One issue that comes up a lot during residency is payback. If you get sick or take a leave for some other reason, should you offer to pay back the people who covered you (by covering something for them)?
In theory, I believe the answer is no.
I feel like it always evens out in the end. I didn't "pay back" any of the residents who covered me during maternity leave because that would have been pretty much impossible. But later in my residency, I did tons of coverage for others: people on vacation, doing interviews, and for other people on family leave. At some point in residency, most people do need coverage, and at some point, most people receive coverage. It's the Circle of Coverage.
In practice, things are a little different. I'm going to tell two stories about interns who are not me, but that I worked with closely. There are no secrets in internship. I've changed details to protect their privacy.
The first story is about a categorical medicine intern named Jane. Jane's father was diagnosed with cancer and since she was very close with her dad, she became very emotional and started having trouble focusing. She made some mistakes with patients and broke down crying during a call, and when confronted about it by her program director, she admitted what was going on. Her program director made the decision to give her a week's vacation, starting immediately. Jane was on a wards rotation and had one call left, which was on Thanksgiving. She begged the program director to let her do the call, but he decided she was not safe to work and made her take the vacation to regroup and be with her dad.
When she returned to work, she heard that people were mad at her for not covering her call. She was open about her experience and why she had left, but she still heard that people were angry. When her father was doing better, she asked the chief for the name of the person who had covered her call. It was a transitional intern named Don.
Jane approached Don. She told him she had a month of elective coming up in May, and she wanted to repay the call he had done for her on any weekend he wanted. Don angrily told her that he would be on a surgery month, so she would not be able to cover any calls for him. He made it very clear that he did not appreciate having to cover for her.
Jane later found out that Don had actually been pulled second to cover her call. He had covered for another intern named Mike, who had plans for Thanksgiving. Mike had already paid Don back by doing a call for him. Jane then offered to do a call for Mike, who thanked her and said not to worry about it.
Story #2:
After the death of several of her patients in the ICU, Mary became very disillusioned with medicine and told her program director that she was thinking about quitting. They talked it over and she was given a month of leave to think over her decision. Coverage was difficult with an intern unexpectedly gone, but everyone worked together and they got through it.
Mary ultimately made the decision to stay in her residency program, and she resumed her internship. Later in the year, an intern named Sue had to go to a wedding, and she asked Mary (who was on an elective) if she could cover a call for her.
Mary already had plans for that weekend. She felt wracked with guilt. She finally said to Sue that she couldn't do it.
"You know," Sue said. "We all worked really hard covering for you when you were gone."
Mary held her ground, although the fact that she was gone for a month did make her feel obligated to automatically give in to anyone's requests for coverage.
I am starting medical school in 3 weeks and this is the stuff that makes me want to turn back while I can.
ReplyDeleteIt'd be similar in most jobs, if work needs done someone needs to be there to do it. The main difference is most jobs aren't 24/7 so someone off doesn't mean people having to cover more shifts, just do more work while on their own shifts.
DeleteEnjoy medical school. I've just finished it in the UK, starting work in 2 weeks. Med school goes fast, take advantage while you're still there. Be social as much as possible.
You will find petty people no matter where you go in life. Don't let that stop you from following through on a dream! I just graduated from med school as well and I can honestly say that it will simultaneously be one of the most challenging and rewarding things you do. Work hard but enjoy it as much as you can- Good Luck to you!
DeleteThank you for the encouragement - I've already discovered that medicine is the only career that will fulfill me and that dealing with petty people is a very important life skill no matter where you work. I do hope though that we can be an example for others and change some of the negative aspects of the culture (in med school, residency and beyond) soon!
DeleteI "paid back" my maternity leave calls and major surgery leave calls. Because I started later in cycle du to maternity leave they I was taking more calls the remainder of the year to even out the number of calls. but because another trainee was coming to training later in cycel due to her maternity and I was still finishing my year, I basically took her call for 2 months, making it more absoulute number of calls that I did in my training. And still when I had surgery my colleagues, confronted program director to force my "pay back" (I found out when I returned to work weeks later, my patients who had same surgery as me returned to work months later and probably on light duty protected by FMLa or what not). But all formal protection fails when you work with peers you find in medicine. Yes, work is very hard emotionally and physically, but like you said "circles of coverage". Why not show cortesy to your vulnerable colleague, you never know when you will need one. Yet, I find even smallest accomodations are met with aggressive resistance. In the end I remember and will alway those situations when people helped me when they did not have to help me, and noone knew they did (i.e. they did nto get a credit for it). Like a girl who came to present my poster to major national meeting during her day off, as an intern maybe one or two of her days off per month. It was days after I gave birth. The poster was a winner.
