Night Call in a Teaching Hospital: 1979 and 2019

At 6 pm , the on-call residents assemble in the ED, where we would spend the remainder of the night and early morning admitting new patients to the hospital. A night team consists of a senior resident, three junior residents, and two medical students, with each resident being responsible for approximately 20 inpatients. Overnight coverage of the ward mostly occurs remotely; since the ED is often so busy, we address most of the issues through a computer or over the phone. Only in rare cases, such as when a patient is unstable or a death has occurred, do we deal with the matter in person.

To enable rapid remote responses, we each carry an assortment of devices on our waists or lanyards and in our pockets, such as a personal pager, ED consult pager, code blue pager, and hospital-issued smartphones capable of receiving pages, text messages, phone calls, and e-mails. Nurses, pharmacists, and other consultants communicate with us through all of these channels. Few of these interactions occur face-to-face. To our frustration, encounters with patients are frequently interrupted by a stream of beeps, rings, and vibrations—irrespective of whether we are having a difficult discussion about goals of care or performing a delicate procedure.

The ED contains a work space dedicated for residents to enter electronic orders, type notes, and review new admissions. Between consults, we try to discuss exciting cases and provide teaching to the medical students and interns, which we enjoy. Dinner is generally devoured while inputting orders. In exceptional circumstances, a brief reprieve from pages may allow the on-call team to share a meal. Depending on our role, sleep may be possible on certain nights but is never guaranteed. Moments spent with the on-call team—all of us learning, commiserating, and growing together—are some of the most memorable of residency, and many of us become close friends by the end of the rotation.

However, apart from these few familiar faces, we rarely get acquainted with the nurses or residents from other services. Many often refer to themselves by specialty rather than name and phone calls that begin with “Are you Medicine?” can end with “You should really call Orthopedics.” Meanwhile, “Medicine” and “Orthopedics” may pass each other in the hallway without recognition beyond a vague familiarity of a voice heard on the phone.

Every 10 minutes spent with a new patient is accompanied by approximately one hour of “electronic” time, which includes reading through previous medical records, reviewing laboratory data and imaging, and creating an admission note. Interns might groan as they pull up a patient’s electronic health record (EHR); irrelevant details often arise with each click of the mouse, and the cursed “copy-paste” function means that new notes often duplicate older ones. However, with time, we learn to look past the EHR’s shortcomings and appreciate several of its advantages. For example, we are now able to access test results performed outside our hospital and thus limit our repetition of investigations. We can also use the EHR to rapidly glean salient information about a patient in time-critical scenarios. This is always a satisfying process, and it makes us wonder how physicians ever practiced in the era before computers.

Today’s patients are older and sicker than ever before. Many are receiving treatments that did not exist even a decade ago. As residents, we must recognize a seemingly endless variety of drugs—a challenging but intellectually satisfying responsibility. We must also decide whether the patient’s current health state permits their continuation, or whether safer alternatives exist. Some of these decisions cannot wait until the morning.

During handover at 8 am , we often recount moments from our call shift with a sense of vigor that is only partly dulled by fatigue. We may share with pride our management of a sick patient. We may relay a touching exchange with a concerned family member. Or we may recall with satisfaction our handling of a tense situation with a colleague. Taking part in these experiences is one of the most character-building aspects of being on call. The absence of our supervisors can be unnerving at first, but we gradually begin to enjoy the sense of independence. Moreover, we feel empowered to make our patients better with the right combination of carefully selected treatments. Nothing makes us feel more like doctors.

No doubt, being on call is difficult. The next day brings a feeling of relief and accomplishment, knowing that we got through it—whether by floundering or flourishing—in one piece.