I’m an attending physician at an academic medical center, and I spend a lot of time working with residents. I’m just over year removed from the completion of my own residency, so I remember the feeling of being a resident well. We’re just about a month into the start of the new academic year, and with it the imposition of new, stricter rules limiting the number of hours that interns, specifically, may work. These dramatic changes were mandated by the Accreditation Council for Graduate Medical Education (ACGME), which oversees U.S. Residency programs.
It’s early yet to comment definitively on the impact these changes have had on residency programs, but the new limits on what interns may do represent a major paradigm shift in residency training. Interns may only work for 16 hours consecutively now, instead of the 30 hours that were allowed before and are still allowed for upper level residents. There is much to say about the consequences of these changes, including many more patient handoffs and questions about whether interns will acquire enough experience to effectively care for patients as senior residents.
I choose today, however, to mourn the death of the intern call night. Nothing made me feel more like an intern than being on call overnight in the hospital, and in no situation did I learn more about medicine, clinical reasoning, and the natural history of diseases. The fear and anxiety that I initially felt motivated me to be thorough and methodical, and was gradually replaced by experience and self-assurance in my clinical decision making. Nowhere was the learning curve for me as a physician more rapid and steep than as an intern on call overnight in the hospital -- whether it was cross-covering on the wards, admitting from the Emergency Department, or manning the Intensive Care Unit. I commemorated this progression late in my intern year (April 2007) with a poem I wrote for my fellow interns, as a gesture of solidarity. I share it today in memory of a once hallowed rite of passage in medicine.
"The Call Night"
by Sachin D. Shah, MD
(with apologies to Edgar Allan Poe)Once upon a midnight dreary,While I pondered, weak and weary,Stomach empty, eyes quite bleary,Which tone to set my pager beep;I tried to read, though on call,Gazing mostly at the wallAnd felt myself start to fall,Fall into a fitful sleep.Drink a cup of coffee, thought I,For I mustn't fall asleep;My vigilance, I must keep. Ah, distinctly, I remember,It was in the bleak December,Short of rest, and short of temper,Down my will began to creep.Desperately I wished a nap,With book laid shut upon my lap,For at this moment I was sapped,Sapped and pining for some sleep.But the night was young and I had not capped,So from my chair up I leaped;My concentration, I must keep. So on I went with my reading,The inner pleas for rest not heeding,And though feeling like my eyes were bleeding,My focus once again was deep.As I read about the liver,Down my spine I felt a shiver,While in my hand the mug it quivered,Quivered as the steam did seep.I took a sip and set cup down,And resolved tonight to count no sheep;My wits about me, I must keep. But in blurry protest against my will,Both eyes with tears again did fill,With throbbing head and stomach ill,Down my strength began to creep.Despite reminding myself aloud,Of the wakefulness I had vowed,Within a moment I had been cowed,Cowed into a broken sleep.Restful images rushed in like water,And the slope to slumber proved too steep;My guard aloft I could not keep. Ascending to a state of peace,Flying, gliding, a flock of geese,But now a sound that refused to cease,Brought groggy curses: my pager beep.Out of sorts and foul of mood,Belly growling for some food,Ready to cop an attitude,I shook myself awake from sleep.Grumbling I dialed the phone,And bemoaned my scattered flock of sheep;But clear my mind i tried to keep. Having signout for all the floors,At night becomes the worst of chores,For every patient is suddenly yours,And from the call room talk is cheap.The pages soon become incessant,For midnight stirs the convalescent,Mr. Davis wants a cough suppressant,Miss Randolph's dressing starts to seep.Stumbling I climb the stairs,And walk the halls half asleep;Suppressed a yawn I try to keep. An elderly man begins to wheeze,As the epileptic starts to seize,And since problems seem to come in threes,I uneasily await another beep.After a quick fix, as was the plan,Using albuterol and Ativan,Off to the seventh floor I ran,And into my call room bed I leaped.But before I could even count to ten,Another 3 pages denied me sleep,My will to live I try to keep. Two fires out, but three more raging,Hence the continued ceaseless paging,And deep inside me a war is waging:The need to work against the will to sleep.Mental status gone awry,Status post UTI,I scratch my head and wonder why,Why they won't just let me sleep.How nice it'd be to just ignore it,But what you sow is what you reap;Sound my judgment I try to keep. For fevers, a headache, syncope,I get cultures, Tylenol, an EKG,I briefly consider a head CT,But decide against and let him sleep.Then Mr. Cox falls out of bed,Though they didn't think he hit his head,But now his pillow's soaked in red,And he's unarousably asleep.Up the stairs again I march,The flights they seem to grow more steep;Open my eyes I try to keep. Checking labs as the clock strikes four,While hoping, begging, please no more,But then a page from another floor,Stirs awake my angst from deep.Mr. Smith was just on the commode,And now it seems his pulse has slowed,He passes out, and they call a code,So from my keyboard up I leap.I think while running up the stairs,In six short hours I'll be asleep;My motivation I try to keep. By six A.M. my notes are done,As the interns stroll in one by one,While one last time the list is run,And the check boxes get a final sweep.Finally the weight is lifted,And on to another soul is shifted,While standing up on rounds I drifted,Drifted off and fell asleep.I woke up when I lost my balance,And caught myself without a peep.My dignity I try to keep. As rounds are ending at half-past nine,My senior resident winks the sign,I'm free to cross the finish line,So from the team away I creep.Notes in charts and out the door,A pleasant daylong nap in store,And then tomorrow back for more,But for today at last I sleep.Post-call dreams are always pleasant,But such peace of mind is never cheap.Closed with ease my eyes I keep.