ReplyDeleteI would have to disagree with the premise that you should not "pay back" when someone covers for you. Deciding not to repay coverage because "it all evens out" disrespects the person who covers for you and disrespects the disruption you had on their lives.
ReplyDeleteAs a male in a program with a large number of females, someone was always on maternity leave, it seemed. Our female residents did make up the call they missed, though, and those of us who ended up with increased workloads appreciated the effort to pay back. We had families, too, and my children were old enough to miss me when I was gone for extra nights or weekends.
Perhaps my program was atypical, but we had a very collegial group of residents who were willing to cover for each other and also to repay the coverage.
I would agree that covering someone for a death, illness, or family emergency is a bit different and in most, if not all, of these cases you should cover out of kindness and not worry about being repaid.
Just to not show any sexism, I'll mention that there was a male resident in our program who missed several months due to his wife becoming extremely ill after the birth of their child. I was probably the person who covered for him the most. When he came back, he was completely exhausted from all his family issues (much like women are when they return from maternity leave), and I never would have expected him to pay me back in a million years, even if he could have (I was almost done with residency).
DeleteIn that situation, I was actually happy to cover for him because I remembered how other people covered me. If I had to pay back each and every call I missed to the specific person who covered it, and practically killed myself doing it, I probably would have been annoyed for having to cover for that other resident and never get paid back.
I think the solution isn't to be counting calls and worrying about payback. I think we should be very willing to cover others, and know that when we get sick, the coverage will be there guilt-free. Maybe that system would discourage seriously ill residents from dragging themselves to work.
And if you never ever get sick, never have a family emergency... well, I guess you should just be grateful that your life is good otherwise.
Me me me me me me me me.
ReplyDelete(Not you Fizzy, but people.)
I should clarify: I think people should try to pay each other back as much as possible. However that doesn't mean that any and all requests must be granted right then no matter what.
DeleteThe people you describe in this post sound like a bunch of petty jerks. You don't get to treat the person you're covering for like garbage just because you're pissed off that the residency program director asked you to cover her shift. On the other hand, I kind of feel like Mary should have broken her plans (depending on what they were) to cover Sue's shift. It seems very nice of the program director to allow her to take a month off, and it probably did screw over a bunch of the other residents. Most jobs are NOT that accommodating, and Mary SHOULD feel guilty.
I think Mary probably should have broken her plans too. I remember Sue stressing over the wedding, trying to figure out what to do, and I know she didn't just ask Mary as a first resort. I think if you end up needing a lot of coverage, there IS an obligation to generally pay it forward.
DeleteIt may be the circle of coverage, but someone always gets the short end of the stick. In our case, it is usually my husband. He is the nice guy who will cover call for anyone, but when he needs it for something important it is hard to find. Everyone always has other plans (so do we). I think he has only refused once or twice in the last 6 years.
ReplyDeleteYes, but what about someday when your husband gets appendicitis or something and needs emergency coverage? Will it be there for him?
DeleteUgh. Don't get me started. My husband is the Chief of his department. All his partners know he is the nice guy and they all take advantage of that fact. He is always getting dumped on. I suppose they figure it's fine, because he'll get the extra pay for carrying the beeper. But guess what? We don't want the fricken money he makes by carrying the pager those extra shifts! Then when he asks them for coverage, he's so nice, they feel perfectly comfortable saying NO!
ReplyDeleteLike I said, don't get me started. I'll stop now before the obscenities start flying.
Ick. I have to say I've never had trouble like that before, and all maternity leave gets covered later anyway, when you have to extend your residency, so there's none being an ass about it when it happens. But I think it might have something to do with the program: the chiefs are very determined that people are not allowed to be jerks. If you're nice and accommodating to others, your own wishes will be accommodated in the call schedules of subsequent months, and if you need coverage fast, the chiefs bend over backwards to make it happen and even cover themselves. If you're a jerk, however... let's just say we don't have people staying jerks for a long time. A call schedule that makes you stay overnight on the precise nights you requested off, for months on end, with people too angry at you to swap calls: it's enough to make anyone reconsider their ways.
