On call

I am post-call, so this post will be post-call, angular, unedited or strangely so. Like the jokes you make post-call, this post may be just a little too sloppy, a little too specific, a little too true.

The worst part of call is the anticipation of call. The night before, everything feels extreme and over-precious. I have to read just one more book to E because I won’t see her again for almost FORTY-EIGHT WHOLE HOURS. I stroke her hair. I snuggle her little body close. “I have to remember her smell,” I think to myself, as if I am being deported to interstellar space on a mission of national importance with no return ticket. Later, instead of sleeping, which is the only rational way to prepare, I decide to stay up with C watching a movie, because I deserve it in advance. Or I waste a precious hour of sleep reading about the 27 most important things your grandparents would want you to know on buzzfeed. On some level, it feels like if I don’t go to sleep, call won’t come.

The vibrations of my phone alarm signal the worst hour of the whole enterprise. I lie in bed and worry. What if E doesn’t wake up from her sleep? What if the brief migraines I have been having turn out to be a massive AVM and I bleed into it and die before I see C and E again? I’m too tired to do it. I just can’t do it, I think to myself. I just can’t do it again. I don’t have it in me. I wish for death. Not really. But sort of. Or maybe just a permanent disability. Then I get up and stumble through the dark like a blind person getting ready as my most loved ones sigh and shift in their sleep. I only own five pairs of scrubs and have spent more than 5000 hours in them since medical school. In my scrubs I am neither fat nor thin, short nor tall, beautiful nor ugly, girl nor boy. I am just a person who is capable of continuing to function no matter what. The drive to work in the shuttered, sleeping world is ethereal. On the radio, BBC world is telling me about Italian tire factories or sex workers in Malaysia and I am balancing my open container of yogurt between my thighs and trying to avoid black ice. I pray to nobody and everybody: Please don’t let me make a mistake and hurt someone.

Here’s what I love about my job: The faces of children, marked by whatever emotion they are inhabiting in the moment. I love the moment when, despite the chronic exhaustion, despite the parent’s fear and frustration, despite the child’s innate distrust of strangers, you make a connection. You make them laugh, or you acknowledge their fear, and something in the room shifts. You answer a scary question and it is less scary. The kid who is initially clawing at their mother and crying ends up holding the stethoscope against their own chest and they look up at you with curiosity as you hear the familiar acoustics of a beating heart.

Once I step into the workroom to get signout on my patients, the worst part of call — the resistance to call — is over. Now the only way through is through. My co-resident confided to me that he writes the hours 1 – 30 out on a piece of paper and X’s off each hour as it passes. The inevitability of time’s motion will carry you through. As I assemble the little idiosyncratic bundle of checklists and signouts that will be my point of orientation for the next 30 hours, I feel like I imagine any athlete might before the jump, before the climb, before the big game. I’ve done this before, I remember. I can do it again.

What is a more effective method of teaching and learning: Meticulous apprenticeship or trial by fire? Nurses at the hospital where I work are oriented for weeks, even months, to a particular floor before they are allowed to work independently. They work alongside an experienced nurse, first watching them, then being observed and critiqued by them. They are taught exactly what to do. As a resident I switch to a new floor every month — which usually means a new organ system or set of diseases — and am lucky if someone tells me where the staff fridge is. Maybe there is a handout or binder with information on the most common order sets for that floor or the phone numbers of the case manager and social worker. But as far as decision-making goes, it’s luck and guts and humility and intuition and misses and near misses. There are always people you can reach out to for advice, but you have to know what you don’t know.

Yesterday I arrived on the Cardiology floor for the first time ever at 6am and twelve hours later I was the one fielding all the floor calls from nurses who in some cases have been taking care of cardiac patients for 10-15 years. “Can we give the anti-rejection meds for this heart transplant patient late? They’re down at radiology.” Um, sure? Or no? “Is 2000mg of magnesium too much for a patient with heart failure?” (Me making a thinking sound as I madly look up magnesium dosing in the hospital formulary.) “Baby P with the BT shunt looks a little blue and his sats are down. Can you come take a look?” You better fucking believe I’ll come take a look. I will be running there. All I know about BT shunts is what was in the handout I was given just this morning: “BT shunts carry 15% mortality. They can clot off anytime. If anyone is concerned about a patient with a BT shunt, assess them right away.” The last resident on this rotation told me that he was paged about a BT shunt patient who was vomiting and before he could slip on his shoes the child went into bradycardic arrest. As I am staring down at the patient’s tiny blue hands, I am grateful for each of the thousands of hours I have spent assessing patients and watching other people assess patients. At least I know where to begin. Mental status, perfusion, vitals, physical exam. All the hard-won habits.

