How common/uncommon is getting more than a nominal amt. of sleep when on call?

[Trismegistus4]

I'm hearing conflicting stories about residency. On the one hand, the 120-hour-a-week figure is common, and people say that many programs blatantly disregard the new ACGME rules. Lots of doctors have horror stories about that 35th hour on call, so bleary-eyed they didn't know what they were doing. In the second article linked to in this post, Troy Madsen, the guy who blew the whistle on the Hopkins IM program, says he almost made a crucial mistake on his 32nd hour of call and refers to "being awake for 30 consecutive hours."

On the other hand, some people have led me to believe that it's not (nor was it even in the past) that bad. My uncle did an IM residency at a prestigious university hospital in the late 80's, and he shrugs off my mention of the horror stories about being on your feet 36 hours straight, saying "oh, there's always time to sleep." Given what some people say about residency, this would be a laughable statement, but he laughs at the notion that a resident would be awake for 30 consecutive hours. Also, I've heard that, depending on the rotation, there can be a lot of down time during residency--you're not necessarily rushing frome one thing to the next nonstop the whole time you're in the hospital; rather, there are periods during which you're just sitting around, shooting the breeze with fellow residents or reading up on your speciality, waiting for something to happen. On this view, it would seem the burden of residency is primarily the large number of hours one is required to spend in the hospital, as opposed to the crushing avalanche of stressful work. (I.e., yes, it stinks to have to be away from home/your wife and kids/friends/whatever for 36 hours straight, but it's not like you get no sleep during those 36 hours.)

So which view is closer to the truth? Or do conditions vary widely between programs/specialities?

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[GeneGoddess]

I'm not sure how much has changed, but when I did my OB/Gyn rotations as a 3rd year (in 1999), I was on call q4 and worked 36hr shifts with NO sleep every time. It was just "done" that way. I'm not sure when the "rules" changed, but it was after my 3rd year. I know that a friend's wife is a surgery resident at Walter Reed (army) and she regularly "bends" the rules there with regards to work hours. They, apparently, do not pay attention to the current restrictions.

 

[xmxpro]

I'm hearing conflicting stories about residency. On the one hand, the 120-hour-a-week figure is common, and people say that many programs blatantly disregard the new ACGME rules. Lots of doctors have horror stories about that 35th hour on call, so bleary-eyed they didn't know what they were doing. In the second article linked to in this post, Troy Madsen, the guy who blew the whistle on the Hopkins IM program, says he almost made a crucial mistake on his 32nd hour of call and refers to "being awake for 30 consecutive hours."

On the other hand, some people have led me to believe that it's not (nor was it even in the past) that bad. My uncle did an IM residency at a prestigious university hospital in the late 80's, and he shrugs off my mention of the horror stories about being on your feet 36 hours straight, saying "oh, there's always time to sleep." Given what some people say about residency, this would be a laughable statement, but he laughs at the notion that a resident would be awake for 30 consecutive hours. Also, I've heard that, depending on the rotation, there can be a lot of down time during residency--you're not necessarily rushing frome one thing to the next nonstop the whole time you're in the hospital; rather, there are periods during which you're just sitting around, shooting the breeze with fellow residents or reading up on your speciality, waiting for something to happen. On this view, it would seem the burden of residency is primarily the large number of hours one is required to spend in the hospital, as opposed to the crushing avalanche of stressful work. (I.e., yes, it stinks to have to be away from home/your wife and kids/friends/whatever for 36 hours straight, but it's not like you get no sleep during those 36 hours.)

So which view is closer to the truth? Or do conditions vary widely between programs/specialities?

it depends on who your resident is and if you are liked by the staff. If a nurse llikes you, she/he will allow you to sleep. The only time I get a page in the middle of the night is when I have a admit. or for a crisis on my floor.
The best advice I can give you, order all bloods prior to "bedtime," make friends with a nursing staff, and have a good connection with your residents.
Best of luck,
MD

 

[Apollyon]

it depends on who your resident is and if you are liked by the staff. If a nurse llikes you, she/he will allow you to sleep. The only time I get a page in the middle of the night is when I have a admit. or for a crisis on my floor.
The best advice I can give you, order all bloods prior to "bedtime," make friends with a nursing staff, and have a good connection with your residents.
Best of luck,
MD

At the hospital I did prelim at in NYC, I was nice to the nurses, and liked, and, as my reward, I was paged incessantly, because I would answer, and I would come see the pts, whereas an dingus colleague (who nearly got fired for not responding to his pages) would NEVER get paged at night, because the nurses were afraid of him. The most sleep I ever got was 45 minutes.

When I came to my EM program, on off-service rotations, the most I ever got was 8 hours of sleep.

 

[Winged Scapula]

The experience of call is so variable that you will get a variety of answers dependent upon the resident, the program, the rotation, the relationship with staff, whether or not they have sick patients, have to respond to traumas, etc.

I have had plenty of nights (especially in the "old days") when I was up for 36 hrs + and some where I got nary a call or a trauma and has 8 hours of sleep (interruppted by incredulousness that I wasn't being paged). While there is a great deal of waiting around (ie, labs to come in, ORs to start, patients to come back from tests), it is not often enough time to lie down (unless you are one of those 15 minute power nappers). Then again I have had nights when I haven't sat down. Its really hard to predict. Ob-Gyn is notoriously busy with unpredictable hours, as is Trauma and some Surgical Services. I've had some nights on PRS home call for Face Injuries when I spent the entire night in the trauma bay and others without a call; I've had nights on Gen Surg putting in lines right and left, and others with only a few calls.

