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.

Related posts:

1. Duty hours, patient safety and resident education
2. Adapting to work hour restrictions
3. Night float – a plus or a minus
4. Work hours – medical student perspective
5. The 80 hour work week

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