Thoughts about Night Float vs. Overnight Call?

[QofQuimica]

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Bah! Night float's not that bad.

Obviously I'm only speaking from a med student perspective, but I liked night float way more than taking a 30 hour call. jdh, do you have any thoughts about what proportion of programs have night float versus 30 hour call?

 

[jdh71]

Obviously I'm only speaking from a med student perspective, but I liked night float way more than taking a 30 hour call. jdh, do you have any thoughts about what proportion of programs have night float versus 30 hour call?

I honestly have no idea about the proportion overall, but when I was interviewing two years ago I'd say most of the programs I looked at had some sort of night float system maybe 7 or 8 of the 10 where I interviewed. Where I am at currently it's kind of a mixed system, with a night float covering sunday through thursday, and a 30 hour call Fri and Sat. Most 2nd year residents not on night float have one 30 hour call per month. It's not too bad.

The other nice thing about night float is that it much more easily allows for "golden weekends". Where I train you usually work two weekends and have two full weekends off. This seemed strange to me coming from a traditional call system in medical school, but having two days in a row off during residency feels like a mini vacation. Good for morale.

Now I know and have heard most of the arguments against night float from people on a traditional call system but 1) just don't think the arguments are that strong and 2) I think the future of hospital medicine is shift work, so we should all start getting used to working that way.

Plus I really like the autonomy granted by night float as a supervising resident. The house is literally YOURS for 12 hours every night for a month. I put in more lines my night float month than either of my ICU months (though not combined). I ran more codes my night float month than either of my ICU months combined, mostly because there is always an attending or fellow around during business hours.

(I also discovered my new favorite cartoon - Metalocalypse 😀)

The month was also nice because I was able to make it to the gym 5 times a week - go home after 8AM check-out, sleep, wake up around 4, to the gym, eat, and to work. I was also able to have time to catch up on my reading and data collection for my current research project between admission and other night-time shenanigans.

The drawbacks for me personally, were 1) I like to see the sun, 2) you miss your friends who are working days, 3) if you are on with the wrong people it will be a long month, 4) its harder to conduct normally everyday business.

 

[gutonc]

Obviously I'm only speaking from a med student perspective, but I liked night float way more than taking a 30 hour call. jdh, do you have any thoughts about what proportion of programs have night float versus 30 hour call?

I'm not JDH but I'll bite. I too have no idea the percentage of places that have NF vs o/n call. Our program has a mix of the two (overnight on the University wards and VA ICU and NF on VA wards and Univ ICU and CCU) with a cross-cover system to smooth out some bumps. NF rotations are 1-2 weeks (1 week on ICU/CCU as part of a regular 4 week rotation; 2 weeks at the VA, usually followed or preceded by vacation).

Keeping in mind the potential issues with hand-offs (and also keeping in mind that even in a q3 overnight call system, there will be patient hand-offs so this is something of a straw man argument), I think night float creates a more humane training system and provides patients with rested, focused physicians to care for them.

 

[kenshin1]

I'm not JDH but I'll bite. I too have no idea the percentage of places that have NF vs o/n call. Our program has a mix of the two (overnight on the University wards and VA ICU and NF on VA wards and Univ ICU and CCU) with a cross-cover system to smooth out some bumps. NF rotations are 1-2 weeks (1 week on ICU/CCU as part of a regular 4 week rotation; 2 weeks at the VA, usually followed or preceded by vacation).

Keeping in mind the potential issues with hand-offs (and also keeping in mind that even in a q3 overnight call system, there will be patient hand-offs so this is something of a straw man argument), I think night float creates a more humane training system and provides patients with rested, focused physicians to care for them.

I went to med school at a program with a nf system and I am now an intern at a program with a traditional q4 ward/ q3 unit schedule. I honestly much prefer the latter system. Although i agree the hand off argument is silly, there is something to be said for admitting a pt then managing them in the acute phase of their illness

 

[jdh71]

I went to med school at a program with a nf system and I am now an intern at a program with a traditional q4 ward/ q3 unit schedule. I honestly much prefer the latter system. Although i agree the hand off argument is silly, there is something to be said for admitting a pt then managing them in the acute phase of their illness

The other argument that is mostly nonsense . . . and only makes sense in the context of the ICU or CCU and only with some patients even then, DKA into the unit for instance.

