Intake lasts until about nine-thirty, at which time an X-ray conference begins. At this conference, all X rays taken the day before are reviewed with the radiologists. This X-ray conference usually lasts until ten o’clock.
Then comes attending rounds, when the ward team meets with a member of the faculty. During attending rounds, admissions from the night before are focused upon, the presenting symptoms dissected, and the patients’ diagnoses discussed at length. The ward attending is the person who is ultimately responsible for the care that’s delivered, and so in addition to teaching about the conditions that afflict the patients, the attending must make sure that the proper things are being done in a timely fashion. Depending on how many patients were admitted the day before and how long-winded the attending is, rounds can go on until between eleven o’clock and noon. Every day at noon there is a didactic lecture on a pertinent topic in pediatric medicine. So, the average intern may not get down to attacking the scut list until after one o’clock in the afternoon.
Most interns will tell you that scut is the sole reason for their existence. Scut includes blood drawing, IV starting, the tracking down of lab results, the ordering of diagnostic tests, the calling of consulting services, and finally the writing of progress notes. Most of this stuff is sheer frustration and takes hours and hours to complete. While “running the scut” the intern also is responsible for teaching his medical student about pediatrics. Depending on how many patients he’s following, how efficient he is, and how many questions his medical student asks, the intern who’s not on call may get out of the hospital anywhere between three in the afternoon and nine o’clock at night, with the average being around six.
When they’re on call, of course, they don’t go anywhere. They stay all night, managing any complication that may arise in any of the patients on the ward and admitting all new patients who are sent up from the emergency room. Sometimes, when the emergency room is quiet and the patients on the ward are stable, the intern might be able to retire to the on-call room to get some sleep; at other times, when things are hectic, he or she might not even have enough free time to go to the bathroom. And the daily routine begins again at seven-thirty the next morning; even if the intern has gotten no sleep during a night on call, he or she is expected to participate in all the activities that occur during the entire postcall day.
This cycle is repeated every third night. Interns spend the first night in the hospital. The next night, when they’re postcall, they usually are unable to do anything other than go home and hit the sack. The final night in the cycle, the precall night, is the only one in which most interns feel alive enough to go out and have a little fun. But very often, the precall night is ruined by anxiety; lurking in the back of the intern’s mind when they’re precall is the fact that the following night may be a complete and utter disaster. And so, in a sense, even when they’re out of the hospital, there’s no escape.
The interns are also expected to carry out certain tasks that are not all that difficult when well rested but may prove to be impossible after a night spent on call without any sleep. Without sleep, an intern can lose track of the subtle social skills that are necessary for communication; as a result, talking to patients and their families can become torture. The intern also is expected to present orally, during attending rounds the next day, all the patients who were admitted during his or her shift. Keeping track of names, symptoms, physical findings, lab results, and treatments can become an insurmountable task when you’re having trouble just keeping awake. And screwing up a presentation can bring on the wrath of the attending, who is relying on the intern’s information, and a lowering of the intern’s own self-esteem.
This system of night call has come under a great deal of scrutiny in recent years. Public awareness, however, has not been focused on the toll that these long shifts are taking on the interns and residents, but rather on the toll that they’re taking on the patients. It’s been argued that a house officer who’s been up all night can’t possibly provide adequate care for critically ill patients. So, over the past few months, some alternatives to the current system have been proposed. The most popular of these would limit both the number of hours an intern or resident could work during a single stretch to twenty-four, and the number of hours worked within a single week to eighty.
On the surface, this seems as if it would be a good situation, but some house staff members have expressed fear that new regulations such as these would actually make their lives more miserable. These house officers recognize the fact that to provide staffing of the wards and emergency rooms on a twenty-four-hour basis, hospitals would have two choices: Either hire 25 percent more interns, or have the existing interns work twelve-hour shifts seven days a week. Because of the lack of availability of funds to pay for a whole crop of new house officers, as well as the problem of finding qualified medical school graduates to fill these positions, people are worried that the second choice is the one that would be instituted. And almost everyone agrees that they’d much rather work thirty-six hours at a stretch and have a day off every week than work shorter periods every day of the week.