Duration of shift in FM/IM

[Fortress]

I know that at McGill shifts do not exceed 12 hours in both FM and IM. However, I know that in Ontario there are 24 hour shifts, both for FM and IM. I would appreciate it if people can share their experience about whether other provinces have 24 hour shifts for FM/IM as well, as this is an important factor for me.

[JohnGrisham]

If you are trying to compare FM and IM residencies, for the types of shifts..you're thinking about it from an odd approach.

Generally FM is only 2 years, where IM is minimum 4 years, but more commonly 5+ depending on what supspec you do. So by nature of the much shorter duration, you're "Exposure" to call and 24hr call in particular is much less.

I can't think of any residency that will not have 24/26hr shifts in the R1 year when you are "off service" on rotations such as IM CTU/MCU, ICU, Surgery, Obstetrics etc etc- that said, there are some FM programs across the country that are minimizing 24hr call for off-service rotations, but still will generally have it for Obstetrics(because babies come at all times). 

What is your reason for asking the question, in order to avoid 24hr shifts? If thats the case, you will want to stick with FM. 

There is no way there is any program in the country that doesn't have 24hr shifts for IM. It is commonplace, and often intense call frequency in the first 2 years in particular of the IM programs.   Unless somehow McGill IM went to a complete overhaul night-float system...but I can't imagine thats the case.

 

[ellorie]

As far as I know, Quebec is the only province that has formally capped the duration of shifts (at 16 hours, I think) for all residents.

The difficulty with your question in the rest of Canada where there isn't that kind of limit is that most residents spend a substantial amount of time off-service (especially FM), so even if the home service doesn't have 24 hour call (which may be true for FM but I imagine would be rare for IM outside of Quebec), off-service rotations likely will.

In my program (psychiatry) we did have some residents who had accommodations such that they didn't do 24 hour call.  So if you have a medical reason, sometimes there are ways to work with that (I can imagine this might be challenging to arrange in GIM though), but if you just don't want to ever do 24 hour call because you don't want to, outside of Quebec your options are going to be pretty limited.  Maybe some of the smaller FM programs arrange things like this?  I think at least one of the UBC non-Vancouver programs only has 24 hour call for OB and not for other rotations.  Someone in FM might know more clearly.

[gogogo]

It seems like there's a lot of variation in FM programs. Where do you get this info?

[ellorie]

2 minutes ago, gogogo said:

It seems like there's a lot of variation in FM programs. Where do you get this info?

Check their program websites or program descriptions on the CaRMS website, ask residents, find out at interviews.

[JohnGrisham]

21 minutes ago, ellorie said:

As far as I know, Quebec is the only province that has formally capped the duration of shifts (at 16 hours, I think) for all residents.

The difficulty with your question in the rest of Canada where there isn't that kind of limit is that most residents spend a substantial amount of time off-service (especially FM), so even if the home service doesn't have 24 hour call (which may be true for FM but I imagine would be rare for IM outside of Quebec), off-service rotations likely will.

In my program (psychiatry) we did have some residents who had accommodations such that they didn't do 24 hour call.  So if you have a medical reason, sometimes there are ways to work with that (I can imagine this might be challenging to arrange in GIM though), but if you just don't want to ever do 24 hour call because you don't want to, outside of Quebec your options are going to be pretty limited.  Maybe some of the smaller FM programs arrange things like this?  I think at least one of the UBC non-Vancouver programs only has 24 hour call for OB and not for other rotations.  Someone in FM might know more clearly.

Wow, Quebec was able to pull that off? That's impressive..would love to hear IM residents thoughts on that. Something to be said im sure about skills building at 2am as the Senior IM resident triaging consults/admits from emerg/wards.

I know of a few FM programs(mostly in ON) who have only overnight call for OB. 

I also know of FM programs that have 1:4 call overnight in hospital throughout the 2 year residency(pumping out very competent in-patient FM docs). 

Lots of variation - need to spend alot of time for whichever specialty residency you're going for to get the lay of the land during carms interviews/ even beforehand from researching/asking.

[ellorie]

Yeah I'm also interested to know how it's working for them - when I was a resident, my program was always debating back and forth about going to a night float model instead of 24 hour call, people would write proposals etc, but when it came to a vote, there was never enough momentum behind it.

I voted against it.  I don't like change and also honestly I thought I'd hate a block of consistent nights way more than intermittent call (especially since our call frequency was relatively low - I might have felt differently if we did 1:4).

