Responsibility, anxiety, and expectations converge for an on-duty resident.
Luke Burns, MD
Nothing can compare to the old days of medicine when residents were literally “residents” of the hospital, but demands on US medical trainees are still unique in the Western world.
Last month I worked 3 weeks in a row without a break and by the end of it I was bone tired and mentally drained. My Sunday night was going just as I had planned and I was relishing my last few hours of freedom when I received a group-text from one of the senior residents asking if anyone could fill in for the night call resident, who was sick.
When it became clear that I was the only one available, I somewhat reluctantly donned my scrubs, went hunting for my stethoscope, and headed to the hospital.
And so began “signout,” the transfer of responsibility from the day team to me. Information on medical and surgical histories, issues and complaints, and likelihood of patients spontaneously dying overnight all were relayed to me as the resident “coming on.” Like two friends fighting to pay the check, the “day” resident and I each volleyed responsibility for last-minute tasks:
“I’ll just finish this discharge summary, then I’ll be done.”
“No, you’ve been working all day, I’ll do it, go home!”
“It’s okay, I should have done this earlier-“
“I got it, go home! Go home!”
With signout completed, I was now responsible, during the night, for every patient in the hospital with a gynecological concern. Consults in the emergency room and phone calls from patients at home with gynecologic issues would also fall to me. With all these unfamiliar patients, many of whom were very sick with cancer or recovering from major surgery, the idea wasn’t to heal. It was simply to keep them alive overnight.
Of course, I was never completely alone. There is a chain of authority that night residents can climb with questions, starting with the senior resident working on labor and delivery, moving up to a junior attending “on call” from home, all the way up to the senior attendings. But sometimes calling for backup isn’t an option. There is a certain compulsion not to phone the sleeping attending at home, especially for small problems we’re expected to know how to fix on our own.
And then, it’s 3 am and I’m being “hammer-paged,” as nurses, emergency room staff and patients calling the telephone consult service all vie for my attention:
“Patient in bed 22 says she has 9/10 pain, have already given oxycodone and Tylenol, she cannot get Motrin due to kidney disease, what do you want to do?”
“Patient calling from home has had heavy bleeding since 6 am; call back immediately.”
“Hi, consult in the ED. 79-year-old with chemo-resistant ovarian cancer, now with likely small bowel obstruction, please come see her asap, thanks”
Each page is triaged for severity, corralled into a “to-do list of importance.” Then I do a quick mental calculation of the best path to take through the hospital to tick off as many tasks as efficiently as I can. All the while, there is paperwork to complete and an escalating mountain of notes to write. I do my best to document as I go, because in a few short hours, I’ll be signing out to the day team.
It feels like any mistake I make has dramatic consequences. Forget to ask a patient what medications they take? I won’t know she needs insulin and might send her into diabetic ketoacidosis. Overlook an obvious lab order? The morning attending will lay the blame on the day resident for the life-threatening electrolyte imbalance that I missed.
Night call is a game of constantly spinning plates, managing multiple sources of anxiety, scribbling notes as I clutch a phone in the crook of my neck and mouth apologies to the emergency medicine resident, who has been waiting 2 hours for my treatment recommendations. Residents are expected to be experts in their field, but I often find myself scouring medical websites on my phone looking for answers on the way to a patient awaiting my keen clinical input.
And then finally, slowly, the morning approaches. My phone rings and I meet the day resident for another signout. This time, I’m the one recounting the events of the past shift-everything that happened overnight, everything I did for every patient who came in, everything still waiting to be done. Usually I will sign out to a more senior resident, whose gentle probing about each patient reveals the important details I forgot to gather. Kindly the resident will reassure me, promise it gets easier with time, and then repeat the “signout” pantomime:
“I still have a consult sitting in the ED I need to get to…”
“No, no, you go home, I’ll do it.”
“I can’t make you do that! It was my fault.”
“You need to sleep! Go home!”
“Well…are you sure?”
Leaving the hospital at this time of day carries a unique warmth. Against the flow of foot traffic headed toward the hospital elevators, I lope toward the parking lot, nodding knowingly at other who recognize the semi-delirious smile of a night resident going home.
After my first few night shifts, I was anxious about turning off my pager, nervous that someone might get sick or die if I didn’t immediately answer, or that I’d miss a call from an angry attending who couldn’t comprehend my treatment plan from the night before. But now I understand the meaning of signout, that informal but very real transfer of power and responsibility at the beginning and end of each day. I relish the moment I can turn off my pager, when I can cut the cord tying me to the hospital, to the impossible responsibility of caring for several dozen very sick strangers, and instead crawl into a familiar bed to pretend I am a lazy teenager again, sleeping deep into the late afternoon.