Night Call in a Teaching Hospital: 1979 and 2019

N o matter the era, few aspects of residency are more defining or memorable than overnight call. Nights can be a time of growth and learning but also of fear and uncertainty, as residents take on the responsibility of managing sick patients on their own. One of us (ASD) started his residency in 1978 at the Massachusetts General Hospital in Boston; the other two (ST and BCY) started theirs in 2016 and 2017, respectively, at the University of Toronto. In this essay, we reflect on our experiences of night call separated by 40 years, highlighting what has changed and what has stayed the same.

At 6 pm, a calm overtook the hospital as the daytime staff emptied out of the building. The only remaining residents were those on call for the night. Each team had one resident and one medical student responsible for about 20 inpatients. Teams also admitted new patients from the emergency department (ED). Since there were three teams who rotated the admissions, we were able to spend a part of our night on the inpatient ward. Most of the new patients had been thoroughly evaluated by a medical resident in the ED before we saw them, giving us a head start on eliciting their stories, performing physical examinations, reviewing the laboratory workup, and generating plans to present to the attending physician (who was called “the visit”) the next morning at 10 am .

We carried one pager that was about 7 inches long and 2 inches wide clipped to the waist of our pants. It could only make a beep; we then had to call the page operator to find out who wanted us. However, the pages were relatively few. Nurses called only when a patient was unstable, and other residents called only when a new patient was ready in the emergency department. At 9 pm , the laboratory data for the day were delivered to the ward nursing stations on computer-generated paper. Our job was to separate the pages connected by serrated breaks, review the results, and then file the pages in the charts. The nurses were aware of this routine, so they saved their questions for our presence on the wards, reducing the need to page us. At 10 pm , residents from all services went to the cafeteria for the “10 o’clock meal” when the food was free.We learned early in the year to drop everything at 10 pm ; otherwise, we did not eat. The social aspect of the group meal was comforting, but compared with today, the group was much more homogeneous and therefore less interesting. There were several women medical residents (although almost none in surgery), but very few minorities, and no openly gay residents.

Gathering data about patients prior to the current hospitalization required reviewing the “old chart,” which had to be delivered from patient records but was generally available when the patient was still in the ED. It contained typed discharge summaries and progress notes often handwritten by coresidents whom we knew. The handwriting was often difficult to read, outpatient notes were not included, and information from other hospitals was absent—but despite these deficiencies, we somehow managed just fine.

The patients on the inpatient ward were mostly stable, but more importantly, we had very few medications and tests to order. I recall prescribing fewer than 20 drugs—furosemide, hydrochlorothiazide, penicillins, cephalosporins, gentamicin, isoniazid, lidocaine, nitroglycerin, aminophylline, alpha-methyldopa, clonidine, propranolol, digoxin, hydralazine, indomethacin, steroids, and morphine. Orders for tests and imaging had to be physically written in the chart and could not be inputted remotely, which was a nuisance when we were away from the ward. However, we rarely ordered any imaging beyond plain radiographs at night. We did draw arterial blood gases and venous blood, administer oxygen, insert intravenous and central lines, take electrocardiograms, and perform urinalyses by microscopy. We did all these tasks ourselves for patients on the “ward service” (as opposed to the “private service”, which had to do with the type of insurance the patients possessed). As a result, we became experts in both blood drawing and intravenous line insertion—skills that might be less familiar to today’s residents.

Of course, patients did get acutely ill during the night. I recall intubating, cardioverting, performing phlebotomy to alleviate pulmonary edema, sending patients to surgery, and pronouncing death. Nevertheless, we often got sleep, and sometimes, several hours in a row. I had a rule; I always took a shower the next morning and put on clean clothes (we stayed until 5 pm , making the shifts 33.5 hours long). There was a camaraderie that existed between all of us at night. We were supportive, friendly, and knew each other by name, and more.

We were often frightened by the responsibility of managing sick patients alone. On particularly challenging nights, we would record our fears and feelings in a “night call diary” in one of the conference rooms—generally at 4 am . Some entries became legendary as people read and reread those months and years later. Mornings always brought a sense of relief and accomplishment, because when the sun came up, we knew that the other residents would not be far behind; when they arrived, we could tell our stories and get help.

There was definitely competitiveness to the work. Those who responded quickly to deteriorating patients were applauded; those who did not really know what to do were subtly disdained. However, over time, we all got the hang of it, and this led to a growing confidence that we were indeed doctors. The graded autonomy afforded by night call was a crucial part of that journey.