Being On Call and Nightfloat: Questions from a German perspective

[Medizinstudent]

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As I am a German who is interested in the American system I would like to ask a few questions about call during residency in the US. First of all, I will explain how it works in Germany as a point of comparison.

In Germany the resident on call will work his regular shift from about 0730 to 1600. During this time he will follow his normal schedule like any other day. After that he has to stay in the hospital untill 0730 the next morning. After that, the resident can go home and gets the rest of the day off. You can’t be on call two following days due to work hour regulations. In smaller hospitals the resident on call has to cover all wards, the ICU and the emergency room of his specialty. In bigger hospitals with more residents there is one on-call resident for each of these. Additonally, most hospitals feature a less experiencd resident on secondary call who supports the resident on primary call or who renders assistance in the OR. But this only applies to the bigger specialties like Internal Medicne or Surgery and hospitals with enough personell. The on-call resident can alway reach an attending physician of his deparment by phone, who does background call from home. Each resident on call has his own room where he can sleep and carries a wireless phone which is used to contact him. In my experience there are only very few patients admitted to a hospital ward during the night. Most “emergencies“ in the ER require ambulatory attention only. Depending on the specialty residents take about 5-8 calls a month. The normal work week is monday to friday, so it depends on the call schedule, how many days you have to work on weekends. A call schedule is written for every month by the residents themselves or the attendings, so there is no fixed call intervall like q3 or q5. Finally, you have to say that German physician are paid for a 40 hour week. Therefore every day on-call normaly increases your salary because some of the time worked counts as overtime. With call time taken into account residents work about 60h a week. Some hospitals have dismissed this traditonal system and use a three-shift-system with an early shift from 0730 to 1600, a late shift from 1400 –2230 and a night shift from 2200 to 0800.

How long has a resident on-call to work in the US? Which departments does he has to cover? Are there more than one resident/intern on call covering the same patients? Who writes the call schedule? Are there any special duties for a resident on call during regular hours? (which last from about 0600 to 1800 in the US, correct?) Are there a lot of patients admitted into the hospital during the night or are there mostly small emergencies which don’t require an overnight stay like in Germany? I know this can differ from specialty to specialty, so I would like to concentrate on Intermal Medicine and General Surgery.

Additonally, I would like to ask a question about nightfloat. I had never heart of that before? What does it mean and how does nightfloat work? Sometimes I get the impression that with a nightfloat system the residents work from 0600 to 1800 and the residents who are on nightfloat come in from 1800 to 0600. I would be really glad if someone could clarify how nightfloat works.

Many thanks for any answers.

 

[dragonfly99]

Thank you for that very interesting and informative post about the call system in Germany. It is fun to learn about other countries. Also, you have perfect English. We really need to do better w/learning languages here 🙂
I only speak Spanish and English, and my Spanish isn't so great.

There are different call systems in the US. Each department (general surgery, internal med, pediatrics, etc.) would set the call schedule for the residents; residents generally aren't involved in deciding when they will be on call. The schedule is written by someone above you (boss/program director or someone called the "chief resident" who is like a fellow assigned to teaching, making the call schedules, etc.). Usually it is set weeks before. For internal medicine residency you will do several months per year of being on call. In my hospital we took call every 4th night and you would come in at your regular time (say 6 or 6:30 am or whatever) work like it is a regular day and then stay there all night and then stay there the next day until noon or 1 pm (the limit is 30 hours in a row). Yes, we did frequently get admissions at night as well as during the day...not as many during the middle of the night but sometimes up all night admitting patients. Also we take phone calls from nurses and speak to family members about all internal medicine patients we are "covering" for the night - this includes all our new admissions, all our old patients, and patients who belong to other (not on call) interns and residents during the day. In internal medicine one normally takes call with a team - 2 interns and one resident is the usual way. The resident is there to supervise, but occasionally has to do patient admissions himself/herself if needed. Many admissions come through the emergency department and thus have been evaluated (at least briefly) by the attending (not just resident) in the ER. We normally did not talk to our internal medicine attending/supervising doctor about the patients until the next day, but if there is any problem we would definitely be able to call someone above us (either fellow or attending). Around 7 a.m. after the on call night, the other interns and residents will come back to the hospital, so you don't have to take care of ("cover") their patients any more. You will round with your attending doctor, the other intern and resident on your team, decide what to do with the patients you admitted last night, discharge any ready to go home, order labs and tests, write notes, maybe attend an educational lecture, and if you are lucky go home around noon. That was my typical internal medicine call night as a resident. Also, we did 1 or 2 months in the intensive care unit, where the call would be 1 night out of every 3, but we would tend to be able to go home very early (like noon) the day before we were on call as well as the day after being on call. Essentially you work very hard on your on call night and the next morning, but not very hard on the day before your call. You only admit and take care of patients sick enough to need to be in the intensive care unit. Some are on ventilators, etc. and many are on heart rhythm monitor. We often got 1 day in every 6 "off" when on the ICU, which was nice.

