Making night float work


Category : Medical Rants


My post on night float stimulated significant interest.  Rural Doctoring is currently writing a series of articles in support of night float.  Last month Medscape featured a very interesting perspective on work hours – The Disappearing Doctors.  The author tells the story of discontinuity in patient care and education.

Besides ensuring excellent medical treatment for patients, the ACGME work rules were intended to keep residents alert so that they could fully engage in the work and education needed to become fine physicians. The rules, however, are backfiring. Residents no longer are able to observe the timing of a patient’s response to an intervention; they can’t follow the tempo of a fever or the bloom-and-fade cycles of a rash even when, as responsible physicians would, they sincerely want to. Their heads are crammed with the facts they’ve learned during medical school, but they can’t see firsthand the course of a birth or a gall bladder attack or the phases of recovery from a surgical procedure and then integrate those facts into informed decision making. Instead of producing physicians with high professional standards who see their patients through to the end (of labor, of an operation, of an illness, of a life), the current system is creating a legion of shift-worker physicians who leave when the clock strikes a certain hour rather than when the job has been completed.

In evaluating their training programs, residents often ask for increased autonomy. They realize that in the future they’ll be solely responsible for the care of their patients, and they worry that without a certain amount of autonomy during their training, they won’t be adequately prepared for independent decision making. Yet with their current here-today-and-gone-tomorrow schedules, they can’t be given increased autonomy—they won’t be around for the next step or haven’t been around for the last step. They don’t have the big picture.

The problem with most night float systems stems from a lack of a clear statement of goals.  Does that sentence make sense?  I suspect that I must explain further.  Too many night float systems are developed to meet work hour restrictions without regard for underlying principles.  Some programs have designed their work hour adjustments (including night float) based on underlying principles of maximizing continuity, decreasing the number of "hand offs", and understanding that patients’ need daily continuity (even though night time often has discontinuity.) 

One can develop a night float system that insures team continuity on a daily basis.  The program where I do my internal medicine teaching has developed a system which maximizes team continuity.  This system was not developed just to meet work hour requirements, but rather was designed to preserve patient care and team continuity.  Thus, for a 2 intern and 1 resident team, days off are arranged so that another team member can "pick up the slack."  As the ward attending, I add to the continuity.

Is this the best answer?  While I cannot answer that question, I do know that we work hard to balance education, work hours and optimal patient care. 

Night float is a key component in allowing our residents to meet work hour restriction and yet do our best to maintain a good educational program. 

Night float sucks for the night float intern.  Night float, combined with a thoughtful schedule, improves the residents’ ability to learn for the other 11 months of the year, by making their lives less stressful. 

To me the big message is that we must teach interns and residents how to develop efficient hand offs, write excellent notes so that the cross covering physician has the best chance to provide optimal care.  We must design night float systems, not to meet numbers but to optimize education and patient care.  It can be done.


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Comments (2)

I agree absolutely. My Night Float experience was relatively well-integrated into the overall residency curriculum, and I think it enhanced rather than detracted from my learning experience. However, many Night Float systems are merely tacked onto an already busy curriculum as a work-hours saving device, and these are–I suspect–less educational. I’m going to propose a Modest Solution on my blog at the end of the week.

I think another very good alternative is Day Float. At our program, we have a day float resident. A hospitalist team admits from 0600-noon, allowing teams to round without interruption. We have a day float resident who rounds with the on-call team, and takes admissions from noon to 1700. Meanwhile, the resident for the on-call team comes in at 1700 and takes turnover from the day float resident. Meanwhile, interns alternate q4 long and short call–short call admits during the day until 8pm, and then the long call takes over. This way, interns rarely “cap”, and somebody from the on-call team is involved in every admission. Plus, the next day, the overnight intern leaves by noon, and is able to hand off his/her work to the other intern on the team and the resident.

It maximizes continuity, there is only q8 overnight call, nobody has any work hour issues, and there is still time for didactics.

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