When I am called to a bedside to assess a sick child, I try to assemble as many other people around me as possible — the parents, the nurse, a respiratory therapist.  Anyone with eyes and, preferably, more experience than me. I listen, I try to make a good decision, I elicit feedback on my decisions. As more time passes and I get a little better at this job, I am more confident about what I know and more confident in admitting what I don’t know and asking for help. During a 30 hour call, one thought dominates: What could I be missing?

For me, all calls contain the following elements:

1) The click: Sometimes only once, sometimes more than once, you make a decision, you have a good conversation with a family, you get in the groove with a nurse, you help a patient get better and you think: I nailed that one. Maybe I am, in fact, learning something. This moment is usually followed by:

2) The total fail: No matter how many times you make your list and check it twice, you will inevitably miss something — you didn’t look in the ears?! you didn’t order a lipase?! or bigger, scarier things like forgetting to get antibiotics approved. Often this mistake will become the disproportionate focus of the team on rounds. I have learned to embrace the total fail. It’s like the imperfection in the Persian rug through which God is allowed to enter. I am imperfect!, I want to shout into the whirring fluorescent hospital lights, I am broken and divine! (Actually, I obsess endlessly over these mistakes whether small or large and have great difficulty forgiving myself.)

Corollaries to the click and the total fail are:

3) The tiny point of light: The attending turns to you and asks a question like, “What was the last bicarb on the previous admission?” And from somewhere in the recesses of your exhausted, addled, overstuffed mind, the right answer pops out: 16! The human brain is a miraculous thing. Everyone seems impressed even though they are all also using the electronic medical record via which this piece of information is readily available. There there’s:

4) The endless sea of ridiculously specific questions you don’t know the answer to: “What dose of metoprolol was this patient on in 2012?” “Was the pancreatic duct visualized on the CT scan three years ago?” “Do you know if this patient has ever seen a dermatologist?” Um, no idea, don’t know, and no. This was my sixth admission last night and I’m not a soothsayer.

And no call would be complete without:

5) An assortment of bizarre physical sensations: A hand momentarily goes numb. I am awoken from the abyss of sleep by my pager and I jerk out of bed, convinced that I am lying in a pool of water. I catch a glimpse of one of my own hairs out of the corner of my eye and am momentarily convinced that there is a squirrel running up the wall. The exhausted human mind is a den of snakes. And:

6) An interpersonal glitch: On every call someone will do something so strangely anti-social, so rude, or so galling that you have to sit back and marvel. It might be a nurse, a fellow resident, and attending, a patient or a patient’s parent, or (most likely) a subspecialist consultant whom you are forced to call overnight. The other night I had to call the dermatologist on call (key words being “on call”) and he said, “Um, I’m trying to sleep.” Ha! Sorry, buddy, we’re all here in the hospital trying to take care of sick people! Everyone who is working overnight is at least a little tried and stressed out. It’s a cauldron of bad behavior. Then again, people are also the kindest to each other during these moments. It can go one of two ways. When you encounter people who are kind to you in spite of an annoying request you are forced to make of them, you remember that forever. Similarly, when someone lets slip a racist comment or yells at you over the phone, you remember that forever too. The stress of call has a searing effect on memory (though not the kind of memory that helps you memorize the nuances of pathophysiology).

Call time is a vortex. Admitting a patient at 2am, you have to keep asking them, “Do you mean yesterday, like the yesterday that just happened or the yesterday before yesterday?” The cafeteria closes at 7:30pm and you can almost never make it there even if you start trying to get there at 4:30. You can complete a five page note in ten minutes and then it can take you 45 minutes to figure out what the right home dose of a seizure medication is. One minute it’s 5pm, then next its 2am and you still haven’t finished your admission notes from the daytime. I am getting off the elevator on my way out of work and a woman gets on the elevator with two pieces of pizza and a Diet Coke. “Ew,” I think to myself, “who eats sausage pizza for breakfast?” Then I remember that it is actually noon. Since I started work, that woman had gotten up, eaten breakfast, come to work, eaten lunch, worked some more, went home, ate dinner, slept all night, gotten up, eaten breakfast, come to work, worked all morning, and gotten her lunch. No matter how you cut it, it’s just crazy. As the hospital doors slide open, my eyes sting with the light and the cold and the wind.

