are stigmatized sometimes if you disclose and stigmatized sometimes if you don't disclose and it's a constant balancing act of trying to figure out what is going to serve you best.  But there are no easy answers. 

The best people to speak to are student affairs (because they will be able to speak about what other students have gotten in the past) and possibly the physician health program depending on the nature of your disability (they mainly handle substance and psychiatric issues).  If you have trusted resident friends, you can also speak with them, but make sure they are people you trust to be discreet.

In an ideal world, things would be a lot different.  But in my experience, you have to be really pragmatic - the reality of having a disability in medicine is that it's hard, people will find out no matter how much everyone tells you it's completely confidential, and you have to be smart and thoughtful in order to protect yourself.  I would say I have been lucky but I have had some difficult experiences that taught me hard lessons about how careful you have to be about these things.

I don't mean to be bleak - I think the culture of medicine is changing and I have experienced a lot of support from co-residents and preceptors - the good experiences have outweighed the bad - but the bad experiences have been very bad.  And my program is not toxic or malignant on the whole, and psychiatry as a specialty values resident well-being more than others.

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On 6/8/2020 at 11:08 PM, WLG said:

Glad someone brought this topic up. I am in the same boat as OP. Still unsure how to approach CaRMS. I am currently interested in IM/FM (leaning more towards internal). I know internal is more intensive than FM, but perhaps I could ask for accommodation? Even if I were to pursue FM, I would still have to do overnight call which would still be a problem.

I am also aware that different programs structure call differently. Perhaps there are sites that are more accommodating or that are less call-intensive than others? Not sure if that’s true.

This is my un-authoritative opinion, but I would assume IM is probably off the table. I just can't imagine most CTU/MTUs giving someone accommodations to not do over-night call, especially when a goal is to get juniors becoming triage seniors etc.. Especially when you're doing many many blocks of in-patient IM and developing your skills, and the call obligations.  Of course after residency, you can very easily put yourself in a position without call requirments depending on the specialty you choose. But you have to somehow get through residency to get there, and unfortunately it seems like a big uphill battle.

FM is the best bet, and find the least call-intensive program. Many programs do not require surgical rotations anymore, many have only evening call until 11pm.  Much easier to get vacation time in on an off-service rotation that requires call, and then get accommodations as a one-off for a few rotations...then trying to do a program like IM where call is an integral part of the learning experience and hidden curriculum.

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