Nightly call during residency is a painful but necessary part of the training experience. Each program handles how this is distributed within the context of its organizational possibilities. Those who distribute calls usually take in much of the anxiety and emotion created by the anticipation of long, stressful nights of work. This letter reviews the dynamics between residents taking call and those in charge of assigning call duties. It is intended to provide a systemic perspective, discussion about the interaction between the two parties, and alternatives to improve the system.

We base this letter on our experience as a call committee in a 40-resident psychiatry-training program. In many other programs, either chief residents or a program coordinator constructs the call schedule. In our program, usually two second- or third-year residents handle this task on a voluntary basis. The duties of this "call committee" include distributing calls evenly among residents, ensuring alternative call coverage in emergencies, updating the call policy, and handling complaints about the schedule. Our program’s call schedule has been particularly complex because we have had to schedule residents to cover between two to three hospitals. Additionally, the recent nationally imposed duty hour restrictions have made scheduling more difficult for all programs. Though our committee generally functions autonomously, either chief residents or the program director is occasionally called upon to assist in settling disputes.

Interpersonally, we have found serving on the call committee to be much more difficult than expected. Committee members are usually scrutinized by their peers as they represent program authority. As a result, they become easy scapegoats for peers frustrated by unresolved program issues. Our committee was performing the call-scheduling duties during a period where hospital closure, facility change, and faculty turnover were underway. With little outlet for expressing their anxiety to the administration, peers instead transferred their emotions dramatically to the call committee. Residents would often express their frustrations in the form of hostile complaints about the call scheduling and indirect personal attacks on the call committee. The committee came to recognize the benefits of the residents venting their anger,but also realized that it became an additional burden for them. Discussions among the larger group as well as in peer groups addressing the underlying issues tended to absorb some of this projection.

The availability of two residents on the committee allowed for one resident to represent the "bad object," hated by a group of residents and the "container" for their anger. Meanwhile, the other represented "the good and caring mother." Passiveness of one committee member often led to the other becoming a lightning rod for all of the residents’ emotions. Furthermore, intense disagreements between committee members were often found to mirror the dynamics between the committee and the residents as a group.

It is our experience that the dissatisfied residents usually expressed no interest in volunteering for the job when given the chance. Also, we noticed that residents rarely criticized committee members from their training classes. In some cases, lower year residents lacked full knowledge of the call policy, which caused conflict: aiding one resident’s dilemma often led to an outbreak of sibling rivalry.

Chief residents are the most ideal candidates to perform the duty of assigning call. Lighter clinical loads, knowledge of the program, and being vested with authority and status prepare them for this duty. However, in our program other administrative responsibilities, lack of incentive, and off-site rotations make them less interested in performing this task. A call committee consisting of both second- and third-year residents may be advantageous; they can support each other, perform the job for more than 1 year, and compeers from the same year express less transference towards them. Members of the committee have to be active, communicating frequently with each other as well as with other residents during the resident meetings. Pre-distribution of the yearly holiday call schedule and crediting a weekend call as a compensation for the last day off might help with holiday call coverage. Written predetermined policies for number of calls, sickness, missed calls, lateness, and weekend and holiday priorities are likely to decrease paranoia and conflict among lower level residents but will not eliminate them entirely.

Support from a faculty member who is not necessarily the residency director is an important resource in helping the call committee members cope with the interpersonal issues involved in organizing the schedule. He or she cannot only help the committee resolve differences between them, but more importantly help them recognize that they may become containers for unexpressed and unresolved emotions directed toward other members of the larger medical and residency system. Members of the committee should be encouraged to become comfortable with being both the "good" and "bad" objects.

This analysis is limited in that our program recently faced unique circumstances not encountered by most other programs. The closure of one of our hospitals and simultaneous transition to a new program director added a level of stress not typical to this type of situation. In other programs, the program director or chief residents might prepare the schedule, which would change the dynamics analyzed here. Analysis over multiple years and interviews with individual residents would have helped us gain more direct insights into the residents’ feelings and perspectives relating to on-call scheduling. However, given that we were part of the system being studied, it would have been difficult for us to objectively collect these data. We hope our experience and thoughts will provide some useful insights and information about the group dynamics in scheduling call.