Jeopardy is the essential backup coverage mechanism that ensures continuous patient care when residents face unexpected absences. Programs without robust jeopardy systems face constant scrambles when residents call in sick, while well-designed systems improve both coverage reliability and resident wellness. This guide covers how jeopardy works in practice—activation workflows, common models, eligibility rules, and the challenges programs face.
Jeopardy is a backup coverage system where designated residents remain on standby to provide coverage when another resident cannot work due to illness, family emergencies, bereavement, or other unforeseen circumstances. The term derives from the “jeopardy” of losing coverage—patient care is at risk until backup is activated.
Critical distinction from “float” coverage: Jeopardy is exclusively for unexpected absences. Float residents handle workload distribution and planned coverage gaps. As University of Wisconsin explicitly states: “The Jeopardy resident is NOT available as a ‘float’ to cover individuals who wish to leave their assigned shifts early for personal or social reasons.” Anticipated absences (conferences, weddings, interviews) should be covered through pre-arranged schedule swaps, not jeopardy activation.
Jeopardy serves three interrelated purposes. First, it ensures continuous patient care on services that depend heavily on resident staffing—primarily inpatient wards and ICUs. Second, it supports resident wellness by enabling time off without guilt or fear of negative consequences, which ACGME now explicitly requires. Third, it reduces administrative burden on chief residents who would otherwise scramble to fill gaps ad-hoc.
The activation workflow follows a standard pattern across programs, with the chief resident serving as coordinator rather than allowing direct contact between the sick resident and their backup.
Standard activation sequence: The absent resident contacts the chief resident on call (not the jeopardy resident directly). The chief evaluates whether jeopardy coverage is actually necessary—sometimes the service can absorb the absence. If coverage is needed, the chief activates the appropriate jeopardy tier (J1 first, J2 if J1 is unavailable). The jeopardy resident receives notification via page, text, or app push notification and must respond within 15-20 minutes and arrive at the hospital within 45-60 minutes for active jeopardy. The jeopardy resident notifies their current rotation attending and receives a basic clinical handoff.
Typical triggers for activation include personal illness (most common), family emergencies, bereavement, medical appointments that cannot be rescheduled, and brief medical disability. Some programs also allow activation for capped teams when census exceeds safe limits, though this is controversial and risks overutilization.
What should NOT trigger jeopardy: Car problems, routine doctor appointments, moonlighting conflicts, events known more than 24-72 hours in advance, or requests to leave shifts early. These should be handled through scheduled swaps or PTO.
Programs have developed several distinct models, each with different tradeoffs for coverage reliability, resident experience, and administrative complexity.
The most common approach assigns multiple backup tiers with different response requirements. University of Colorado’s model illustrates this well:
| Tier | Response time | Restrictions |
|---|---|---|
| Active Jeopardy (J1) | 45-60 minutes | Must stay local, no mountain trips, no flights |
| Backup Jeopardy (J2) | 24 hours advance notice | No flights, must be able to return within 24 hours |
| Tertiary (J3) | As needed | Contacted only if J1 and J2 exhausted |
J1 is activated first; J2 converts to active status only if J1 is unavailable or if multiple absences occur simultaneously. This layered approach provides flexibility—backup jeopardy residents can take day trips while still being available if needed.
UCLA Pathology developed an innovative model where jeopardy becomes a formal rotation. Each resident is assigned 4 “Jeopardy-Elective” (JE) rotations over their training, combining standby coverage duty with elective time. When not covering absences, JE residents work on electives of their choice.
Results from this model were positive: residents covered an average of 8.5 days out of 20 workdays per JE rotation, satisfaction with taking sick days improved significantly (p=0.03), and 82% of residents wanted to retain the system. The model also increased PTO usage from 16 to 20 days per resident annually—suggesting residents felt more comfortable taking time off.
Larger programs (130+ residents) often assign two residents per day as “A” (first-call) and “B” (second-call) jeopardy, drawn from those on elective or outpatient rotations. This distributes the burden widely—typically 2 jeopardy days per month per eligible resident.
