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How Advanced Practice Providers (APPs) Can Help Residents Get More Time Off

Op-Med is a collection of original articles contributed by Doximity members.

Residency programs are under a huge amount of pressure to emphasize wellness for their trainees. The pressure comes from the governing bodies, from the residents and applicants themselves, as well as the public in some part. I think there, for sure, have been some improvements from the old days of medicine; however, there have been some unintended consequences as well. I think we could do better with a different approach.

For those of you who don’t know, residents used to work much more than 80 hours a week at the hospital. Doing 16 or 24-hour shifts were regular, and sometimes they lasted even longer. Residents literally lived at the hospital, and they learned how to take care of people much like you might learn to swim: by being thrown into the deep end of a pool. Recently, hour restrictions have been put in place limiting the longest shift to 24 hours plus four hours for handoff of care (a sort of fine print trick if you ask me). From an outside regulator point of view this seems like a reasonable solution for keeping residents from seeing patients for excess hours, however it simply isn’t the case. The sign out times simply aren’t protected from pages, emergencies, and from carry over if a doctor is in the middle of a task like a surgery or procedure. Besides, even if we were protected, writing notes and clicking through an electronic medical record that constantly gives you errors for prescribing medications that are commonly used together as “dangerous” or have nonsensical lists of allowable “hospital problems” for the purpose of billing and coding is still a nightmare at hour 26 awake. We know that we would hardly let someone drive at that point, yet we take the wheel of people’s medical records every week in this situation. 

I personally am no stranger to long shifts. I have worked in EMS through college and medical school. I regularly did overnight 12-hour shifts with obligations the day before and after the shift. Of course it was hard, and it trained me to be able to get by with little sleep and taught me the value of time off. However, a key difference here is the amount of sleep you get on call overnight. In the hospital you might be cross covering other daytime team patients leaving you with 60 to 80 patients that you will get paged about for problems ranging from emergency to minor inconvenience. Most EMS systems in my experience have some downtime and you might be able to get a few hours of shut-eye in between calls. Bunk rooms are readily available next door to your work environment that is sitting in the garage bay waiting to go at a moments notice. Hospital call rooms seem to be off the floor you are actually responsible for, or in some hospitals the call rooms are in a state of disrepair. This is a seemingly architectural problem that needs to be addressed moving forward in hospital design of the future. 

One thing being done is an emphasis on wellness, slideshows that bring attention to burnout that get interrupted by pages from the floor, emphasis that counseling is available for free and is encouraged, although sessions are probably not available on a weeknight during those two hours you have between the late end of your shift and the early bedtime you need to maintain a sense of clarity during the day. I had a PhD in clinical psychology tell me that most people probably need a few sessions a week to make some headway in whatever is bothering them yet the medical professional schedule makes a few hours a month hard to come by. Unfortunately, there is work to be done on the floors and someone has to always be covering it. The problem isn’t that we need counseling or support groups at odd hours of the day, or time for slideshows to tell us about burnout and all of its friends; we just need some time off. 

Time off has been the great cure for burnout for me in the past. We all know how good a three-day weekend feels yet many programs or rotations offer a “golden weekend,” the name given to a standard two-day weekend, once a month. The rest of the time you may get one day off a week on a rotating schedule. Nothing like having a Tuesday off when all of your friends are working. The inability to maintain real life social support networks outside of your hospital due to time off never lining up with the rest of the world is almost certainly an exacerbating factor of burnout. Programs sometimes have blocks of “protected time” for education but often flank it with clinical duties that leave you scrambling to finish your work so you can make it to education or conference. I think the solution to this problem is to hire more competent clinicians. This is an expensive solution that programs probably hate, but it is really the only way that I see wellness moving forward. Residency program expansion is difficult and does require many hoops of red tape to jump through, however hiring more well-trained advanced practice providers (APPs) is an easier way to get some time off for residents. I remember a few programs I interviewed at saying that a good metric of how much you have to work is if the residents can all get off for any reason on a regular basis. If they had the APPs to cover the service with attending physicians then you were there to learn and train and not fundamentally to work. Is this a feasible option for most hospitals or most programs? I’m not sure. However, I don’t think the status quo of physician mental illness and suicide is a feasible alternative to settle on. 

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