concept: "on call"

This is a concept I had completely wrong before I came to medical school. Considering I'm about to do four weeks of q4 (I'll explain later) call, I thought it would be a good time to explain what being "on call" actually means.

So when I was a young fresh-faced college student applying to medical school, I imagined being "on call" actually had to do with receiving calls - silly me! I imagined being "on call" meant your lightest day - either you stay at home all day and just answer calls about patients, or that you are at home but have to be ready to go in if needed. The strangest thing about this idea was when I heard that medical students did it - considering we know practically nothing compared to the residents and attendings and because our opinions very rarely (read: never) matter.

Turns out this wasn't completely wrong, but what I was imagining is actually specifically called "home call." It's also true that only the senior residents and attendings have home call where during certain periods they are responsible for answering calls and making decisions - but here's the wrench - another, younger resident actually has to be there at the hospital to call and to do the bidding of the more senior resident. And the medical student gets to be there right along with the resident! So my idea of call days being the lightest days was actually the complete opposite of reality - similar to many of the other things I imagined about medical school.

So what being "on call" really means is that you are the person on a particular service responsible for accepting patients. When someone comes to the ER and it's decided that they need to be admitted into the hospital, they are assigned to a medical service related to their problem. Heart attack goes to cardiology, stroke goes to neurology, etc. There has to be someone there from your "team" to accept the patient, take their history, do a physical exam, and start any work-ups and necessary treatments overnight. So the way "call" has classically worked is that you come in the morning for rounds, stay all day and overnight in the hospital, then stay through rounds the next morning to present the new patients to the team. So after approximately 30 hours you go home, hopefully sleep a lot, then come in the next morning.

A visual illustration. (Not my actual schedule for next week, just in case anyone wanted to stalk me.)

I would argue that this is a ridiculously stupid system. As scientists who study things like sleep cycles, circadian rhythms, cortisol peaks, and the mental consequences of sleep deprivation, it astounds me how we continue to expect physicians to be these magical people who can go without sleep every fourth night and still function at an exceptional level. Simple shift work at night has been shown to be detrimental to health as compared to day shift work, but at least your body has a chance to adjust. Having an irregular sleep schedule in addition to sleep deprivation seems like a terrible idea to maximize mental acuity of residents, not to mention maximizing their health. So far I have only done two weeks of q4 call when I was on the neurology inpatient service - and I was a complete mess. I actually began this blog post at that time (about 3 months ago)...

At least there is some hope. There are two things that are changing/have changed about this system now.

One is that we are doing call less frequently. When I say "q4" call I mean that I do this overnight, 30 hour work day every fourth night. Older attendings will tell you how residents nowadays "have it easy" because they used to have to work q3 call, but this has essentially gone away with increasing work hour restrictions for residents. While I would agree that their lives clearly sucked and that q3 call sounds terrible, I don't think that means q4 call is a joyful schedule full of free time.

The newest solution to this problem that many residencies are now implementing - the one I personally like the best - is a "night float" person instead (also known as the "mouse" on ob/gyn). Thus instead of working q4 call during your entire residency, you work a couple months out of the year where you are consistently on nights for a whole month. Granted I haven't worked nights yet, this sounds so much better than working q4 call. At least you are able to establish a steady sleep schedule (in addition to purchasing dark blinds).

Obviously someone has to be there at night. Obviously no one wants to be that person. Obviously, as a resident you will be that person. But I still think it would be nice if we used a little scientific reasoning when we come up with the best way to schedule shift work.

advice for the OB/GYN shelf exam

This is an atypical post for me because I usually tend toward the narrative - and write for a non-medical audience. However, the only medical blogs I look at myself are ones that give advice on how to study for the NBME shelf exams or USMLE step exams. Until this point, I really didn't feel like I did well enough on anything to be worthy of giving advice, but considering on how often I look at this blog post about third year shelf exams, I wanted to put in my two cents about how to do well on the ob/gyn shelf exam - because for once this year, I did do well on a shelf exam!

Here are the resources I used: 

1. Blueprints Obstetrics and Gynecology - This book is great for the people who prefer to read text, and I believe this edition is considered to be the best in this series. I think the obstetrics chapters are more helpful/detailed than the gynecology ones. What I found really useful about reading this book is that I read the chapters in coordination with the 10 APGO questions on that topic. This is my favorite learning format (think back to ExamKrackers for the MCAT) so I liked doing it this way, although I think it might have been more time-consuming than necessary.

2. Case Files: Obstetrics and Gynecology - I was really glad I forced myself to finish this book during the last week of my rotation. It was more updated than Blueprints and I thought it explained certain differentials with more clarity. I wondered whether I should have read through Case Files during the first two weeks of my rotation (but I was on Gyn Onc, so this is really useless wondering). It did seem nice to have fresh in my brain right before the shelf, but I really think reading this first, then reading Blueprints (if you have time), is probably the better way to go.

3. APGO U Wise Question Bank - This is the indispensable resource in my mind. Unfortunately, I've read that not all schools pay for this question bank, but it was definitely the best resource I used. It contains ~580 questions grouped into 10 question quizzes by topic, as well as 50-question and 100-question comprehensive tests. A nice piece of trivia to know is that the 50 question tests are actually just randomly generated from the question bank. This means that you will recognize questions if you were able to go through the whole bank, but it also means that if you are studying at the last minute, just doing the 50 question test over a few times would expose you to a smattering of topics. I'm unsure whether or not the 100 question comprehensive test contains questions from the bank. Some of them seemed familiar to me, but by the time I was taking this my brain started to feel a little numb, so I'm not sure. Still worth taking to see how ready you are for the shelf.

4. UWorld Question Bank - I made the plunge and paid for this question bank for the whole year, and I always do the topical questions before each shelf. There are about 200 questions for ob/gyn. I did them all on tutor mode over the last couple days before my shelf. I would recommend going through them, although I did find that some were more nit-picky than I found the shelf and APGO questions to be. A usual recommendation is to then go through your incorrects, but I didn't have time to do this.

Summary: 

I was definitely glad I was thorough with my studying because the exam was harder than I expected. I had heard it was one of the easier exams to prepare for because it actually stays on-topic (unlike surgery, psych, neuro, oh yeah... all shelf exams), which was true, but I thought the questions were more complex than the questions in APGO and UWorld. So although the question banks were great prep, I was glad I read something in addition. Also, just a reminder that I really want to go into OB/GYN, so I was highly motivated to do well, and otherwise I definitely wouldn't have come home and studied two hours every night while working 80-hour weeks on L&D. I think you could still do pretty well with simply doing the APGO questions.

Hope this helps and good luck!