We're busier now with work hour restrictions (yes, many programs are violating them but most are making some attempt to reduce them) because the work load is the same but there are fewer people on call and in house post call.

I had the same experience as another poster. If you are nice to the nurses and answer your pages promptly, you may find that you are paged MORE than the jerk who isn't (I've had nurses tell me that they paged me instead of the resident on call because she/he wasn't nice/would yell at them/wouldn't call back, etc.)

 

[fourthyear]

Depends on the specialty and the program.

Surgery you are much more likely to be on your feet nonstop all day and night at least some of your call nights. But at some smaller programs with less trauma, this may not so often be the case. I usually get about 1-3 hours of sleep, if I'm super lucky it's maybe 4 (I'm talking 2-4 hours of staying in the call room without having to go see a patient, although it's usually interrupted by a few pages for things like fevers or medication questions). I would think it's quite rare the above poster who refers to an 8 hour night of sleep on call - I hardly ever even get this at home, probably b/c surgery residents usually get up and start so early!

I imagine that when the original poster's uncle did residency, they probably had many more nights on call and less cross-coverage than now. Now that our hours are limited, you are on call less but covering more patients and more services when you are on call, so you will have less down-time at work, but more home time.

 

[Seaglass]

So far when I have been on call I have not slept.

 

[fourthyear]

I personally don't think a 30 hour shift is all that bad, even on the non-stop busy nights with no sleep at all. It's after the 30 hours that gets tough for me to focus and pay attention, so I think this 30 hour limit is quite fair really.

As for Troy Madsen's excuse of being so tired he made a mistake - I really think his error was one of inexperience, not exhaustion. All he forgot to do was order a lab. He was an intern in his first month - show me one intern in their first month who thought or remembered to write every order they were supposed to on every patient they were involved with - you will find that this happens very frequently to everyone whether post call or well rested.

We must remember that in-house call is not just for the purpose of service to the hosptial, it's also a learning opportunity for residents. Taking care of those trauma patients, those critically ill patients, seeing new consults, handling urgent issues....When you realize that you are on your own once you finish residency - there will be no one to call to ask what should you do when you are an attending on call - then you realize you'd better stay busy on your call nights and gather up as much experience and learning as you can while you are in a training program. Playing video games in the call room never made anyone a better doctor.

 

[Seaglass]

Playing video games in the call room never made anyone a better doctor.

It might if you were a hack at minimally invasive surgery.

 

[osuer]

I know it may seem unusual to some to imagine a full call night without sleep; since that call night I referred to in "The New Physician" piece, I've had plenty of call nights where I've gotten, maybe, 2-4 hours of sleep. On that particular night, though, I had gone almost 34 hours without sleep when I failed to make sure a second set of cardiac enzymes was drawn on a patient. Part of that error was due to inexperience, but I feel the more significant contributor was the lack of sleep and the resultant impairment.

I do find it ironic that, in residency training, inexperienced physicians are made to work in an impaired condition (please see the Nature study citing skills equivalent to a blood alcohol level of 0.1% after 24 hours awake) while making crucial decisions with significant potential for detrimental effects on the patients under our care. I've had plenty of call nights since that time when I've run codes at 5 a.m., after being awake all night, and just felt my brain swimming. After a year of residency, I can't say that I really feel much education takes place after eighteen hours awake, although I do feel the thirty-hour limit is a reasonable compromise, and continue to feel a certain disappointment at the number of residencies in violation of this limit (and of the ACGME's efforts at enforcement and whisteblower protection).

In response to fourthyear's comment, yes, inexperience was part of that error, but significant mental impairment from a lack of sleep certainly didn't help the situation, either.

-Troy Madsen

 

[onceinawhile]

I have started my PGY-2 in the ICU, and so far each night I was on call (q3) I got zero sleep. It is certainly due to the fact the interns are new and I get paged about everything including KCl orders.
I have noticed one thing about being up 30+ hours. I get emotionally very labile. I cry easily, I get upset easily, on the better days I laugh easily. I once got into a nasty fight with a nurse that probably would have never happen had I slept at least an hour or two.
Anybody has similar experience?

 

[Apollyon]

I have started my PGY-2 in the ICU, and so far each night I was on call (q3) I got zero sleep. It is certainly due to the fact the interns are new and I get paged about everything including KCl orders.
I have noticed one thing about being up 30+ hours. I get emotionally very labile. I cry easily, I get upset easily, on the better days I laugh easily. I once got into a nasty fight with a nurse that probably would have never happen had I slept at least an hour or two.
Anybody has similar experience?

When I was on call for IM my prelim year, in the mornings, my mouth had the filter removed. I did NOT care one bit what I said, no matter how rude, classless, or "unprofessional', because I was just completely tapped out, and did NOT give a damn. Patient care was done for the day (and night), and it was just presenting the cases, and I just did not care - I just wanted to go home and crash. More than once, some inane, *****ic thing went down, and I said what was really on my mind.

I have actually gotten to use the t-shirt from Scutwork.com. If you review a program, they send you a t-shirt. On the back, it has a frazzled guy, and it says, "Don't bother me - I'm post call!" I, more than once, turned around, and told people, "read it".