I wonder what my family and friends think I’m doing when I tell them that I am on call. I suspect that they envision me drinking tea at home waiting “to be called”. Well while there might be a hint of truth in that, it’s not entirely the case.
Let me explain.
Being on call really means different things depending on the type of physician, the type of practice, the level of training, and the location of practice.
On Call as a Medical Resident
For example, when I was a medical resident, on call meant that when the other residents left the hospital around 5 pm, my team and I continued to take care of the medical patients, admit new patients from the emergency room, and answer calls in-house, until about 10 pm or until the following morning if in the intensive care units. Yes, I’m an #80hourworkweek baby.
I haven’t taken in-house call since 2007. Thank goodness. I like sleeping in my bed.
ID Weekday On Call
Being on call as an infectious disease physician in private practice is actually not bad as compared to other physicians. I mean it’s bad, but it could be much worse.
On call on a weekday means that at the end of the work day (let’s say 5 pm) I get to leave the hospital but I better have my pager (yes, we still use those) or phone close by at all times since any questions that may arise about patients on the service, mine or my partners, or patients that are perplexing other physicians will need to be answered in a timely manner.
As a first year fellow training to be an infectious disease specialist, I was paralyzed on call. It didn’t matter that just the week earlier I was as knowledgeable as the medical resident now calling me asking my opinion and guidance on a complicated infectious disease case. Talk about trial by fire. I would rush to get home so that I could lay out my reference books to better answer the questions that came my way. I was terrified of getting paged on my drive home. Good grief!
Now, obviously, I don’t need to carry the Sanford Guide into the shower or to bed with me. I have no qualms about going out to dinner or hanging out with friends while on call. But I still can’t go to a show, a concert, or the movies. I can’t keep leaving the theater and inconveniencing everyone around to answer a patient related phone call don’t you know. So yes, on a typical weeknight on call which occurs about once weekly, I may be eating crumpets and drinking cocoa in my pajamas while fielding the few patient related calls that come my way.
Luckily as an infectious disease physician, there are rarely any emergencies that would actually need me to get dressed and head back to the hospital. Unlike, say a nephrologist (kidney specialist), who might need to return to start a critically ill patient urgently on hemodialysis, or maybe a cardiologist (heart specialist) who might need to open up the blocked coronary vessels of someone having an acute heart attack. For the most part, I know that once I tuck in for the night, I’m good.
Once, as a fellow though, I actually woke up and went into the hospital at one in the morning for a necrotizing fasciitis case (flesh-eating bacterial infection), who, by the time I arrived, was in the operating room where he ought to have been, thus was never actually seen by me. It was absolutely unnecessary for me to have done that trip for although it was a grave situation for the patient, I could have easily told the resident on the phone which antibiotics to order (which I did in my weak attempt at protesting the request to actually come in). What the patient urgently needed was to be in the operating room with a surgeon getting the infected tissue cut out. Knife-cillin generically known as “cold hard steel” once again proving to be the best “antibiotic”.
The Joy of Night Call
Sometimes the pager goes off just once at night. Sometimes it goes off several times during the night. Any time of the night. Several times. It could be 2 am, and the emergency room shift-working physician is on the other end of the line asking my opinion on a brand new case. It’s sometimes comical, truly how the system expects doctors woken up from sleep in the middle of the night to be fully coherent and competent. It’s annoying when the question is really something that could be looked up. Really? You are going to wake me up at 3 am to ask me how to dose an antibiotic? When any other occasion your attitude is “me too, I learnt antibiotics in first year medical school so I should be allowed to order any and every antibiotic I want when I want.”
While I understand (and agree), that a physician may need an expert to bounce off ideas and thoughts about a complicated patient, it amazes me that I am yet to spew out nonsense as the specialist on one of those awoken-from-deep-slumber-sleep-talking night calls.
Worse are the calls from nurses who call at four or five in the morning saying “I hope I didn’t wake you up, I’ve been meaning to tell you that the patient in room 503 had a fever of 99.8F at two this morning, so we gave Tylenol, did you want us to do anything else?” Argh!! No, I was not just getting up and Mr. X has had so-called fevers for days. Why then am I being bothered about it at 4 am? Ah, of course. So the nurse can document “physician aware” in the chart. By the time I shut my eyes again the alarm goes off signalling the start of another work day. Sigh!
So that’s a week day call for me. Not too bad.
Weekend On Call
Now a weekend call is another issue. I could do without being on call on the weekend, ever. Ugh! Let me explain.
