The Road through Residency:

Sleepless in Dayton

The crisp white coat I'm wearing belies the coffee stains that have spattered my button-up shirt beneath it. The past 30 hours while I have been on call have left the white oxford littered with brown discolorations - a splash of Sumatra here, a few drops of Arabica there. I pull my glasses off as I set the coffee cup down gently on the counter, careful not to splatter my only clean white coat. One of the young interns comes up to query me before the attending is upon us.

"Mrs. B's white count is up," he says with a hint of regret. His face carries a feeling of shame, as if every patient must make a speedy and complete recovery before he releases them back into the wild.

"Why do you think that is?" I ask, prodding. I have already seen Mrs. B's white count, examined her, and figured out why her labs are slightly abnormal. But I know that if I tell him, he won't learn. Teach a man to fish ... you know the proverb.

"I'm not sure. It could be infectious, a urinary tract infection." He sits down and hangs his head in his hands. He has been up all night too. Looking at his fatigue, so obvious upon his face in rings and circles, I stop my Socratic questioning and tell him.

"Steroids. We started steroids, remember?"

"That's right! I forgot."

"It's fine," I say. "The good news is she can probably go home."

"You know, I just can't think after a night on call," he explains. He heads off to finish up before rounds.

I look at my watch to gauge how much time we'll have to round on patients, if we'll have enough, and whether I should take a few minutes to discuss a topic for the interns and medical students. As I'm running the list through my mind and sipping my coffee, our medical student arrives. Her eyes are bright and well-rested, and she is showered, smelling of lilac perfume and Dove soap. At this time in the morning after a night on call, you would sell your soul for a shower and a pillow.

"You look a little tired, Dr. Faber," she says.

"Jason," I correct her. "And yes, I am a little tired. But you get used to it."

"How many hours do you have to stay up?"

"Depends," I say. "Sometimes it's all night, sometimes you get two to three hours of sleep or more. But the experience is important, and it teaches you your limitations."

"Well I hope I can get several hours of sleep when I'm on call," she says.

"Conceivably, you might never have to worry about that." I proceed to tell her about the changes coming.

Throughout medical training, long in-hospital calls have been commonplace. Although many programs now have shift work - with interns and residents to handle the night shift - many still have interns stay overnight while on call every fourth day. The hope is that this experience, under the watchful eye of a resident, will give the newly minted physician a taste of long hours, which are common in the real world. I remember my time in the hospital as an intern, staying 30 hours and watching patients and their progressing or worsening state. Managing sick patients over the first 24 hours can be an exceptional, valuable learning experience.

Starting next July, the Accreditation Council for Graduate Medical Education, the accrediting body for residency programs, has stipulated that interns be on call for no longer than 16 hours at a time. This could result in physicians never having to spend more than 16 hours in the hospital during their entire training. I fondly remember those long days on call, while young physicians years from now will shake their heads and say, "Nobody ever stays longer than 16 hours."

"So," the medical student asks, "do you think that means I won't get enough training?"

"I don't know if this change is good or bad," I tell her. "But I think my days of sleepless nights have made me more resilient, and ready for what the future has to bring."