The Good Old Bad Days of Learning On Call

Photo by Jeff Cleary Tarayn (Grizzard) Fairlie

I miss Q4 overnight call. This is shameful to admit these days when medical training is heading toward kinder, gentler systems. Sure, Q4 overnight call sounds like a nightmare: two overnights in the hospital every week, often without significant sleep, plus the next-day duties of notes, rounds, and the menial work that the on-call person typically must complete. Getting home by 1:00 p.m. the following day—meaning, a 30-hour total shift—is the usual goal.

Of course, Q4 call is open to many abuses, including work-hour violations, something not to be taken lightly given the significant risk to patient safety. Yet for all of the risks and problems with the system, Q4 (or more frequent) overnight call is how most doctors were trained, myself included. So for me, it remains the standard by which to judge all other systems.

Nowadays, as an intern, I rotate in a manner entirely different. I’m on call slightly less often than every fourth night, and during the week, I don’t even stay the night. Sunday through Thursday, I only stay to 8 or 9 p.m., depending on what shift I work during the day, and Sundays I work from 8 a.m. to 9 p.m. On Friday and Saturday, I spend the night, true, but I usually leave by 8:30 in the morning, and at worst, by 11.

I know it sounds great: less call, better overall schedule. But I find it challenging for reasons that may seem self-destructive. First and foremost, I’m a family medicine resident, which means that during the day I could be doing anything from obstetrics to orthopedics. Yet when I take call, I work on the medicine team, and so I care for very ill patients whom I don’t know and who have problems that I may not have thought about in months.

It seems risky to be on call at night this way, with only one other resident available for help, and to have neither of us well prepared to manage any acute problems. As a result, I feel that when I’m on call I can barely keep step with the patients on the service, much less manage them appropriately. I also think that it’s best if I just mark the time down when I’m on, since whatever I may contribute may be undone by the regular team and, at worst, may harm the patients. This is the second and more insidious problem with non-traditional call. On-call residents now often play “Saturday night quarterback” with treatments and medications while lacking the understanding of the case that the other doctors have, creating potentially harmful or simply ineffectual clinical situations.

In a traditional medical team, most residents get to know the patients they admit and care for in the hospital during the week. They know how their clinical picture has changed, what medicines were discontinued and why, and a million other small details that become exceedingly important when a transfer to a critical care unit is happening or a code is called. For more experienced physicians, maybe the small day-to-day details that patients offer aren’t so important. For housestaff, though, this data provides the bulk of our information for assessment and management, since we don’t have decades of experience to draw upon.

In short, my learning curve is now steep, and every call night I hardly climb more than a step or two. Formerly, call nights were more of a foundation for learning, the times when trainees climbed to new heights in skill and knowledge. So I miss the good old days of Q4 call when, after a sleepless night and harried morning, I could tell myself that I really, truly learned something from being in the hospital for 30 hours straight. Now, all I know is that what I’m doing doesn’t give me the same opportunity to learn on my feet, caring for the patients I know best twice a week, all night long—a lifestyle to which I’d gladly return, even if it meant less sleep.

—Tarayn (Grizzard) Fairlie, HMS ’06, is a family medicine resident at Middlesex Hospital in Middletown, Conn.

The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.

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