Night float is a system that they have at some US hospitals. I think it is pretty much similar to what you were saying in your original post. It is there so that the daytime interns and residents will not have to stay up all night admitting patients and taking nurse phone calls about patients.

 

[core0]

snip

Additonally, I would like to ask a question about nightfloat. I had never heart of that before? What does it mean and how does nightfloat work? Sometimes I get the impression that with a nightfloat system the residents work from 0600 to 1800 and the residents who are on nightfloat come in from 1800 to 0600. I would be really glad if someone could clarify how nightfloat works.

Many thanks for any answers.

I'll try to answer the night float question. It helps to understand the historical perspective. Prior to 2003 there were no limits on how long a resident could be required to work. Residents frequently worked a day shift then covered a night shift and then covered another day shift before getting time off. Some shifts could be as long as sixty hours straight. In 2003 the ACGME instituted work hours rules seen here:
http://www.acgme.org/acwebsite/dutyhours/dh_lang703.pdf
This limited the amount of call shifts and the amount of hours the resident could work total and in a row.

Prior to the work rules residents could be called on to work every second or third night overnight. With the new rules this was no longer possible. In order to maximize coverage some programs consolidated all of the overnight duties into one person. Instead of a number of residents taking overnight call, one resident covers multiple services.

In our institution the surgical night float covers all of the inpatient surgical patients. This usually is slightly less than 100. They work 1800-0700 six days per week. The other night is covered by a different residents. If you add this up its 78 hours plus the one hour of required grand rounds for a total of 79 hours or just under 80 hours. So the pain of repeated night call is exchanged for one month of continuous call.

Whether these work hours help or hinder medical education is subject to debate. Whether programs abide by work hours rules is another debate.

Hope this helps.

David Carpenter, PA-C

 

[dragonfly99]

good post Coreo
I would add the caveat that the 80 hour workweek didn't eliminate Q3 call. They can still have Q3 call, but just not every 2 nights / Q2 like they used to.

 

[Medizinstudent]

Thank you for these answers.

Therefore, if there is a nightfloat system in effect at a hospital there is no call for a resident? Instead there is some kind of nightfloat rotation and the rest of the year a resident can go home at about 1800?

As I see it a US resident has to work harder than a German one. One the other hand, German residency programms are not as structured as their American counterparts. As a consequence, German residencies tend to last longer than necessary, for example because a surgical resident is not able to perform all the necessesary procedures he needs to take his final exams. Additonally, we do not have the sole position of attending, but have several levels of hirachy for board certified physicians. So, as a certified physician you still can't work on your own, because you directly report to the physician above you in the chain of command. Finally, salary of doctors in a hospital never increases much above the amount of money an experienced resident gets. Everything taken into account, I like your system more. 😀

 

[dragonfly99]

Not necessarily true that night float takes away all the call.

Sometimes night float is there just to "crosscover" other interns' patients, but the on call intern and resident still have to stay overnight and accept new patients. That's called "partial night float" or something I think.

Also there are various "short call" systems so that sometimes the night float doesn't take over until 10pm or something...so you may be on call but instead of admitting all night you take admissions only until 9 or 10pm, and then can either go home at midnight or so when your work is done, or sometimes be required to sleep at the hospital (but have a better call because you aren't admitting patients and taking nurse pages all night on other people's patients that you are covering).

But I agree with you about the hierarchy thing. We have "fellows" here, who have competed a residency but are further specializing. They are already licensed to practice medicine but are choosing to further specialize. They can work on their own if they want (not in a specialized area but on the side in a clinic or for a hospital, etc.) since theyhave a license. But they cannot independently practice a subspecialty (like GI or thoracic surgery or cardiology) yet b/c they aren't full trained in that. There are levels of academic doctors too ("Assisant professor" "associate professor" "full professor") and the high up ones get paid more. So we do have levels of physicians. But not every attending physician has to directly answer to the people above him for every admission, etc.