The On-call Experience

There are few things in the field of medicine that are as miserable as being on-call. People get sick at all times of the day, and so hospitals remain operational all day long, all week long, and every single day of the year, without any breaks. And that means that hospitals require doctors, nurses, technicians, and ancillary staff to be present at all times.

For the non-physicians, this isn't quite as bad because they mostly work in shifts. So there will be someone who works the 5pm-1am shift and then another person who works the 1-9 shift. Not too bad if you can manage being nocturnal.

But for doctors, it's a different story. When we're on-call, we arrive just like any other day, at 7am and we work the regular day, cover the night, and then even work into the next afternoon. So in the end, what was 4 nursing shifts becomes one physician 30 hour shift. And depending on the call schedule, we do it every third day.

It doesn't seem to make a lot of sense to have doctors be so overworked and tired all the time, but we do it for the patients. Sick people who are admitted to the hospital can be very complicated. Medication lists can be 20-30 drugs long and each patient has their own set of medical problems, allergies, histories, and social issues. We have to know our patients extremely well because if the patient suddenly turns south in the middle of the night, we have to be able to think quickly and not be fumbling with the chart.

If doctors worked in shifts, they would not know their patients as well. The night doctor has no idea what happened during the day. Furthermore, they are just "covering" until the morning arrives, so there really is no incentive to learn about the patient. The patient may very well sleep through the night without any active issues.

So that's why doctor's have to work the grueling hours that they do.

Time has a different meaning when you're on-call. In a 9-5 job, when 4:30 hits, your eyes start to gloss over and all you can do is think about going home. And then when 5 o'clock arrives, you're already in your car, hoping nobody saw you leave early. When you're on-call and 5pm hits, you realize that you're equally as tired but that you're not even half way done with your "work day". The busiest, most difficult part of your call hasn't even begun.

At 5am, when things finally start to settle down in the hospital and you can think about getting a few minutes of sleep, you realize that in just another hour, people will be arriving to start a new day. So you decide just to stay up and get some work done so that you can go home as soon as possible.

The post-call morning is probably the worst and best part of a call. It's the best because in just a few hours you could possibly be going home and getting some sleep. It's the worst because you haven't slept, you were incredibly busy, and you have to remember what happened to all the patients overnight to report to the next team. Your vision gets kind of blurry, you get this sick feeling in the pit of your stomach, and you date things incorrectly because you forget that a whole day has passed since yesterday.

Morning rounds is the worst because some attendings like to take their time and do some teaching, some chatting, and read their newspaper. I've never been so close to falling asleep while standing in my life. Then when it's finally time to present your patients, you enter this zone of cloudiness where you are talking, but don't even realize what is coming out of your mouth. You respond to questions that weren't asked and you start to laugh at things that aren't even funny.

I like to call it the post-call psychosis. If you ever get a chance to sit in on morning rounds, find out who is post-call and observe their behavior. It's due to a combination of sleep deprivation and elation that you may get to go home soon.

The truth is that you get used to it--you wouldn't survive if you didn't. And not all calls are that bad. My hospital was a small community based hospital, so there were random nights when you could steal 4-5 hours of sleep. The alarm would go off at 6am and I would be shocked at how refreshed I felt. My first instinct was always to check my pager to see if it ran out of batteries. There's also a certain camaraderie that comes with working nights. There aren't as many people around, so you tend to bond with the people around you.

And the best learning happens when you're on-call. While there is always back-up if you need it, for the most part, you are alone. So if you get a call from a nurse that your patient is becoming cyanotic, you have to be the one to find a solution. You can try different things to see what works and gradually build your own approach to treating patients with certain problems. If you fail, well, the patient will pay for it. But truth is that in today's litigious society, hospitals are so careful that you are hardly ever with some kind of supervision. In most cases it's the nurses who will tell you what to do. Instead of saying, "Your patient is cyanotic, what do you want to do?", they will say, "Your patient is cyanotic, do you want me to give him a nebulizer treatment?" And for the beginning intern, all you have to do is say yes.

So while being on-call is a painful, exhausting, arduous experience, it is something that is important both for the care of patients and for the training of a young doctor. Right now, I'm a radiology resident, so call is a little bit rarer and less terrifying. But looking back on my internship, I actually have some fond memories from being on call. But I wouldn't want to do it again.