Sunday, October 17, 2010

In Support of Overnight call

One of the greatest fictions in medicine (if you look at how we staff) is that somehow people are less sick on the nights or weekends.  At the same time, continued political pressure without good evidence to support is shortening resident work hours, now to the point of ludicrous 16 hour shifts.  While this seems long, a 30 hour shift requires 1 commute to work each way, and 1 sign-in and sign-out, a 16 hour shift doubles these requirements. Depending on how far away one lives from the hospital, this can be hours out of each day wasted in minimally productive activities that are neither educational or providing a service to patients.  The mentality of a resident on overnight call is different than one going home that day.  When we are trying to get out, anything and everything that happens to delay our exit (and eventual return) to the hospital increases stress.  Our goal becomes to provide the care that we need to provide so we can finish our day.  There is less time to delve into interesting findings, spend time with patients, and think. Education time gets squashed out.  When on overnight call, we know we aren't going anywhere.  This produces a relaxed atmosphere.  Rather than the always intense pace of a normal day with an uncertain end, intensity varies.  There is time to teach, learn and discuss. It is frankly more fun to do the job all the way and stay overnight, than do it almost all the way, but just as stressed and tired, but without the benefit that comes at the cost of the few extra hours.

But most importantly, as one of my great attendings once said, all of the good things happen at night.  While on call this past week I was able to spend several hours observing an attempt to *cure* a stroke by direct removal of clot in the brain... through a catheter placed in the groin.  I had only heard/read about this before, but I got to experience every minute of it.  This took place between 9pm and 2am.  If I had the choice of whether or not to stay, knowing a full day was ahead of me, would I?  Was it worth it?  These are questions each of us have to answer for ourselves, but I am certain I would not have had this amazing experience if not on overnight. 

The decision to continually and arbitrarily limit work hours for all specialities of medicine equally, without individual program flexibility is inherently a political one.  The root decisions all stem from the tragic loss of a politically connected young woman in New York.  There is not nor has there ever been evidence that spending less time with patients as a result of limited work hours would have saved that girl's life.  And yet we keep moving in that direction, for fear that if we, as a profession, do not appear to be regulating ourselves, that some worse bogeyman of the government will do it for us.  I ask if we really have self-determination if we regulate ourselves to appease regulators waiting in the wings.  And I ask if it does anybody- patients, residents, any good.

There is another way to ensure that residents have fair and equitable hours in which to work, learn and live... but that is another post!

No comments: