Does residency education need to be reformed?

John Bream, MD

Founder, Bream Medical


                It’s 445am in Greenville, North Carolina, sometime in the spring of 2012. 

It’s been a busy Saturday night (now Sunday morning) on trauma.  I’ve been on-duty as the senior trauma resident for almost 24 hours.  The trauma team has just completed multiple hours in a row of trauma activations from across eastern North Carolina.  I haven’t had time to leave the trauma bays except for a brief stent to go upstairs to the ICU and intubate someone while my attending was in the OR.  The trauma junior is running around upstairs putting out fires, and I need to check in with her. I pick up my pager, and there is a slew of pages to return.  Am I tired?  Sure. 

You know what’s worse than having worked almost 24 hours in a row, being crazy busy, tired, and still having several hours to go? 

Realizing I’ve run out of honey buns and Diet Mountain Dew! 


Does medical student/resident education need to be reformed?

Anecdotes like this are why many people are critical of the residency training model. 

Are 30-hour shifts safe? What are the physical and emotional consequences of working 80-hour weeks in the hospital?  Are there other methods to obtain the same amount of education without these long call shifts? Do you want your family member to be under the care of someone who has been up for 24 hours?  These are all reasonable questions to consider. 

I was in residency training from 2009-2012.  I was in the last class of interns (at the time) who were allowed to do 30-hour call shifts.  Starting in 2010, ACGME no longer allowed interns to do these shifts, and instead went to a “night float” system.  So, given the choice between doing 14-hour shifts or 30-hour call shifts, what would I choose?

I would choose honey buns, Diet Mountain Dew, and a 30-hour call shifts.  Every. Single. Time.


Understanding residency life

To understand this decision, it is important to understand what life in residency looks like.  My typical call day as the trauma senior looked like this:

0445 – wake up, shower, get ready

0545 – arrive at hospital

0600-0610 – morning report, take the trauma senior pager

0610-0720 – round on my 4-5 patients in the surgical intermediate unit, study on the case we predict will be discussed in morning report

720 – grab breakfast to-go

730-900 – trauma morning report/pray I know the answer to whatever questions are coming my way

0900-1200 – round on the entire surgical intermediate unit with the entire team (charge nurse, medical students, residents from other services, attending physician).  I’m busy taking notes on every patient on the unit.  As the trauma senior on call, EVERY patient on the trauma service is under my care (about 75-100 patients) after sign out at 4pm

1200 – 1600 – lunch, catch up on notes, write discharge summaries, respond to all the trauma activations that occur during the day, meet with your team of junior residents, and ensure they completed all their tasks on the intermediate unit

1600 – take sign out from the surgical ICU team

1600-0530 – whatever needs to be done, by any means necessary.  After dinner is usually when the trauma activations start coming in rapid fire.  I think the most trauma activations (people who come in from all over Eastern North Carolina with injuries) I did in one night was about 25.  Our goal was to be out of the trauma bay and to CT or OR in 10 minutes.  If possible, sneak in dinner around 6-7pm and a late-night snack between 1-3am when the cafeteria is open. 

0530 – make sure the trauma junior has “the list” up-to-date for sign out at 0600.

0600-0610 – hand over the trauma senior pager at morning report

0610-0720 – round on my 4-5 patients in the surgical intermediate unit

720 – grab breakfast to-go

730-900 – trauma morning report

0900 – round on surgical intermediate unit.  Thankfully, the person on-call has their patients rounded on first. 

0930 – complete the tasks that need to be done before leaving on your patients (placing orders, discharge summaries, complete daily rounding note, etc.).

~ 1000-1030 – head home to sleep

During a 28-day rotation on trauma, I would do eight of these call shifts.  Four of them would be accompanied by a post-call day (so up to 30-hour shift, 18 hours off, another off day) and there would be one week of just chaos (call shift, 18 hours off, call shift, 18 hours off, call shift, 18 hours off, call shift, 18 hours off, post-call day). 

                The alternative to this is called “night float.”  I did this on some of my rotations (MICU and OB).  This involved doing 10–11 hour days Monday-Friday, and then switching to 14 hour “night float” shifts Sunday-Saturday.  So, essentially, with night float, you work the same amount of hours, but you flip your schedule between days and nights.  Some rotations just had a scheduled “night float” that only did the night shifts for one month. 