Smaller programs may assign one resident per week as the designated jeopardy coverage. This creates longer on-call windows but simpler scheduling. The jeopardy resident treats it as a “work from home” week when not activated—available by pager but continuing their elective work remotely.
Eligibility rules determine which residents can be assigned to jeopardy, and these rules need to be built into any scheduling software.
Eligible rotations: Residents on outpatient clinics, electives, research blocks, non-clinical rotations, or administrative time. The key criterion is whether the rotation can absorb the resident’s absence—clinics that operate without trainees are ideal jeopardy-eligible assignments.
Ineligible rotations: Residents on vacation, inpatient services, ICU, night float, or high-acuity procedural services cannot be jeopardized. Their current assignment cannot absorb their absence.
Training level matching: Coverage should be provided by residents at the same PGY level or higher. A PGY-2 cannot cover for a PGY-3 on a service requiring senior-level competency. For subspecialty services, the covering resident must have completed relevant rotations—cardiac anesthesia jeopardy requires prior cardiac rotation experience.
First-year exclusions: Many programs exclude CA-1s and interns from jeopardy during their first month (or longer) until they have sufficient service experience to provide meaningful coverage.
Moonlighting conflicts: Residents cannot moonlight while on jeopardy. If activated, their external commitment creates a conflict. Most programs explicitly prohibit scheduling moonlighting during jeopardy periods.
ACGME does not use the term “jeopardy” in its regulations, but jeopardy systems must operate within the duty hour framework. All time worked during jeopardy activation counts toward ACGME limits—there is no exemption for backup coverage.
80-hour weekly maximum: Clinical and educational work hours cannot exceed 80 hours per week, averaged over four weeks. When jeopardy is activated, those hours count fully. Programs scheduling residents near 80 hours should build in buffer—ACGME explicitly notes that programs “that regularly schedule residents to work 80 hours per week and permit trainee flexibility are likely to exceed 80 weekly hours.”
Maximum shift length (24+4 hours): Continuous clinical work cannot exceed 24 hours, with up to 4 additional hours permitted only for transitions of care. If a jeopardy resident is already working and gets called in, total continuous work cannot breach this limit.
Time off between shifts: Residents must have at least 14 hours free after 24 hours of in-house call. For shorter shifts, 8 hours off is recommended (but not required). Post-jeopardy, if the resident worked overnight, they cannot have clinical duties for at least 10-14 hours.
One day off in seven: Residents must have one day in seven free of clinical work, averaged over four weeks (4 days off per 28-day block). Critically, jeopardy cannot be assigned on these required days off. If a resident is on jeopardy and gets called in on a scheduled day off, that day no longer counts as a day off for compliance purposes.
Home call jeopardy (most common): The resident stays home but must be reachable and able to arrive within 45-60 minutes. ACGME does not require a day off after home call, but if the resident comes in and works, those hours count toward the 80-hour limit.
In-house jeopardy (less common): The resident stays overnight at the hospital. ACGME requires the following day off. This is typically reserved for high-acuity services requiring immediate availability.
Programs must track jeopardy activations and log them appropriately. When jeopardy is activated, the shift must be recorded in duty hour tracking systems (MedHub, New Innovations). The key logging distinction: “At-Home Call—Not Called In” does not count toward 80 hours; “At-Home Call—Called In” must be counted.
Research and program documentation reveal several practices that distinguish effective jeopardy systems.
Centralized coordination through chiefs: The sick resident should never contact the jeopardy resident directly. Chiefs coordinate across multiple services and can determine if jeopardy is actually necessary—sometimes the service can absorb an absence.
Transparent fairness tracking: Programs should track how many jeopardy shifts each resident covers and use this data to distribute future assignments equitably. However, programs should NOT track how many days each resident uses jeopardy—this discourages appropriate use and perpetuates the “culture of bravado when it came to toughing it out through illness.”
Clear activation criteria: Document explicitly what does and does not warrant jeopardy activation. Ambiguity leads to overutilization (busy services calling jeopardy for high census rather than true absences) or underutilization (residents coming in sick because they’re unsure if their situation qualifies).
