Decisions made in a sleep-disrupted state, and sandwiched between two normal workdays, are fraught with stress and risk.
My most recent issue of “The Physician Executive”, the journal of the American College of Physician Executives includes an article about paying specialists for ER call, a topic I’ll return to next week. It is an interesting juxtaposition to a spike I’ve noted in recent months in calls from present or former ER physicians looking to explore career alternatives.
I can’t say I’m surprised that both topics loom large in physicians’ minds. It’s now almost two years to the day since I saw my last patient in a direct care-giving capacity. While there are aspects of clinical care that I miss, being on call from the ER at night is not one of them.
Even with years of clinical experience, training in both internal medicine and neurology, strong clinical skills, and mostly taking calls direct from a resident, I don’t think there was one night on call ever where I slept properly.
Perhaps the infrequency of call that I took relative to a private practitioner meant I never got over some hump that would then allow me sleep well, but I doubt it. I know a lot of physicians who admit to being a bit on edge each time they are on call, irrespective of their experience or practice milieu.
My routine on call was to go to bed late to forestall just getting to sleep only to be jolted awake by the phone. Given my initial clinical experience in my native Dublin, where the pubs close at 11 pm (winter), and 11.30 pm (summer), and that old habits (formed knowing that there was almost always post-closing time business) die hard, this meant I was usually up until at least midnight. Strike 1 for stress and risk.
Having a normal workday on either side of being on call was also a problem. ER calls were particularly bad news for the upcoming day. I hated arriving to work feeling like a wet dishcloth. I disliked that this was even a prospect when I went to bed the previous night. Strike 2.
Taking calls from residents was a mixed blessing. Usually they’d know brainstem anatomy better than an ER physician but they were less canny clinically. Neither obviated the dilemma that another individual was telling you a story, and expecting an opinion based on their history and physical examination. Were you awake enough to think clearly? Did you put the phone down and replay the dialogue and decisions a handful of times before Hypnos and Morpheus half-claimed you back to them? Would you be a wall or a sieve? Would you be right? Strike 3.
ERs are tough places to earn a buck. They are also tough to visit or take occasional calls from. Uncertainty makes the mentally strongest of us nervous, and ERs are laden with uncertainty. I’m impressed by the fortitude of those who work there, fully sympathetic with those who want to consider alternative careers, and finally, understanding of the physicians who raise their hand and say; “for me to take call from the ER, there has to be some additional form of compensation.”