ReplyDeleteWhile doing an elective (medical student) rotation in the UK, I found their system to be a bit better. If a training doctor is unable to work for whatever reason, then a Locum Tenens doctor is called to fill in that day so that the work is covered and people are not stretched too thin. Doctors that want the extra money and can fill in can then apply to work as Locums for triple their base pay. Of course this is also the system that runs on European working hours laws allowing no physician to work more than 48 hours in a week!
ReplyDeleteI like this idea, but the residency programs probably enjoy the free labor a bit too much for this to work.
I disagree. I think that if someone agrees to cover for you, you should at least have the courtesy to offer to pay them back. If they say no, that's their choice. But you should never not offer.
ReplyDeleteI am a pretty reasonable person and will always try to help someone out if I can. I was asked to cover a weekend shift for another intern during my transitional year because of an "unforseen emergency." I heard later that he was bragging to some of our fellow interns how he spent the weekend hanging out with his girlfriend and that he wouldn't have to pay it back because it was late in the year and I had no more weekend shifts left. You bet your arse I confronted him, threatened to speak with the program director, and made him take a fellow intern's upcoming weekend shift (who was very nice to me during the year).
Well, good for you getting back at that intern. It sucks when people abuse the system.
DeleteIn Mary's case above, there were dozens of people who shared coverage for her when she was gone. To pay back all those people would have been ridiculous, likely would mean giving up every single free weekend for the rest of the year, and possibly driven her to quit again. And people were MAD at her when she came back, so nobody would have given her a break.
I can see if it's a specific person that you asked for a favor, definitely pay back.
ReplyDeleteIf you're on maternity leave or something lengthier, it's hard to "pay back" because there's no specific person that really "took it" for you. Least imho - and note, I haven't been through maternity leave myself (I'm 21).
I don't see how anyone could *not* pay back call if it's a favor.
DeleteAs you said, maternity leave is trickier because it's such a huge period of time with so much coverage, and when you return, you're a total mess.
hasn't anyone here heard of jeopardy call? in my program (a large peds program in the midwest), every day of the year, including holidays, has at least two people who are on "jeopardy" call. these are residents who are on elective. the jeopardy schedule is published months in advance, along with the rest of the schedule. when you're on jeopardy, for those 24 hours you are not allowed to drink alcohol and you must be within 1 hour of the hospital. if a resident is sick or otherwise unable to come to work, and they're essential (as in, they're on call or on an overnight shift), then jeopardy 1 gets "jeopardized". there's no payback, but over the course of a 3 or 4-year residency, we all do plenty of jeopardy call. some people are lucky and don't get jeopardized much, others not so lucky. but jeopardy call is evenly distributed and nobody can call it unfair. a close friend of mine got jeopardized for me for a PICU call when my grandmother died. when i thanked her, she just said, "no worries, that's what jeopardy is for", and that's pretty much the universal sentiment here.
ReplyDeleteif someone needed to miss a whole month for a serious illness or another unplanned leave, somebody who was on elective would likely be asked to step in for that month and do their elective another time. since they'd be fulfilling a residency requirement anyway (all of our inpatient months are required months), it wouldn't make that much of a difference for them in the long run.
all of your programs sound terrible.
i would add, in our program, in a typical one-month elective you would probably have one jeopardy 1 call and one jeopardy 2 call, and one of the two would be on a weekend. that's it. if your jeopardy calls conflict with your schedule, you can try to trade them with other residents.
Deleteone more thing: this system makes it much less personal. when my grandma died, i didn't have to call my friend and ask her to fill in for me. i told my chief, they said, "go to the funeral, we'll take care of everything," and they called the jeopardy person in to take the call.
DeleteYes, in Jane's case, it was a person on "jeopardy call" who stepped in to cover her. And she still felt she was expected to pay it back.
DeleteIf a person on elective is pulled to cover a wards month, then get their elective later, who covers wards on their original wards month? Does someone else get pulled off an elective? Does everyone's schedule get totally rearranged?