BUT when you're on for gen medicine . . .

Admit basic old lady pneumonia, start antibiotic, start home meds. Don't get called again or follow up a single other thing because you don't need to. Patient is fine.

Admit basic old guy COPD exacerbation, start antibiotic, give steroids, gives nebs, restart home meds. Don't get called again or need to follow up a single other thing because you don't need to.

Admit "psychiatric" chest pain. Trops times 3, start home meds. Don't get called again, check the computer at midnight for a negative troponin.

Ect.

With a night float system you learn to deal with hand offs and you still get to see the f/u for the day when you're on the day team. You still get to see BOTH sides of the equation just not for the same patient the same month. You don't miss out on any of it anywhere, not really. And like I said the future of hospital medicine is shift work. You'll come in at 8PM and your colleagues will check out and go home, and you will check out to them in the morning. This is a skill people need to learn. It's not like there are Q3-4 hospitalist groups like residency.

 

[kenshin1]

Well, dka never goes to the unit at my program. Regardless, I disagree with you. There are BS admissions which you can ignore overnight but there are many others that require follow up on. Also, since I am alone on call, I "run the house" every fourth night.

 

[jdh71]

Well, dka never goes to the unit at my program. Regardless, I disagree with you. There are BS admissions which you can ignore overnight but there are many others that require follow up on. Also, since I am alone on call, I "run the house" every fourth night.

DKA doesn't require the unit (most of the time), but its often the only place you can get nurses to do Q1 accuchecks and get Q2-4 blood draws.

But you missed my point. When you are on night float you follow that part of the admission and when you are the accepting team for the team, you follow the patient during the day. You get to do both parts at some point during your year, therefore, night float and traditional call have the SAME amount of patient follow-up per the specific diseases that show up and get admitted to medicine. You get no extra bonus for being on all day and all night, unless you prefer Q4 sleep deprivation (I tend to classify this as a negative, but to each his own).

Lastly, for MOST medicine admits at night, once orders are on the chart there is really not much left to do or even check on.

The surgeons have a much better argument for this than we do because they are a procedure based practice. Medicine is not.

 

[QofQuimica]

Keeping in mind the potential issues with hand-offs (and also keeping in mind that even in a q3 overnight call system, there will be patient hand-offs so this is something of a straw man argument), I think night float creates a more humane training system and provides patients with rested, focused physicians to care for them.

Your input is appreciated, and I agree based on my much more limited experience as well.

I went to med school at a program with a nf system and I am now an intern at a program with a traditional q4 ward/ q3 unit schedule. I honestly much prefer the latter system. Although i agree the hand off argument is silly, there is something to be said for admitting a pt then managing them in the acute phase of their illness

So do you not find the sleep deprivation to be a significant downside? I know that after a 30 hour call, I felt kind of hung over without having had any fun the night before.

But you missed my point. When you are on night float you follow that part of the admission and when you are the accepting team for the team, you follow the patient during the day. You get to do both parts at some point during your year, therefore, night float and traditional call have the SAME amount of patient follow-up per the specific diseases that show up and get admitted to medicine. You get no extra bonus for being on all day and all night, unless you prefer Q4 sleep deprivation (I tend to classify this as a negative, but to each his own).

This is not something I had ever thought about in quite this way (not missing anything because you're seeing similar patients on both days and nights), but it makes sense to me.

I'm thinking that since we're taking the OP's thread off track, it might be a good idea to separate out these posts into their own thread. If anyone else has input about night float versus overnight call, I'd definitely be interested in hearing it.

 

[Scaredshizzles]

Your input is appreciated, and I agree based on my much more limited experience as well.


So do you not find the sleep deprivation to be a significant downside? I know that after a 30 hour call, I felt kind of hung over without having had any fun the night before.


This is not something I had ever thought about in quite this way (not missing anything because you're seeing similar patients on both days and nights), but it makes sense to me.