The end of call should be the best part, but for me the best part is when the first of my colleagues arrives for signout in the morning. A blessing on the head of each of my co-residents who, moored to their own undulating schedule of exhaustion and relief, has rescued me from the solitary crucible of call. It’s so nice to be able to run a decision by someone, to laugh about that crazy thing that mom said, to hand a patient back to the clinician who knows them best, hopefully none the worse for their time in your care. It is a tradition that the on call person brings the post-call person breakfast and no eggs are ever sweeter than those eggs. The only thing worse than call would be having to take it all alone.

And then it all begins again. Driving home, I have to put the car in park at each stop light because I am nodding off. My body feels too light and too heavy at the same time. This afternoon, I will sleep without any awareness of time and space, then the ecstatic reunion. “Mommy!!!” E will shout and then run in the opposite direction because that’s her way of saying hello. There will be cuddling. There will be cookies. I will not demand anything of myself nor will I make healthy food choices. I will rest because I will be capable of almost nothing else. The post-call flop-out doesn’t cancel out the exhaustion and stress but it does help.

One thing I have learned from residency is that it is hard to kill a human. The patients I am taking care of these days have one, two, even more holes and misdirected parts in their hearts. They undergo surgery after surgery, unattaching and reattaching their vessels too many times, and yet still, the blood finds its path through the madmade maze. Life is amazingly committed to its own continuation. The same, I think, can be said of people’s souls. People are remarkably resilient! They find a way, in spite of everything, to survive.

34 thoughts on “On call

  1. Love how you captured the pain and triumphs of a call. I don’t think people who haven’t been residents can fully understand this experience, but you write about it so eloquently that I think it is the next best thing.

  2. “My co-resident confided to me that he writes the hours 1 – 30 out on a piece of paper and X’s off each hour as it passes”…..do they see their patients or keep staring at their watches. The beauty of having a ridiculously busy call is not realizing how busy it was until you were done..time simply flies. I’ve been doing 30 hour calls for the last 9 years ( 2 residencies from 2 busiest and biggest programs in two different continents and now in 3rd year of fellowship) and has not experienced even 20% of what this author has mentioned. “I have to read just one more book to E because I won’t see her again for almost FORTY-EIGHT WHOLE HOURS” please don’t make it up. you can not work more than 30 hours continuously at least in the United states. otherwise, ACGME people will shut down your program. your journey becomes really painful if keep thinking how hard your job is. just enjoy it. Only lucky people get this kind of opportunity. someone’s life under your watch.

    • Hi Ron, Thanks for reading! I’m glad your experience of training has been such a good one. I am having a good experience, too, in my own way, but for me it helps to acknowledge the difficulties and complexities. My fellow resident who counts the hours is an excellent doctor, but call can be hard and we all have our strategies. And yes, I don’t see my daughter for almost 48 hours every 4th day, because I put her to sleep at 7pm the night before call, leave the house the next morning before she wakes up, am on call over that next night, get home when she is already at daycare, sleep for a few hours, then pick her up at 4 or 5pm, so that’s 45 or 46 hours, which is almost 50% of every four days. As a mother, there is no way for me to enjoy this aspect of training, even though I chose it and I know I am lucky to have the job I have.

    • Rob, you are obviously not a full time working mother trying to balance family, work, and life! I think her post is very accurate. As a resident who is a mother of a 16mo old I can completely relate. While you have dedicated your life to training, there are those who have a life outside of medicine. Being a mom is something to be very proud of and finding a balance is top priority.

    • Actually RON, look around you. Yes, there are laws now that say the resident isn’t SUPPOSED to work more than specified BUT they end up doing it MANY times and if they don’t they are ridiculed or shamed into staying. I, also, wouldn’t expect an egotistical, MALE such as yourself to understand the what it is like to be both a mother and a physician. Most males don’t give a crap how their kids turn out as long as they have a wife to raise them and the male can go about his IMPORTANT business. The type of male you are makes most of us sick to our stomachs. So self-righteous and sanctimonious. Karma is a bitch and has no timeline. YOU WILL GET YOURS at some point. I’m sure you will feel OBLIGATED to return with your remarks but save it, I’ve heard it all before and your attitude is what gives 80% of males bad names. Have a good life SAINT RON!!!

  3. Hi Ron, Maybe you should go back and re-read #6. You are one of those folks in this world who is “so galling I just have to sit back and marvel.” Seriously, this young mother and resident gave me a vivid idea of what a 30 hour call is like and you have the arrogance to try and put her on the defensive. You need a dose of humility my friend. And an apology to this doctor would be nice as well.