In my Internal Medicine internship program we were expected to pay back Jeopardy call.
DeleteI tried to use it once for severe illness on a day I was scheduled to take overnight call. My chief resident asked me to do my best to come to see and write notes on my team's patients then determine if I still felt too sick to stay.
It was one of the hardest days of my training thus far, but I stayed 31+ hours. My program sucked every last drop of life out of the interns and we all hated it, but it prepared me very, very well for the IM portion and workload of residency. Glad I did it. Wouldn't do it again for anything.
i guess my program has the benefit of being all categorical, so there are no prelims, and huge (at any given time, there are literally dozens of people on electives). so, a pgy-2 might be asked to fill in on a ward month at the last minute, but then they would get to do one fewer ward month as a pgy-3 (and one more elective). since next year's schedule hasn't even been made yet it's not hard to figure it out. for things like maternity leave, it's planned for in advance as much as that's possible. it must be just a cultural thing in my program too - nobody expects payback for being jeopardized, and nobody feels bad about causing someone else to be jeopardized. most of us have been on one side and the other.
Deletein response to the post above, in my program we generally consider it in poor taste to come to work and take care of sick, often immunocompromised patients if we are actively sick. if you have the sniffles, fine, wear a mask. if you have the flu, gastro, or worse, aren't you compromising patient care so you can feel like a tough guy for sticking it out? not worth it.
DeleteIn a smaller program where everyone already has very few electives and already is working very hard, it's more difficult to shrug off being jeopardized. It's also harder to call in sick when you know you'll have to give up one of your few weekends off to make up for it...
Delete@ahd Yes, I assumed the program would not want me there but was swiftly corrected. They just want a warm body (plus or minus mask) to do the work.
Deletehad a fellow male surgery resident who would simply disappear for weeks at a time. never got fired, but never finished the program. we were all so busy we were happy to see him back. just try to avoid a rotation with him to avoid the risk of the severe burn. and when he did come back, we were all so busy there was no chance of a payback.
ReplyDeleteI have to agree with AHD above. A lot of your programs sound horrible. During my first two years of residency, we had jeopardy call. There was no pay back of call days, but you GOT PAID if you were called in (moonlighting $$, not too shabby).
ReplyDeleteDuring my last three years of residency, we had jeopardy with pay back of the call days. People almost never called out, so it was not really an issue.
For my maternity leave, someone took an entire service month for me, and I took a month for her the following year. And,I missed one month of elective (for 8 weeks total leave). Seemed entirely fair and appropriate to me. We do have plenty of elective time at the end of our residency, however, so the extra service month the following year was easily buffered. It never would have occurred to me that we should have done anything other than trade service months.
Yeah, residency is often horrible. Programs like yours are the exception rather than the rule, as you can see.
DeleteMakes you wonder how to sniff out the "good" programs during the interview process.... without coming off like a complete slacker.
DeleteI think in general, large academic programs are better for internship. Some people will chose "easy" programs because they think it will be easier, but then it ends up being harder because their co-interns are total slackers and make life harder.
DeleteIn a specialty residency, it's very hard to avoid this problem because most of those programs are relatively small. But the best way is probably to ask a resident who's had a baby because they know all the coverage issues.
I don't agree that a person has to pay back every call that was covered for them while on leave, but I am also not a big believer in the "it all evens out in the end" either. I couldn't even get my chief resident to cover a single weekend when my mother was dieing in the ICU but have since, on multiple occasions, covered maternity leaves, stress leaves, sick leaves and poorly timed vacations that shouldn't have been approved.
ReplyDeleteThough I am going on research block soon (still covering call but at a reduced amount) so maybe I will be able to sleep again eventually.
One of the obstacles that drives animosity when residents require coverage is the lack of incentives (other than goodwill and charity) for voluntary or involuntary coverage of shifts. Out in the "real world," coverage of additional shifts usually means extra pay. A system should be in place to allow at least some modest form of monetary compensation (rather than the elusive promise of future reciprocation) for what might be a brutal 28-hour call shift; it would change a person's opinion about being pulled to provide coverage. In general, it seems that human self-interest is a more reliable motivator than spontaneous generosity.
ReplyDelete-the Daily Medical Examiner