‘A structure built for wellness’: Pediatrics training program supports work-life balance with tandem schedule

Third-year pediatrics resident Arianna Sjamsu, D.O., knew residency was going to be challenging no matter where she matched. The “notoriously hard” phase of medical training has a reputation for long, grueling hours, Sjamsu said, and some institutions’ claims of prioritizing resident wellness lacked the framework she was looking for. 

“On the interview trail, a lot of places will try to sell you on their work-life balance,” Sjamsu said. “Something that stuck out to me at VCU was that they had a structure built for wellness, and that is giving us the tools to succeed when we’re the attending doctors.”  

On average, residents in the U.S. work between 40-80 hours per week, depending on the specialty and rotation. In many specialties this includes overnight and 24-hour inpatient shifts. Up to 75% of residents experience burnout at some point in their training and around 40% of American physicians are dissatisfied with their work-life balance, almost double the rate of other American working adults. 

Centered around resident resiliency, VCU School of Medicine’s pediatric residency program operates on a tandem schedule in which residents rotate every two weeks between inpatient and outpatient care, rather than the more typical four-week rotations. This schedule was specifically designed to meet Accreditation Council for Graduate Medical Education’s training standards while giving residents breaks between the long and strenuous hours that inpatient rotations require. VCU leadership supports the structure because it “allows for more flexibility to accommodate life,” said Shari Barkin, M.D., chair of the Department of Pediatrics and physician-in-chief at the Children’s Hospital of Richmond at VCU.  

“Caring for our patients means we also need to care for ourselves,” Barkin said. “This approach bakes in more flexibility than the standard resident schedule.” 

Changing for the better 

The switch to the tandem schedule came around 2013, according to interim pediatric residency program director Marieka Helou, M.D. She said residency leadership was “nudged” by new regulations from the ACGME that limited residents to 80 work hours per week and one day off per seven days worked averaged over four weeks. To meet this new standard, Helou said leadership found that the tandem schedule made it easier to comply while also prioritizing residents’ physical and mental wellbeing.  

“We found that it’s easier to meet that average over four weeks if you weren’t doing four weeks of the same thing,” Helou said. “The reception has been great. We get multiple applicants telling us that’s why they ranked VCU.” 

The tandem schedule also gives residents at least one full weekend off per month during outpatient rotation blocks, which, anecdotally, current residents say they haven’t seen at other pediatric programs.  

Inpatient rotations are physically and mentally demanding, Ashlie Tseng, M.D., associate professor in the Department of Pediatrics and associate program director of the pediatric residency, said. They often include overnight shifts, long hours on one's feet and more intensive care, which Tseng said all contribute to resident burnout. 

“Having to put in the time, energy and effort and having time to learn can be very tiring if it's a month-long block,” Tseng said. “The two-week blocks allow residents time to process and learn while still managing the daily life stuff that doesn’t stop when you’re on inpatient.” 

In addition to physical and mental demands, Helou said rotations in pediatric inpatient care can be emotionally draining, especially in the pediatric intensive care unit (PICU) and pediatric oncology. She said the two-week block allows residents to decompress and return to challenging rotations with more emotional strength. 

“Pediatrics is unique in that our populations are typically, and thankfully, very healthy and fun to work with,” Helou said. “But when you are exposed to children who are very unhealthy or suffering, it's really heavy on the soul.”  

While resident wellbeing is a universal issue that affects trainees in all specialties, Helou and Tseng said that the tandem schedule is not a one-size-fits-all remedy for combatting fatigue and burnout. Many residency programs, Helou said, operate almost exclusively in inpatient care, or have cohorts that are too large to coordinate the more frequent rotations. Other residency programs at VCU have implemented a tandem schedule, including the ophthalmology residency program and the internal medicine residency program.

When the tandem schedule was first launched, some faculty and trainees raised concerns about continuity of care, worried that a more frequent provider turnover would negatively impact patients. To mitigate these concerns and ensure consistency, Tseng said the program does its best to ensure that residents work alongside the same attending doctors and co-residents each time they return to the inpatient wards. 

“Overall, the residents approach rotations with a more positive manner,” Tseng said. “They have a fresh perspective and they come in happier.” 

Meeting milestones 

Most students graduate medical school in their late 20s and wrap up residency and fellowship training by their early to mid-30s. This timeline, and the commitment it requires, has led to some new doctors feeling “stunted” when it comes to their social and community development, Helou said.  

“All of a sudden, you’re in your late 30s and you’re just now looking for a job and a home and these other things your non-doctor peers have already done,” Helou said. “It's wonderful if you choose to start those things later in life, but when you feel forced to put all of those things to the side, it's a very unhealthy position for physicians to be put in.” 

Helou believes that the tandem schedule has helped alleviate some of the anxiety new doctors may feel when it comes to social growth. Over the past few years, Helou said the residents have celebrated several marriages, childbirths and other life milestones, which she did not witness in her own residency cohort during the late 2000s. 

“We want our physicians to be mentally healthy and that means allowing them to enjoy the same aspects of life as everyone else,” Helou said. 

Chief resident Allison Shaw, M.D., who gave birth to her son, James, last year, said VCU's was the only program with two-week scheduling that she encountered during her interview process. She noted that many programs have adapted the X+Y model, which usually means six weeks of inpatient followed by two weeks of outpatient, but the tandem scheduling made VCU one of her top choices.  

“Having two weeks on outpatient rotations meant that I wasn’t on my feet all the time,” Shaw said. “It made being pregnant as a resident more realistic.” 

Shaw said the tandem schedule was a major draw when she was ranking residency programs as an M4, and that her experience as a resident at CHoR has lived up to her wellness expectations and allowed her to take time for herself and her family. 

“Requesting time off is very flexible,” Shaw said. “I get to spend time at home more frequently, which is very important for me as a new mom.” 

Sjamsu, like Shaw, said the tandem schedule has allowed her to enjoy her life more fully and have a greater appreciation for the present. 

“Residency is a hard thing, regardless of where you are, but if I burned myself out in these past three years, I’d have to ask, ‘Was it really worth it?’” Sjamsu said. “It’s important for programs to be aware of what residents need and support them while they’re learning and growing.” 

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