Payback policies with caution: Some programs require payback when jeopardy is used. University of Colorado uses a 3:1 penalty ratio for missed jeopardy—miss your assignment, owe three shifts to the covering resident. This can promote accountability but risks creating punitive culture. Other programs use point-based systems where covering earns points and requesting deducts them, with points influencing future jeopardy priority.
Response time enforcement: Active jeopardy residents should respond to pages within 15 minutes and arrive within 45-60 minutes. Some programs treat failure to respond as a professionalism issue.
Understanding the problems programs encounter helps inform software design decisions.
Overutilization and definitional ambiguity: UCLA’s study found the primary modification request was “further clarifying instances where Jeopardy should be called and to prevent overutilization by busy services.” Without clear guidelines, jeopardy gets activated for inappropriate reasons—unexpectedly high case volume, fellow absences, inexperienced residents struggling.
Unfair distribution: Before automated scheduling, variance in jeopardy assignments created resentment. Manual scheduling makes equitable distribution nearly impossible across an academic year. Yale’s AIMS automated scheduling tool explicitly measured and reduced this variance.
Chief resident burden: Manual scheduling is described as “NP-complete”—exponentially more complex with more trainees and rotations. Chiefs spend weeks creating schedules and still produce errors. Automation reduced this task from weeks to days and made it “much more enjoyable.”
Unpredictability stress: Residents on jeopardy cannot plan activities, take weekend trips, or schedule exams. They must keep pagers on and stay geographically constrained. This creates ongoing low-grade stress even when jeopardy is never activated.
Cultural barriers to appropriate use: Many physicians work sick “because of obligations to colleagues and patient care.” The word “jeopardy” itself implies danger, potentially discouraging use. Some have suggested renaming it “Family Emergency/Illness Patient Care Backup.”
Different specialties have distinct jeopardy requirements reflecting their clinical patterns.
Internal medicine uses tiered systems (J1/J2/J3) with separate intern and resident pools. Point-based tracking promotes fairness. Coverage includes wards, ICU, and admissions. Some programs trigger jeopardy for capped teams when census exceeds safe limits.
Surgery often links jeopardy to moonlighting privileges—lab residents (research years) form the primary pool. Coverage requires procedural competency, so subspecialty matching is critical. UCSF caps jeopardy at 3 consecutive days or 24 consecutive hours and pays standard moonlighting rates for activated shifts.
Anesthesiology requires strict class-level matching (CA-1s cover CA-1 cases only) and subspecialty-specific coverage. The ASA recommends 2:1 repayment for missed coverage and excluding CA-1s during their first month.
Emergency medicine operates on shift-based models rather than traditional call, making jeopardy conceptually different—more like “backup shifts” scheduled 24 hours in advance. Night float systems are more common than traditional jeopardy. ShiftAdmin is the dominant platform (53% market share).
Pathology has implemented the Jeopardy-Elective rotation model most successfully, leveraging the specialty’s less time-critical nature. First-year residents are excluded due to insufficient service experience.
Program size matters significantly: Small programs (≤30 residents) have limited jeopardy pool depth and may rely on attending coverage when the pool is exhausted. Jeopardy activations are rare—sometimes once or twice per year. Large programs (130+ residents) need deep pools, sophisticated tiered systems, and robust tracking. Academic medical centers face additional complexity from multiple training sites, fellow involvement, and research rotations expanding the eligibility pool.
Effective jeopardy systems balance three competing demands: reliable coverage, resident wellness, and administrative simplicity.
The most successful programs treat jeopardy as infrastructure for wellness rather than punishment for sick residents. Key elements include: - Tiered activation that provides flexibility while ensuring coverage - Clear eligibility rules based on rotation type, PGY level, and subspecialty experience - Fairness tracking for shifts covered (but not for days used—that discourages appropriate use) - Centralized coordination through chief residents rather than direct contact
The UCLA Jeopardy-Elective model offers a compelling example: formal jeopardy rotations that provide both reliable coverage and protected elective time, with documented improvements in resident satisfaction and PTO utilization.