al-ross-is-there-a-doctor-in-the-house-that-s-the-call-harold-s-been-waiting-new-yorker-cartoonMedical students no longer dissect a cadaver in most medical schools. After hours call, or working outside of regular work hours to provide care to hospitalized patients needing assistance, is rapidly becoming an anachronism as well. Teaching hospitals used to use residents and students in lieu of hiring physicians to work at night. The learners would take care of sick people at night and in exchange teaching would occur during the day. One attending I had fond memories of his call days as an intern, sitting at the nurses station playing the guitar.

When I was in medical school, call was busy. The medical student would be expected (at least at Tulane in the 1980s) to come into work at Zero dark thirty and work all day taking care of the daytime patients. When the day’s clinical duties were winding down, the student who was on call would find the resident that was on call (protocol varied from service to service) and get “sign-out,”  or in other words find out what tasks needed to be done between now and 0 dark thirty tomorrow. The time that sign-out occurred varied depending on the speed of the clinical team you were on as well as the willingness of the other team to accept sign-out. You might be finished by four but if the on-call team wasn’t ready for you, tough. The feeling was that you were responsible for your patients 24/7/365 and the privilege of sign-out could only be enjoyed if both parties were ready. I remember several nights when I was not on call but was not afforded the luxury of sign-out until 8 pm or later.

The job of the person on call was to work-up all of the new admissions as well as take care of the work that was left over from the folks who signed out. Oh yeah, there was nobody to draw blood, transport the patients to x-ray, or any other menial tasks. Oh yeah, and no radiologists, either.

Resident: Take the new admission up to CT, he’s still not right and I don’t think we can wait until morning. After you drop him off go run this blood to the lab and tell them we need it STAT! Then go find an endotracheal tube. We’re going to have to intubate.

Me: On my way

Me, to CT tech: I’m leaving this guy here and going get some stuff. He needs a CT without contrast. Yes I paged my attending (a white lie) and he says we need it. Page me if he stops breathing.

Me, to lab clerk: We need this STAT

Lab clerk: The tech is on break, feel free to run it yourself (which we actually did at Charity)

Me to central supply clerk: I need a number 7.5 ET tube

Bored clerk: It’s in the back somewhere, knock yourself out.

After a night of admitting sick people, running labs, gathering equipment, and in general feeling useful, we (after, as Doctor Eaton points out in the comments, “morning report” where the attending would grill us for not knowing what we were doing) then had to work the next day until “sign-out.” The difference being that as the off-coming team we got to sign-out first.

This was the job of residents and students because, as we used to say at Tulane, calling an attending after hours was a “sign of weakness.”

At least that is the way it seems in my 30 year old memories. In actuality, what I remember is being bone tired, being scared to death that I wasn’t doing the right thing by the patient, but living with the certainty that late in the night New Orleans in the 1980s I was the best shot for these folks to get better because the alternative was death on the streets.

Today, the trends that led to my bad call nights have accelerated. Hospitalizations are much shorter (Average length of stay 11 days for hospitalized Medicare patients in 1980, 5.7 days today) and patients are much sicker (50% of hospitalized Medicare patients are obese up from 25% in 1980, over half have over 2 chronic conditions, and almost 1 in 5 are on dialysis).  Consequently, the world of hospital call (and medicine) has changed. Medical students and residents are only allowed to work 80 hours in a week, and if they are working a 24 hour shift they must be allowed to “strategically nap.” Sign-out is now termed Check-Out and is much more formalized. The expectation is that, though the patient has a primary physician, a team will see the patient through the hospitalization. That team includes physicians, nurses, techs, and others whose job it is to get the person healthy enough to leave the hospital as soon as possible. Many times check-out is to a night float resident (and a night float attending) who only work from 7pm to 7am.

We are still working through some kinks such as how best to handle the hand-offs. Despite these challenges, I believe that teaching hospitals are almost certainly much safer today as a result of the changes.