Say the words “night float” and you get many responses. Many residents and interns see night float as an undesirable, but necessary evil. Night float makes the other months more tractable, but that month (or 2 weeks) is a special level of hell that Dante never imagined. For those who know nothing about night float (and who care) this article tells the story well – The Nightmare of Night Float: Is an ignorant doctor really better than a tired one? Thanks to the reader who sent me the link!
Night float is the product of reforms in medical education that limit the number of hours that residents and interns—doctors in training—can work. Because they can no longer rely on the same doctor caring for a group of patients day and night, teaching hospitals have had to arrange more cross-coverage when the primary resident is not on duty. Most have created the position of a resident who works the night shift, usually for a few weeks. The upside is that other residents can sleep. The downside is frequent patient handoffs, which can result in the transfer of faulty or inadequate information. The nightmare of night float raises a central question about work limits for interns: Is it better to be cared for by a tired resident who knows your case or a rested resident who does not?
I have a love hate relationship with night float. Since night float started, post call rounds are actually more educational. The night float intern allows my interns to be more alert and have education receptors. Before night float, the interns were doing the cross-coverage for their colleagues on other admission teams. The cross-coverage activity is the one that wears down interns (both emotionally and intellectually.)
Night float interns make mistakes because they do not understand the context of the patient. Night float interns create more work for the admitting team, because of their mistakes.
Night float interns are usually miserable. Imagine an entire month of vampire’s hours. Your circadian rhythms are destroyed. The night float intern eschews education. Thus, we have had to create a non-educational month.
If tired residents hurt patients, but the ignorance of night float and cross-coverage also pose a danger, what should hospitals do? No doctor can work 24 hours a day, seven days a week, so cross-coverage is essential. The optimal system would provide rested night floats with all the information they need. The best way to accomplish this is for teaching hospitals to have standardized, electronic handoff systems. In medicine, as in aviation, most errors occur at transitions: by pilots, during takeoff and landing, and by doctors, after handoffs. Because of work limits, an intern today might be involved in more than 300 handoffs during an average monthlong rotation. Too many hospitals continue to rely on one intern signing out verbally to another, an invitation for error. Less than 5 percent of hospitals have electronic handoff systems in place.
Without better handoff systems, work limits may well weaken medicine more than exhausted residents ever did. As a doctor in training, you have to see a patient’s illness through its course—observe the arc—to get a grip on the dynamics of disease. It is possible to overcorrect for even the most serious of problems. And in trying to get young doctors a bit more rest, we may have come up with a cure that is worse than the disease.
As an alter cocker, I worry about the next generation of physicians. Are the sleep deprivation activists ruining medical training? (As an aside, when will they start boycotting Jack Bauer?) Will the graduates of our programs deliver a lower quality care because they just did not see enough patients? Will the decrease in educational opportunities which our byzantine scheduling induces leave our graduates at an intellectual disadvantage?
I love night float; I hate night float. Night float is a necessary evil, but make no mistake it is an evil. And I see no alternative.