Imagine you have two colleagues. The three of you on a regular work day address all your patients needs as it applies to your expertise which in this case is infectious diseases. On any given day, there are lets say about 60 patients, that you divide and conquer, so to speak. But you all can’t work every single day of the year, 24/7/365. Man needs a break. So does woman. So every third weekend one person is on call so that the others can get a weekend or two off. So every third weekend from Friday 5 pm to Monday 8 am you are IT. You and your pager/phone are one. Not only are you fielding random calls similar to weekday calls, somebody has to see to it that those 60 patients are evaluated and treated. And that someone is you.
Imagine now, during the week, it takes you all day to see about 15-25 patients some of who are brand new to you. So you know right off the bat that on a weekend when you are solo, there’s no way you are going to be able to lay eyes on sixty patients, let alone examine them, review their labs, listen to them talk about their dog Fido left all alone at home, or listen to family tell you that grandpa now languishing was the perfect picture of vitality just the other day. Better yet, dare to interrupt a patient who just got their lunch tray or is on the phone with the dog Fido, or dare the transporter with your evil stare to grab the patient’s chart from your death grip, or deal with attitude from the medical assistant who thinks that browsing Macy’s at the computer supersedes your using said computer for patient care. Then figure out what’s wrong with the patient, discuss the case with the primary team…when they finally call back 15 minutes later, wait for the computerized medical record to load so you can write orders, give instructions to the nurse etcetera all in that same time period. Impossible!
To be fair your colleagues know that. After all, they also have an on call weekend coming right on up. So they do give some guidance and tell you which patients you could potentially skip. Yes, as a consultant you don’t actually have to see each patient each day although a seen patient is a billed patient and a billed patient is a chance at reimbursed work, just saying, kaching!
So maybe out of the 60 patients on the census you have 30 must-sees. Patients are are still undergoing workup. Patients who are critically ill. The game plan then is to go in to the hospital earlier and leave later than you would have on a routine work day. But wait, there’s more. For, people always show up to the emergency room with one complaint or another. Or a patient unknown to your service who has been in the hospital 30 days already suddenly crashes and needs your expertise. So through the course of your Saturday or Sunday, you might get 10 or more additional patients, all new to you, and all very time-consuming. Yikes! The best part is that you never have a clue how many patients you are going to get so you can’t really plan your day. You just work as efficiently as possible for when you get slammed. And you will get slammed.
Now assume that you actually have five colleagues and the six of you split work at two hospitals 30 minutes apart on a regular week day. So now on a weekend, your census is about 120 patients and the day is spent driving between hospitals. Fun! Fun! Fun!
Nah! I still haven’t found a routine that allows for the maintenance of sanity on an on call weekend. I hate on call weekends. No matter how early I start, it’s a sprint in which I am guaranteed to never get to the finish line. I start out strong but by late afternoon I’ve run out of steam yet there are still more patients to be seen. By evening, I’m falling asleep while trying to dictate my examination and impression of the 14th new patient. How many years have I done this, and I still haven’t learnt how to take some me time and eat a proper breakfast or lunch…or dinner. Rather I wolf down junk while running around like a chicken without a head.
When I finally crawl home, I am still answering those ER or nurse calls at 3 am while trying very hard to catch some shut-eye, because quelle surprise, the next day is Sunday and I am still on call. It’s the twilight zone magnified. They can only kill me until Monday! They can only kill me until Monday! They can only kill me until Monday!
When I finally crawl home Sunday night, I have Monday, a work day, to look forward to, and though I’m no longer on call (yes!) I’m thoroughly exhausted and I have the pleasure of working another 5 days before I get a break. Those Mondays post-call, I look at the patient census which has had remarkable turnover and I can’t differentiate Mr. Simpson from Mr. Samson both of whom were new consults, both of whom are on the same medical floor, both of whom have something wrong with one of their legs. They are just one big blur. Sigh!
But wait, there’s more. Silly me, I forgot it is the weekend, and for normal people, the weekend means catching up with friends and family or doing laundry, shopping, and other errands. You know, basically chillaxing. So I’m in the middle of all this craziness and of course my phone rings. Ring! Ring! It’s my mother/father/sister/friend. “H-e-y”, the light-hearted voice lazily sing-songs on the other end, “what’s up? Can you show me how you mix henna for the hair? Can you show me how to fix my computer? I just wanted to catch up; it’s been ages…” and all I really want to do is throw that darned phone out the window but I can’t really can I for how else am I going to return patient related calls?
I hate on call weekends. Did I mention that before? They make me hypertensive. They give me gastric ulcers. They are going to be the main cause of my future urinary incontinence, dementia, premature graying, irritable bowel, obesity, you name it. On-call weekends make me crabby because even though I know I can’t physically examine and evaluate 60-120 patients in a day I’m going to try my very hardest to be that Bionic Woman.
ARGH!!!!!
I hate on call weekends! Pure madness, every few weeks like a recurrent nightmare. The things we do!
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