[blah1234]

As much as I am in favour of making things more reasonable for residents the problem is that many staff still do long stretches of call coverage. There's utility in building habits and skills to perform when exhausted and overnight. I don't count on this trend changing in the staff world so I do think there is value to train in a way that is reflective of the majority of your career.

[medigeek]

It's 2 years. Go somewhere more rigorous to become as competent as you can. 

[ellorie]

Some people actually do have medical conditions that make 24 hour call a problem. 
 

For me, I was really scared I wouldn’t be able to handle the sleep deprivation just because I had never done it before (always valued and prioritized sleep, never pulled all nighters), but I threw myself in, and was definitely able to handle it and did learn a lot. I surprised myself with how much I can do and that was a nice experience in some ways. I do think at least in psychiatry there are other ways to learn just as much but there’s something to be said for call for sure. 

But for some people with particular neurological or psychiatric issues it’s just not medically safe. And since many doctors don’t need to do call as part of their eventual roles, there’s no reason to exclude people from medicine entirely just because they’re not able to work objectively insane hours. 

[medigeek]

3 hours ago, ellorie said:

Some people actually do have medical conditions that make 24 hour call a problem. 
 

For me, I was really scared I wouldn’t be able to handle the sleep deprivation just because I had never done it before (always valued and prioritized sleep, never pulled all nighters), but I threw myself in, and was definitely able to handle it and did learn a lot. I surprised myself with how much I can do and that was a nice experience in some ways. I do think at least in psychiatry there are other ways to learn just as much but there’s something to be said for call for sure. 

But for some people with particular neurological or psychiatric issues it’s just not medically safe. And since many doctors don’t need to do call as part of their eventual roles, there’s no reason to exclude people from medicine entirely just because they’re not able to work objectively insane hours. 

But you know these are exceptional circumstances. 

I just meant that in general, going somewhere more rigorous for family medicine specifically is a better idea. Even if you just want to do bread and butter outpatient only. 

[ellorie]

I'm not in FM so wouldn't care to comment  But I do think (in general, not you specifically) there is a lot of judgment towards people who can't do call.

[Dr. JJ]

21 hours ago, Fortress said:

I know that at McGill shifts do not exceed 12 hours in both FM and IM. However, I know that in Ontario there are 24 hour shifts, both for FM and IM. I would appreciate it if people can share their experience about whether other provinces have 24 hour shifts for FM/IM as well, as this is an important factor for me.

Both IM and FM shifts in both Alberta and BC can effectively be up to 26/27* hours, in both rural and urban settings. My recommendation is definitely to try and ask residents themselves, as the actual program admins/coordinators may gloss a little bit over how often this is the case.

Essentially the "base" time commitment remains 24 hours, but there may be an "Expectation" that you get there up to an hour early, and you may be required to stay up to a couple of hours of overlap for handover the next morning.

-JJ

[gogogo]

On 1/3/2021 at 7:25 PM, JohnGrisham said:

Wow, Quebec was able to pull that off? That's impressive..would love to hear IM residents thoughts on that. Something to be said im sure about skills building at 2am as the Senior IM resident triaging consults/admits from emerg/wards.

I know of a few FM programs(mostly in ON) who have only overnight call for OB. 

I also know of FM programs that have 1:4 call overnight in hospital throughout the 2 year residency(pumping out very competent in-patient FM docs). 

Lots of variation - need to spend alot of time for whichever specialty residency you're going for to get the lay of the land during carms interviews/ even beforehand from researching/asking.

 

5 hours ago, medigeek said:

But you know these are exceptional circumstances. 

I just meant that in general, going somewhere more rigorous for family medicine specifically is a better idea. Even if you just want to do bread and butter outpatient only. 

I was going to ask whether the heavier programs (e.g., 1:4 call) are really necessary if the plan is to only do regular family clinic. I guess it's still a good idea. 

I will look into the program descriptions, etc. but from your experience/anecdotes, which are the more rigorous programs in Ontario that train highly competent FM?

[JohnGrisham]

35 minutes ago, gogogo said:

 

I was going to ask whether the heavier programs (e.g., 1:4 call) are really necessary if the plan is to only do regular family clinic. I guess it's still a good idea. 

I will look into the program descriptions, etc. but from your experience/anecdotes, which are the more rigorous programs in Ontario that train highly competent FM?

Definitely necessary to make competent Hospitalists and in-patient FM docs, as well for rural areas where you need more breadth in inpatient medicine / rural emerg coverage.

But for those who know for sure they don't want to do anything inpatient, and will only do outpatient FM - then yes for sure, not necessary on a practical level (but can't hurt either to feel more confident).