                To be fair, not all rotations have this kind of schedule.  There are easier months to offset the tough call months, which are generally ICU rotations.  In my Emergency Medicine residency, we also had months that had either banker’s hours or more relaxed hours requirements.  Our emergency medicine shifts were 10 hours.  Intern year, we did 19 ER shifts per month, second year 18, and third year 16.  So, on each ER rotation, you got between 9-12 days off.  Not too shabby.   

                Why do I choose call shifts instead of night float?

30-hour shifts are safer for patients.  I know that may sound absurd but hear me out. 

  • Less sign out is safer for the patients

When I do a 30-hour shift, I know all the patients.  And when I say know the patient, I mean, I KNOW the patients.  Many of them I would have admitted on the call shift the day before.  Having participated on rounds on the day of call, I get to hear all the patient presentations, take notes, and know what is happening so I can be prepared and somewhat anticipate what might happen when I’m on call.  Plus, I’m only making decisions for 24 hours; the other six hours, I’m just wrapping up other things and rounding. 

On night float, I would come in, get sign out, and not really know the intricacies of the patient.  As such, I was basically just putting out fires, admitting patients, and handing them off to day shift again. 

Sign out is the most dangerous thing in medicine.  You’re handing off a patient you know to someone who doesn’t know anything about them other than the 30 second snippet that you tell them before leaving.  More errors happen from sign out than any other part of medicine – because things get missed.  Overnight calls minimize sign out, which is a positive for patient care. 

  • It is less tiring

It may seem counterintuitive, but even though the longer calls are grueling, you can basically sleep until you go back to work, and you get post-call days to recuperate.  On night float, you get either one day off to flip your schedule back and forth or get to stay on a permanent night schedule for one month and then go back to rotation that usually on a day shift schedule.  Having done both, I was much more tired on night float than I was on my call rotations. 

  • Better education and preparedness

There is simply no replacement for the volume of patients you encounter in 30 hours shifts versus 14 hours.  Night float essentially turns in to a stabilize and treat scenario and most of the procedures that are done end up happening on day shift.  Additionally, being on night float renders you unable to participate in educational activities, which generally happen during the day.  So, for multiple reasons, night float rotations end up being less educational.  

Even today, I can stay up for 24 hours on command.  It may not be the healthiest thing, but there are times when it is a necessity.  With night float, you become conditioned to working 12-14 hours.  With call shifts, you develop the endurance to work for 24 hours – if needed.   You never know when your colleague may have an emergency and can’t come into work.  These things happen.  Additionally, some places, especially in rural areas, still run 24-hour shifts.  And, while it would be rare not to get any sleep on those, you must be prepared for that scenario. 

Shouldn’t we just lengthen residency?

Many advocates for changing education argue that residency should be lengthened to allow for more rest.  There are some obvious downsides to this argument. 

  • Lengthening residency would increase the amount of time it takes to pay back loans

Medical school is expensive.  Many residents are carrying debt loads of more than $250,000.  Extending residency by even one year would increase the interest on the loan by over $15,000.

  • If residency is lengthened, some specialists would be mid-career before they can start practicing

Let’s consider the career path of an interventional cardiologist. 

The interventional cardiologist would go to college for 4 years, medical school for 4 years, do a residency in internal medicine for 3 years, then a general cardiology fellowship for 3 years, and then a subspeciality interventional cardiology fellowship for 1-2 years.  Assuming one gets accepted to medical school on the first application attempt, the interventional cardiologist would be at least 33-years-old before even starting their career.  If the length of training was increased, it’s feasible many physicians would be 40 before they started their career in earnest.

  • Shortening shifts and reducing work hours limits doesn’t increase the total amount of time performing patient care, so the exposure to pathology/knowledge gained is unchanged

So, essentially, there are no great options for changing residency education.  But, given the options, I think staying with the 30-hour call system that many people think is unsafe, and possible inhumane, is the best option for training experience and patient safety.

But what do I know? 

All I know is that after spending a few hours on this blog, I could sure go for a honey bun and Diet Mountain Dew right now!


Bream Medical is an all-inclusive, non-corporate practice that provides urgent care, primary care, and direct primary care services in Salisbury, Stokesdale, and Edenton, NC, and provides telemedicine consultation anywhere in North Carolina.  We provide excellent healthcare by prioritizing patients care – not profits.  To learn more about Bream Medical, visit or call 704.216.1263.

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