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After the Match

After the Match: The Hours Bank

Cook, Thomas MD

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doi: 10.1097/01.EEM.0000454004.06485.c4
    Figure. F
    Figure. F:
    ormer Palmetto Health emergency medicine resident Zubair Chao, MD, right, now a fellow in emergency ultrasound there, on his global mission to India. Read about his experience and those of other residents inEMN's Going Global blog:

    Almost all resident scheduling systems are designed to create equity from one rotation to the next. Unless a resident is on vacation, all the other residents on the service are expected to work the same amount of time. It invariably becomes difficult, if not impossible, however, to have complete equity for every month, and perceptions of inequity will eventually eat like a cancer into the morale of any program.

    But why are we looking at equity from month to month in the first place? Why not look at the amount of work done over the course of residency? Why not allow or even encourage differences in the amount of work from month to month as long as all residents within a program work the same amount over the entire length of their training?

    I attempted to do that in 2009. I figured out how many hours each resident should work in the emergency department over residency training (this is 4,400 hours for us). I ask each resident to tell me when he would like time off when I make up the rotation schedule each spring. I also tell them they can take off as much time as they want. Work hours are then tabulated monthly, and posted on our program's website. Every resident has access to the data and knows how many hours they have worked, how many nights, how many weekends, and how all of this compares with the other residents.

    But there is a catch. Each of them has to work 4,400 hours by the end of training. No exceptions. And they cannot extend their training to make it up. A resident cannot graduate unless he has done the same amount of work as everyone else in the class. If they see they are behind in hours, night shifts, or weekends, they know they will have to work more on future schedules. They each get a lot of autonomy with scheduling, but each of them will have to put in the same amount of time in our ED to get a diploma. I called this plan the Hours Bank.

    What happens when a resident wants to take off two consecutive months? It doesn't happen. You just can't do it. A resident will get too far behind to make it up. Medical school students practice delayed gratification, so they usually look for ways to get ahead on hours rather than look for ways to get behind.

    Now five years later and some tinkering with the rules, the effects of this are interesting. We have essentially no complaining about hours and shifts. Cumulative work hours are posted for everyone to see, and each resident knows where he stands compared with his classmates. Discrepancies can easily be corrected going forward. But even more interesting is what residents do with the freedom to plan their time off: They see more patients.

    Twenty of our residents have gone to 14 countries on 33 global health missions since 2009. One member of the class of 2013 traveled around the world twice during his senior year to work in India, China, and points in-between. He made up for this time off by working extra shifts during his emergency medicine rotations. One of his classmates used a similar plan so he could work six weeks in Sudan and a few weeks in Haiti and Samoa. A resident from the class of 2014 made three global health trips, including a month working off a catamaran in the South Pacific kingdom of Tonga visiting remote islands with a few hundred inhabitants. Twelve of our residents have committed to 16 missions for the 2014-2015 academic year, the most in our program's history.

    How can this be? Why are these notoriously self-gratifying millennials working extra shifts during each emergency medicine rotation so they can spend lots of money to go far away to work even longer hours? What gives? Perhaps it's an example of how motivation can be positively affected by more autonomy. Maybe giving great people an opportunity will make them do great things. Check out Daniel Pink's TED talk, the Puzzle of Motivation, for some insight on this. (

    Next month: How we use the Hours Bank to motivate people to do things no else wants to do.

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