All FM programs will train competent FM docs - but with 2 years, you need to be motivated to get out of your training program what you want. 2 years is not a lot of time to expect to be spoonfed everything you need to know for the practice style that only you would know you want.   So assess what setting you want to work in, if theres any areas of additional focus you're hoping for etc, and approach accordingly. 

[JohnGrisham]

On 1/3/2021 at 4:45 PM, ellorie said:

Yeah I'm also interested to know how it's working for them - when I was a resident, my program was always debating back and forth about going to a night float model instead of 24 hour call, people would write proposals etc, but when it came to a vote, there was never enough momentum behind it.

I voted against it.  I don't like change and also honestly I thought I'd hate a block of consistent nights way more than intermittent call (especially since our call frequency was relatively low - I might have felt differently if we did 1:4).

The few places ive seen night float(somewhat common in peds in our area), the residents i know gave it mixed reviews - alot of them didn't like it, and preferred 26hr call with post-call.

[medigeek]

2 hours ago, gogogo said:

 

I was going to ask whether the heavier programs (e.g., 1:4 call) are really necessary if the plan is to only do regular family clinic. I guess it's still a good idea. 

I will look into the program descriptions, etc. but from your experience/anecdotes, which are the more rigorous programs in Ontario that train highly competent FM?

 

2 hours ago, JohnGrisham said:

Definitely necessary to make competent Hospitalists and in-patient FM docs, as well for rural areas where you need more breadth in inpatient medicine / rural emerg coverage.

But for those who know for sure they don't want to do anything inpatient, and will only do outpatient FM - then yes for sure, not necessary on a practical level (but can't hurt either to feel more confident).

All FM programs will train competent FM docs - but with 2 years, you need to be motivated to get out of your training program what you want. 2 years is not a lot of time to expect to be spoonfed everything you need to know for the practice style that only you would know you want.   So assess what setting you want to work in, if theres any areas of additional focus you're hoping for etc, and approach accordingly. 

You learn a lot more medicine in-depth while inpatient and it is definitely heavily applicable to clinic. You also get much better context to evaluate a clinic patient's condition and how bad it can become. It also broads your differential, among other things. So I would say heavy inpatient is of major benefit to docs who want to do clinic only. 

Also, people change their minds. Especially in FM. You may like X in med school then like Y in residency. Better to be somewhere that trains you better. And honestly programs that are heavily outpatient-only oriented tend to have weaker preceptors and a much simpler patient population. 

[Snowmen]

On 1/3/2021 at 6:49 PM, JohnGrisham said:

There is no way there is any program in the country that doesn't have 24hr shifts for IM.

Quebec doesn't. Call is 17h to 22h. You have different residents covering call from 20h to 8h (those usually are working nights 4 or 5 days/week for a week or a month at a time). The overlap between 20h and 22h is for the evening residents to finish the consults that were received before 20h but weren't completed. The night residents would be responsible for the consults received after 20h. Typically, the consults that can't be completed before 20h are turfed to the night residents so call is basically 17h to 20h-20h30.

[MSWschnoodle]

If you have a medical/psychiatric reason you cannot work overnight call then you might be able to get accommodations through PGME. From what I've heard different PGMEs can vary pretty wildly in how willing they are to accommodate these sorts of things so that would be something to discretely investigate in any programs you are very interested in should it apply to you. 

If your goal is to avoid prolonged call hours... In Ontario make sure you ask about whether or not the program has Post-Call Rounding and ask about the team start time. Because while they will tell you the overnight call is 24/26 hours as per PARO... if the team has a start time of 7AM and have post-call rounding the reality is your call will be much longer. During my IM rotation I wound up stuck in the hospital until noon or 1PM multiple times due to post-call rounding (which made my shift 30 hours, rather than the 26 allowed by PARO). It was ridiculously dangerous and more than once I was worried I was going to get in an accident driving home. 

I found post-call rounding to have a negative enough impact on my mental health and wellbeing that I would never rank a program that required it and I will never require any residents I work with to do it when I'm staff. In psychiatry we do 26 hour call and there have been a couple of times where I've had to stay an hour or two late (and once where I chose to stay very late to help due to an unprecedented string of really unlucky events and was profusely thanked by staff for doing so) but it's not a regular thing and we do not do post-call rounding. 

I don't know if any other provinces or disciplines do post-call rounding. I never encountered it in clerkship. I'm sure lots of surgical residents are currently laughing at me because they skip their post-call days all the time to stay and work the next day... but it's just another question to add to your CaRMs questions if you are looking for a program with shorter call hours :-)