    • Hi Mary — thanks for having my back!! And thanks for reading. Your daughter is one of my all-time faves in residency, by the way — just an amazing person all around. All my best to you!

    • hahaaaaaaaaa dose of humility:))))
      well said marry,ron definitely deserve that’ and hats off to Mommy!

  4. Great entry M. I used to focus on making it until 9pm…that was the halfway point so I told myself it was “all down hill” from there. ;)
    And a note to future residents…own the “total fail.” No one is perfect and it’s the only way to learn

  5. As I read this I grinned and had some flashback anxiety palpitations and even teared up a little. When I look back at residency I don’t know how we did it, and I do know I couldn’t go back and do it again :) Thanks for this beautifully written account of your experience, and hang in there. The only way out really is through, and you’ll be there before you know it. Smarter, tougher, kinder, and done.

  6. I think everyone who has endured medical training can find some piece they share in common with your writing and if they’re honest with themselves several. I am on the other side now and help train future doctors. Sometime during my chief year (4th of 7 years of training), I can’t remember how or why but my perspective changed. My guilt for missing my children shrank when I realized every birthday, christmas, ball game I missed, was giving another family a lifetime of these events (I’m a perinatologist). I’ve explained it this way to my children when they are old enough to understand and while there are still tears sometimes when I leave for work during the waking hours, the barrage of questions when I get home (did you save any babies? are the mommies okay?) validates my work, erases my guilt and justifies the time I miss with my family. I have become profoundly more thankful for the moments I have with my family rather than upset by the ones I miss. Hopefully, you will have a similar moment soon so you can enjoy those moments with C and E before call but turn around and find the gifts you provide those families even more fulfilling. As for #2- I’ve found every good resident berates themselves and holds themselves to a standard higher than what is attainable- don’t lose this self reflection- I’ve seen too many good residents and practicing physicians turn into negligent pricks because they did. Last, I always tell my residents when they are beating themselves up for missing something- “If you knew what you were doing, you wouldn’t have to be a resident. Learn from this.” Enjoy your ride- you’ll never get the opportunity to learn as much as you can during residency and almost everyone leaves residency and fellowship wishing they had learned more. Good luck with your training.

  7. So true and really well written! My daughter was 2 when I stared residency so I had such a similar experience, down to falling asleep at a stoplight on the way home.

  8. I think you captured it perfectly. The dread, that evaporates when you actually have to start working, the highs and lows of a night making decisions on your own, and the euphoria when the cavalry shows up in the morning to relieve you. I didn’t have kids at the time, so I can’t imagine the heartache of missing a whole day of a little one’s life. And i definitely did that—with the checking off the hours until it ended (though it was more than 30 at the time…).

  9. I loved this — such a perfect representation of call. I read whole segments out loud to David, rejoicing in the warm feeling of shared experience.
    In reference to the comments above, I also think that it is possible to experience absolutely everything that you mentioned (and have I ever, especially not being able to make it to dinner before the cafeteria starts, no matter when I start trying; and running in to people on the elevator, who inevitably ask when I got to work this morning, and not even being able to wrap my head around how much time I’ve been at the hospital and what that means in the context of normal life) and to sometimes love call and to always feel privileged to be able to take care of people in the way that we do.

  10. Dear M,

    I stumbled across your blog today, and I’m so glad that I did. I’m a rising 4th year medical student and will be starting residency next year with a 2-year-old. My heart already aches for the hours and days I will miss with my daughter. Thank you for being so honest and so eloquent. I can’t wait to read more.

    With gratitude,
    Anna

    • Thanks, Anna! You and she will find ways to thrive in the new arrangement. At the risk of cliche, I will say: Enjoy the new few months to the hilt! Good luck with the upcoming transition. Try to find some fellow parents in residency — yours will likely be a very different experience. Thanks for reading and all my best, Miriam

  11. Thank you, Miriam, for this peek into your experience as a medical momperson. Surely it is an echo of my dr/daughter’s life as a pediatric anesthesiologist. Via your insights and descriptions — she sent me this to read — I can almost be a bird on her shoulder, to observe a few of the challenges, opportunities, and struggles that she and you face in your noble/divine/flawed calling.