I'm thinking that since we're taking the OP's thread off track, it might be a good idea to separate out these posts into their own thread. If anyone else has input about night float versus overnight call, I'd definitely be interested in hearing it.

I don't think it is a big deal one way or the other, but those who argue for overnight call say that following one individual patient for 24+ hours results in more of a feeling of ownership...You also get to see how certain acute illnesses progress or resolve over a 24 hour+ course.

I think both night float and 24+ call are both draining on the system. Night float hours often tend to be longer, and you can't get a lot of day to day things in your life done during those weeks. It takes a while to really adjust your sleep cycle, so it isn't a huge advantage in that regard compared to overnight call. The only situation where overnight call is an advantage is in places where the patient load isn't so bad that you can actually get some sleep during that overnight call. In that case, post-call can be golden.

 

[Polish Farmer]

After having done Med School in a NF system, and now an R1 doing q4overnight, I can honestly say q4 30hrs blows. But I think it is appropriate in certain situations (in the MICU and CCU), as for the floor, well prob a NF system would be best, but I have seen some disastrous consequences of multiple handoffs with complicated patients.

 

[Frugal Traveler]

Does anyone know when the ACGME/RCC will make any comment about the nap issue? I thought it was supposed to be in February.

 

[Scaredshizzles]

The bottom line is that there are some programs who choose their system on what they feel would be best for the resident's education and quality of life, and some that choose a system based on how they can get as much work as possible out of the residents, without on the surface violating any regulations. I interviewed at program where you do one outpatient clinic week or something every month. The only point to that is that it allows you to average in one light hours week every month, with three very heavy hours week. That way you can stay under the 80 hours/ week average per month without actually being under 80 hours every week...i.e. 3 weeks of 95 hours, and 1 week of 35 hours.

 

[jdh71]

After having done Med School in a NF system, and now an R1 doing q4overnight, I can honestly say q4 30hrs blows. But I think it is appropriate in certain situations (in the MICU and CCU), as for the floor, well prob a NF system would be best, but I have seen some disastrous consequences of multiple handoffs with complicated patients.

I agree. I think q4 is best in the ICU.

 

[jdh71]

The bottom line is that there are some programs who choose their system on what they feel would be best for the resident's education and quality of life, and some that choose a system based on how they can get as much work as possible out of the residents, without on the surface violating any regulations. I interviewed at program where you do one outpatient clinic week or something every month. The only point to that is that it allows you to average in one light hours week every month, with three very heavy hours week. That way you can stay under the 80 hours/ week average per month without actually being under 80 hours every week...i.e. 3 weeks of 95 hours, and 1 week of 35 hours.

That's an interesting way of gaming the system, definitely maintains the letter of the law while anally raping the spirit of it.

 

[dragonfly99]

I trained at places that had no night float. At the time, I thought it was best for my learning. Now, I'm not sure. I actually think that the MICU is the place that should NOT have the 30 hour calls, and the wards are the place where it is O.K. This is because in the unit you have to do more procedures and make more decisions that you could screw up by being tired. Also, there was a study out of Harvard a few years ago that showed that interns made more mistakes with 30 hour overnight call in the MICU versus a day/night system where they only worked 12-16 hour shifts I think.

I do see that some interns and residents at the place I'm currently doing fellowship don't seem to know the patients or take ownership of them very well on rotations that have night float. If you do have night float, then I think it's important in the a.m. that you get a good signout and that you take the time to really examine your patient and know the overnight events, even if you didn't admit the patient...

 

[Gastrapathy]

I do see that some interns and residents at the place I'm currently doing fellowship don't seem to know the patients or take ownership of them very well on rotations that have night float. If you do have night float, then I think it's important in the a.m. that you get a good signout and that you take the time to really examine your patient and know the overnight events, even if you didn't admit the patient...

I trained in a place that switched to a NF while I was there. I felt like I never knew the handed over admissions as well as the patients I met in the ED, no matter how long they stayed. Maybe it was just me but it took some getting used to. Overall, the NF model is the hospitalist model, and I think we should train to what we actually do.

 

[Polish Farmer]

actually, since I am now postcall from my 30+hr shift on the wards yesterday, F*** this!! Anything is better