nightflow

[cinapism]

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I am starting to look into residency programs and I was wondering why there arent more gen surg programs with nightflow systems. Which programs do have the nightflow system and does it work well for them? ...I would think it does.

 

[Winged Scapula]

The correct term is night float.

Resons for lacking such:

1) we've never done it that way (ie, surgeons are resistant to change)
2) the night float residents would miss out on all the day time cases
3) FREIDA is not accurate and any data found there about night floats is probably out of date
4) we don't have enough residents to adopt a night float system
5) its too much trouble to try and figure out

More and more residencies are adding night float to be sure, as they must find a way to reduce working hours. The MAIN concern is the fact that these residents miss out on cases. I believe Socialist's program has a night float system which works well, but they tend to do so in larger programs so that the float can be divided up over a longer period of time.

 

[drdrew267]

night flow huh? good one.... 🙂

From what I've seen, this is another overrated system which is a necessary evil that must be done by a lot of programs to meet the work hours requirements. What are the drawbacks?

1. Imagine slaving away all night on patients that are not yours and who's treatment plans are ultimately not your decision. This is really the worst situation, anything goes wrong? Your fault. Anything goes ok or nothing changes? Who cares.

2. We are not vampires.

3. You don't necessarily get to operate. You have no access to the day cases.

4. Depending on the program, you may crosscover over 4 or maybe even 5 services - the quality of healthcare you administer will inevitably suffer. When they tell you: "just don't kill anyone"...it's pretty literal.

5. Even when you're not the nightfloat, you usually spend up to an hour signing out to the night float - so in reality, even though you are going home "early" with no call - you're actually staying late, everyday.

 

[boston]

This is an eternal debate. I am going to offer the other side in the interest of balanced representation. I am a PGY-5 that has experience with both systems. I worked under the nightfloat system over the past 3 years and had the q4 call system as a PGY-1 and 2. Honestly, there are advantages and disadvantages to both systems, some theoretical, some actual. To address these points:

1. Imagine slaving away all night on patients that are not yours and who's treatment plans are ultimately not your decision. This is really the worst situation, anything goes wrong? Your fault. Anything goes ok or nothing changes? Who cares.

With nightfloat you actually have the same person covering the same services each night, instead of a different person 4 nights in a row crosscovering. First, this enables familiarity to develop with the patients. I have seen this firsthand and IMHO (subjective), the patients get better care. Second, the nightfloat is now better rested and updated on the daily events every evening. Compare that to the previous q4 crosscover who did not know the events of of the past 3 nights. Third, taking ownership and taking responsibility for the patient is a state of mind. You are the primary service as nightfloat. The patients ARE yours. Blaming the system is a poor excuse.

2. We are not vampires.

This actually argues for nightfloat. Once you get in a circadian rhythm, doing the 12 hour night shift every night is easier than continually resetting your clock every 4th day. Residents are better rested now than before.

3. You don't necessarily get to operate. You have no access to the day cases.

True, night float is generally less operative. But at our program PGY-3 and up operate on all the emergent cases at night. As long as no cases during the next day go uncovered, things should balance out over the 5 years and the operative numbers should be the same. The numerator (number of cases) and denominator (number of residents) does not change.

4. Depending on the program, you may crosscover over 4 or maybe even 5 services - the quality of healthcare you administer will inevitably suffer. When they tell you: "just don't kill anyone"...it's pretty literal.

This was also the case prior to nightfloat as it is now. You simply cannot afford to keep a full crew in house at night. In fact the number of interns and the services covered are the same as before we transitioned to night float. Residents are better rested now. There is something to be said for being able to sleep in your own bed. Now if there is a sick patient, I have no problem calling the service chief at home if there is a specific question that is unclear, although this rarely happens.

5. Even when you're not the nightfloat, you usually spend up to an hour signing out to the night float - so in reality, even though you are going home "early" with no call - you're actually staying late, everyday.

I have never seen signouts take an hour. For us they usually take 5-10 minutes. These are not haphazard signouts. You can mention the pertinents and new changes in the day if the crosscover is already familiar with the patient because they have been taking care of them the entire month on nightfloat.

That said, I do miss being able to run some errands on my post call days q4 if I get home earlier post call. This does not mean you cannot go home early anymore with nightfloat. I often try to send my juniors/interns home early if I can -- as long as someone or one of us is here from the primary service in case emergencies arise.

I would be curious to hear opinions from those who have experienced both systems as a resident. With all due respect, a student may stay up the same amount of time, but a student is not exposed to the same degree of stress and responsibility. (I know that I am twice as tired on call as a resident than I was as a student staying up the same hours.)

 

[SocialistMD]

I echo boston's statements about the night float. The best way to find a list of programs is to look at the websites of the programs that interest you and see if they have it; there is no consolidated list (perhaps you could be the nice one to put it together...?).

Regarding drdrew267's third point, I again echo what boston said. I'll also add the math behind it. There are 365 days in a year (not counting this year). You get 21 days of vacation. You get 52 days off. That means, you are working 292 days/year.
If you are q3, you are on call 97 times a year. You also either (a) have to go home by noon on the pre- and post-call day, which cuts you out of the afternoon cases, or (b) go home at signout and then stay a full day the next day, which cuts you out of one day. So you basically miss 97 days of operating, which puts you in the OR a maximum of 197 days a year.
If you are q4, you are on call 73 times a year. You still have to go home by noon and you still lose basically 73 days in the OR a year, so you are only there 219 days a year.
At our program, you do nightfloat twice as an intern (4 weeks each)and once as a PGY-3 and 4 (6 weeks each). Eight weeks x 6 nights a week (you are on one 24 hour shift a week) = 48 days. Then you are q7-q14 the rest of the year = ~25 calls. 48 + 25 = 73 days lost in the OR, but technically you can count 8 of them back because of the 24 hour shift you work each week on nightfloat, so you really only lose 65 days. If you look at the PGY-3 & 4, it is even less time lost. Also, as pointed out, the in-house junior and chief are operating all night and the intern even gets a few bones (not as many as the daytime counterpart, but I did quite a few appys and a couple of amputations while on night float) depending on how much they want to operate and how much they have things under control on the floor.

I know this is simplistic and doesn't account for times spent in the ICU where you are not operating anyway or the rotations where you don't take call at all and blah, blah, blah, but I just wanted to further illustrate that you aren't losing out on time in the OR with the night float system.