concept: "on call"

This is a concept I had completely wrong before I came to medical school. Considering I'm about to do four weeks of q4 (I'll explain later) call, I thought it would be a good time to explain what being "on call" actually means.

So when I was a young fresh-faced college student applying to medical school, I imagined being "on call" actually had to do with receiving calls - silly me! I imagined being "on call" meant your lightest day - either you stay at home all day and just answer calls about patients, or that you are at home but have to be ready to go in if needed. The strangest thing about this idea was when I heard that medical students did it - considering we know practically nothing compared to the residents and attendings and because our opinions very rarely (read: never) matter.

Turns out this wasn't completely wrong, but what I was imagining is actually specifically called "home call." It's also true that only the senior residents and attendings have home call where during certain periods they are responsible for answering calls and making decisions - but here's the wrench - another, younger resident actually has to be there at the hospital to call and to do the bidding of the more senior resident. And the medical student gets to be there right along with the resident! So my idea of call days being the lightest days was actually the complete opposite of reality - similar to many of the other things I imagined about medical school.

So what being "on call" really means is that you are the person on a particular service responsible for accepting patients. When someone comes to the ER and it's decided that they need to be admitted into the hospital, they are assigned to a medical service related to their problem. Heart attack goes to cardiology, stroke goes to neurology, etc. There has to be someone there from your "team" to accept the patient, take their history, do a physical exam, and start any work-ups and necessary treatments overnight. So the way "call" has classically worked is that you come in the morning for rounds, stay all day and overnight in the hospital, then stay through rounds the next morning to present the new patients to the team. So after approximately 30 hours you go home, hopefully sleep a lot, then come in the next morning.

A visual illustration. (Not my actual schedule for next week, just in case anyone wanted to stalk me.)

I would argue that this is a ridiculously stupid system. As scientists who study things like sleep cycles, circadian rhythms, cortisol peaks, and the mental consequences of sleep deprivation, it astounds me how we continue to expect physicians to be these magical people who can go without sleep every fourth night and still function at an exceptional level. Simple shift work at night has been shown to be detrimental to health as compared to day shift work, but at least your body has a chance to adjust. Having an irregular sleep schedule in addition to sleep deprivation seems like a terrible idea to maximize mental acuity of residents, not to mention maximizing their health. So far I have only done two weeks of q4 call when I was on the neurology inpatient service - and I was a complete mess. I actually began this blog post at that time (about 3 months ago)...

At least there is some hope. There are two things that are changing/have changed about this system now.

One is that we are doing call less frequently. When I say "q4" call I mean that I do this overnight, 30 hour work day every fourth night. Older attendings will tell you how residents nowadays "have it easy" because they used to have to work q3 call, but this has essentially gone away with increasing work hour restrictions for residents. While I would agree that their lives clearly sucked and that q3 call sounds terrible, I don't think that means q4 call is a joyful schedule full of free time.

The newest solution to this problem that many residencies are now implementing - the one I personally like the best - is a "night float" person instead (also known as the "mouse" on ob/gyn). Thus instead of working q4 call during your entire residency, you work a couple months out of the year where you are consistently on nights for a whole month. Granted I haven't worked nights yet, this sounds so much better than working q4 call. At least you are able to establish a steady sleep schedule (in addition to purchasing dark blinds).

Obviously someone has to be there at night. Obviously no one wants to be that person. Obviously, as a resident you will be that person. But I still think it would be nice if we used a little scientific reasoning when we come up with the best way to schedule shift work.