  12. Beautifully written, so true. I appreciate the panic over 48 WHOLE HOURS before I see my baby and also being amazed every time about how other people have had a full day, gone to bed, woken up, and had another half day, all in the time I’ve been up for call. I see four shifts of nurses during one call. And since next year I’ll be in a fellow role, I appreciate reading about how a consultant’s attitude can really affect the resident, I will keep that in mind for sure.

    • Hi Lisa — Thanks for reading! What amazes me is how easy it is as you move up in training to lose track of how it felt to be in the roles behind you in the hierarchy. Now as a resident, I have to remember to spend time with my medical students and protect them from the pitfalls of pimping and lack of control over one’s time that I suffered through. Always good to keep these things in mind as you move up. Good luck with fellowship!

  13. Wonderfull written, especially post-call! A slightly different perpesctive here: I was 1 when my mom started residency 32 years ago. Every third night, didn’t see me for two days. I know it hurts her heart to think about it all these years later, but I don’t remember any of it. I have wonderful memories of a mom who loved me and still does. Now, as an adult with a biomedical PhD, I have many friends who are mothers and MDs and I watch their struggle and their guilt and their love of what they do. Hang in there! And keep writing!

    • Thanks, Erin! It’s good to hear from the perspective of the q3 or q4 child. I have to admit I’m relieved to know that you don’t remember the absences! I know that my daughter won’t really remember, and I know that having a successful, professionally engaged mother will be good for her, but I also know that she shines and blossoms when I’m home more. It’s a tension that I think will never fully be relieved. Thanks for reading!

  14. Wow, I have to say that you NAILED it. Totally nailed it. I also had little kids and you just got every piece of the pre-call, call and post-call experience down. Now I’m 9 years out of residency, but my 24 hour calls still sometimes feel like this, but the sheer angst and stress are SO much less.

    The one thing I can tell you is that life does get so much better after residency. It really does. I didn’t believe that in residency–in those months I wanted to quit and tried to quit and my program wouldn’t let me–but now, as an attending, I love my job. You still worry and fail and make mistakes, but there is a much greater overall sense of calm that experience provides, there are residents to help with much of the work, you feel more confident even as you know you must check everything and be vigilant. Hang in there. With your insight and remarkable reflection you are clearly an outstanding physician and patients are lucky to have you.

    • Hi US doc — thanks so much for your kind and reassuring words! I know things will get better but it is always good to hear it. The good part about residency is that you face your own limits again and again and they aren’t so scary anymore. Making (intermittent) peace with failure and error has been one of the hardest and more important aspects of training. Looking forward to the increasing sense of calm that you describe :-).

  15. Brought back some harsh memories for me. I used to dread call too…and definitely dreaded being on “jeopardy” when you never knew if and when you might have to take call! Ahhhh. I am glad to have the “schedule” of residency done….but even 8 years out, I miss the “academics” of residency. It’s a great learning experience and such a bonding experience with colleagues. Think I’m more exhausted by parenting though – it’s “call” every single night! Thanks for sharing!

    • Hi middleofthemadness–Yes! When my colleagues grumble about difficult families or patients, I always remind them that we are q4, but parents of sick kids are q1! I think residency is good preparation for parenting and vice versa. Thanks for reading!

  16. What a great post, I too dread call and even when there are those times where everything goes okay, I still dread it. This is a wonderfully written piece, you should submit it to JAMA for the My Turn section.

    Thanks for capturing this so well. Happy cuddling with E, and happy doctoring!

  17. Hi there, I had two children during my residency. It was the other residents who helped me through my call nights, and my wonderful husband and babysitters. I am now a vice chancellor, but still reflect on the richness and poverty of those long stretches away from my babies to help other babes. Although I believe there must be a better way to train competent/excellent doctors, I still don’t know what it is. I do believe that your reflections will help you get through with dignity and humility, and that you will help others do the same. Many thanks.

  18. My wonderful peds resident daughter (Yr2) thankfully shared your blog with me. Reading your perspective of “on call” only increaes my admiration of all of you who tread the floors of hospitals everywhere.i know she tries to share the ups and downs of residency but I sometimes read my own hopes and expectations into her conversations. A mother’s wish is always for the very best of experiences for her child. It was heartwarming to read about the ups and downs of your experience and know you are a better doctor for it. I hope to read more and become a better listener with K.

  19. Hi M, thank you for your wonderful honesty and insight. I am about to begin my residency in pediatrics (tomorrow!) and am both ecstatic and terrified. I will look forward to reading your posts. Thank you! S

    • Hi S — I hope your first week went as well as a first week can. May you have some moments of connection with your patients amidst the hub bub! Thanks for reading!

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