Call burdens can vary widely in residency programs throughout the country. You have those programs with the dreaded 2nd-year crush. Others distribute calls more equally. Some have the third and fourth years taking the majority of overnights. Whatever the case, each program weighs its independent call schedule slightly differently by residency year. Any program can choose to structure the burdens however appropriate. (as long as 1st years are not taking independent calls as per the ACGME guidelines.) However, educationally speaking, who should bear the brunt of coverage and why? Let’s go through some of the more common call structures and the advantages and disadvantages of the call’s different weightings.
Front Loaded Independent Call For R2 Residents
Although not the most desired distribution of calls by emergency room physicians, residents get the most experience early on in their residency with this structure. It allows the R2 resident to build the radiologist’s confidence early on to practice as a radiologist. This resident can take this experience and apply the rules to the remainder of their residency. As I always have said, you are not an actual radiologist until you have had a call, a venue where you can make independent decisions. Until then, you will always be a student.
Moreover, it allows the current 2nd years to have a cushier future R4 year filled with electives and mini-fellowships (assuming they have passed the core exam). It also gives the resident extra time to study for the core exam at the end of the R3 year. And it allows for time at the AIRP during the R3 year.
Back Weighting For R3 and R4 Residents
Theoretically, weighing the call to the R3 and R4 years gives residency programs the advantage of having their more experienced residents take the most overnights. But, there is a catch-22 to this philosophy. If you want more experienced residents, you must give them independence earlier! Just because you put more senior residents on call does not mean you are getting more experienced reads. Call itself is the most critical experience for building practical knowledge, not studying from a book or reading a faculty radiologist’s final reads.
Whatever the case may be regarding back weighting and experience, the experience of having more calls toward the end of the residency sets the resident up better for independent work and moonlighting in their fellowship or as a full-fledged radiologist. The recency of critical training prepares residents better for the practice of radiology. When you finish the fellowship, it is possible to complete all your calls during your R2 year and not work independently as a radiologist three or four years later. That situation might put you in dire straits for making independent decisions at your first job. By backweighting the call, this issue is no longer a threat.
Even Distributions of R2, R3, R4 Calls (As Much As Possible)
Of course, an even distribution is the least burdensome of call distributions. It allows the resident to experience calls without the burdens of doing them all at once. Moreover, an even distribution gives the resident some experience early on. And it allows the resident to maintain skills throughout the residency. Finally, it even gives the resident the confidence to know that she has the experience to function as faculty when done.
Although it is impossible to make any call exactly, even given the constraints of studying for the core exam and the AIRP, this distribution can benefit from early experience and late reinforcement.
A Program Director’s Perspective of Independent Call Weighting In Today’s Environment
As program directors, we have political and educational concerns when a chief resident gives us a sample schedule for overnight coverage. The program directors and the chief resident often do not have complete control over distributing calls throughout the residency. Sometimes, the emergency department requires more senior residents. Other times, individual rotations such as interventional radiology prohibit residents from taking calls. So, giving the resident the perfect “educational” call weighting during residency is not always possible.
Nevertheless, some call throughout residency seems to give the most balanced education. As much as the ABR leaders say the core exam shouldn’t interfere with this training, the core exam does. A poorly thought-out core exam strikes again! Until we develop a better system than the core examination to test residents, it will always prevent programs from having the optimal mix!
