Dr. Cohen is chief resident, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California.
Dr. Sarkar is assistant professor, Division of General Internal Medicine, University of California, San Francisco, School of Medicine, and Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, California; e-mail: firstname.lastname@example.org.
It was July 1, 2011, the first day of the new duty hours restrictions. Ms. S, a 40-year-old woman with AIDS and cirrhosis, presented to the emergency department with a fever, fatigue, and mild headache. The emergency department staff determined that she should be admitted.
Seth: They paged me, the senior resident, to admit Ms. S around 6 PM. With three hours of the call day remaining, I needed to ensure that our team had plans for our eight new patients, that our orders were in, and that the patients were stable enough to sign out to the night team. I also had to decide what to do about Ms. S, who remained undifferentiated, undiagnosed, and perhaps in need of a lumbar puncture. Although her admittance presented a great learning opportunity, when would we find the time to teach?
Urmimala: At 7:30 PM, as I put my kids to bed, I wondered, as the attending, when would be the best time to call Seth. Our usual practice of “touching base” around 10 PM would not work—He had to be out of the hospital by 9 PM. I’d surely interrupt, though, if I paged him earlier. By 8:30 PM, I’d heard about Ms. S, and I debated between letting the team get back to work and peppering them with questions because the clinical picture remained unclear.
Seth: Under the new duty hours restrictions, I work roughly the same number of hours per week as I did before. The difference is that I no longer stay overnight on call. While interns and residents may be better rested under the new restrictions, I have a hard time leaving my work at the hospital. Instead of sleeping soundly that night, I laid awake thinking about whether we’d missed a diagnosis with Ms. S.
Urmimala: Under the new duty hours restrictions, my work hours have changed. Since we admit almost as many patients, just in fewer hours, I spend more time scouring records or taking longer histories to understand our patients’ stories. I also do less formal teaching. That night, I regretted that we didn’t have time to use Ms. S’s case as a springboard for discussions on core medicine topics like the differential diagnosis of a patient with an altered mental status, or HIV and a fever.
Seth: From the vantage point of the general public (and our family and significant others), the new duty hours restrictions are a step in the right direction. Few on the outside, though, appreciate that our learning often comes from observing a patient’s condition over a long night.
I also miss ice cream rounds. That time of night when patients have been admitted, workup is still evolving, and there is a natural pause to talk as a team about our patients, over ice cream or other midnight snacks. We’ve lost the middle of the night camaraderie, the social and educational interactions that help to define residency. It would have been an opportune time, for example, to reevaluate our approach to a patient like Ms. S as her clinical picture and diagnostic studies evolved.
Urmimala: Hearing the housestaff present new patients at postcall rounds over breakfast is still a highlight of being an inpatient attending. Hearing the presentation on Ms. S, I could assess the housestaff’s critical thinking skills and clinical instincts as well as the resident’s teaching and leadership style. Although the housestaff always present me with an excellent plan for a patient’s main problem, I miss the thorough problem lists, encompassing the management of the patient’s less acute issues. Medical students, in particular, do not have the benefit of running through their presentations in as much detail as in prior years.
Both: With mixed feelings, but abiding by the mandate, we signed out Ms. S to the night team. Although it could have, the extra handoff in Ms. S’s first few hours of hospitalization did not affect her diagnostic process; the system worked as it should. While we lost valuable teaching time that night, we did spend the postcall day discussing her case in detail with a rested team. Amid the many discussions of the benefits and pitfalls of the new duty hours restrictions, we cannot overlook the value of ice cream rounds. A part of each of us mourns the loss of companionship and personal growth that occurred in the quiet of the night.
Authors’ Note: The name in this essay has been changed to protect the identity of the patient.