A hard day's nightBMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7543.s118 (Published 25 March 2006) Cite this as: BMJ 2006;332:s118
- Dilini J Vasanthakumar, medical student,
- Janine L Wright, locum consultant gastroenterologist
Two medical students describe their experience shadowing an on-call medical specialist registrar
The registrar's view
As part of the Hospital at Night project at Newham Healthcare NHS Trust a group of medical students were recruited to collect data on the activities of the junior doctors on call at night. This audit of the doctors' out of hours work was to collect data about all the bleeps and on-call activities carried out over a period of nine days. Two students were allocated to shadow the on-call medical specialist registrar (SpR) for either the day shift or the night shift. As a result of some injudicious on-call swaps I was working four of the on-call shifts during this period and subsequently spent a lot of time with the two students assigned to the medical SpR, one on for day shifts, one for nights. I was struck by the unique learning opportunity that this presented and asked them to keep a diary of all their experiences during this time.
Despite three and a half years at medical college, their understanding of a junior doctor's on-call role was only superficial. They were both surprised and shocked by the on-call responsibility, but as they were obliged to go wherever I went this necessitated experiencing the full breadth of on-call medicine. These students attended arrests and observed critically ill and dying patients. This is often the time when students either withdraw or are sent away, but these medical students were obliged to be present throughout the entire on-call experience.
Increased pressure for on-call doctors owing to targets and greater numbers of patients, coupled with the increased intensity of work associated with shift working, inevitably leads to a reduction in time for medical student teaching on call. Giving the medical student this specific role not only allowed for the audit data collection but also provided valuable experience.
A registrar on night shift has a strange existence. Hospitals already have a peculiar rhythm, a sort of perpetual motion, but the night shift casts that rhythm into something even more bizarre. Becoming part of that existence means learning to seize 15 minutes of sleep and then snapping awake at a moment's notice, sprinting to respond to a crash call, and surviving for nights on end on nothing but toast, adrenaline, and Sky movies.
Nights typically began slowly, strolling from ward to ward and attending to patients. I would observe and try to understand what the registrar looked for in each case. An endless stream of x ray films and electrocardiograms flitted past, each as baffling as the last. Every time I contemplated asking for the answers to my questions, my courage failed me—it just seemed like an imposition to ask. However, by the end of the week my initial anxiety about shadowing the doctors, and getting under their feet, had dissipated. After all, being a doctor doesn't make you any less human. Much of the time was spent observing the registrars perform their numerous clerical duties (usually my cue to switch off), punctuated by totally unpredictable races to accident and emergency (A&E) to treat arrest calls.
A particular episode remains in my mind. A middle aged man had collapsed and been brought to A&E. At first he seemed to be one of many admissions who were “under the influence,” but a computed tomogram revealed a subarachnoid haemorrhage. When the patient began to vomit blood I finally made myself useful by alerting the doctors, and as they sprang into action I watched with a mixture of horror, fear for the patient, and admiration for the team as they rapidly stabilised him. It was the most immediate and dramatic experience of medicine I had ever witnessed first hand—the melodrama of ER and Casualty suddenly looked less exaggerated.
Physically, the experience was draining. There was nowhere to go during the night to have something decent to eat. I survived on an appalling diet and each morning on the way home I felt nauseated. Sleeping through the day somehow eliminates the normal hours of relaxation—life becomes compressed into nothing but sleep and work. Nocturnal shifts turn everything inside out: when you feel like eating pizza it's time for Weetabix, and as everyone else heads to work you are trudging home. It's an eerie parallel existence, lonely and alien to the rest of society. Never seeing daylight left all of us depressed and irritable, but towards the end of the week a change in the students was perceptible. We were all tired, fed up, and longing for a normal routine, yet a tangible sense of solidarity had developed not just between the students but with the staff as well. The junior doctors' mess became home from home, a refuge from the hectic outside where we could console ourselves with toast and cereal. I wondered whether the night time ordeals had contributed to that: we shared in the travails, but also had in common a deep feeling that the work we were witnessing, and would soon take part in, is profoundly worth while.
I occupied a rather strange position in the wards during those nine nights. I wasn't a bystander, but nor was I able to help. I sometimes felt intense frustration at my inability to help, but at times I also felt a certain relief to be spared the immense responsibility of people's lives. On reflection, there is no doubt I gained a tremendous amount of experience from participating in this audit. I am eagerly waiting for the day I can finally call myself a doctor, and maybe one day I will have my very own student shadowing me. Meanwhile, aside from completing my final years in medical school, I'm going to ensure that I sleep as much as I possibly can, in preparation.
Being a greenhorn, I found the prospect of playing doctor very exciting. What I didn't expect was to have my ideas about the practice of medicine transformed completely.
When my shift began at 9 00 am, the night registrar was just handing over patients for review. I was still trying to note that down in my logbook when the registrar dashed off to answer a bleep, which led to a long conversation with a senior house officer (SHO) wanting advice about patient care. The sporadic dives for the phone during ward rounds, patient reviews, supervision of juniors, endless note keeping, and measly interrupted breaks were things I soon became accustomed to. As time went by, my enthusiasm was dulled by a growing awareness of the aching in my feet and the grumbling of my stomach, which was getting embarrassingly loud. I was becoming exhausted.
One thing that surprised me was the large amount of non-medical work that doctors are expected to do. The registrar was bleeped repeatedly, often for the same reason. I had to suppress my urge to throw the bleep out of the window. However, bleep after bleep the registrar continued to answer patiently.
Each day on the audit was different, some hellish, others more so. On one exceptional day, I experienced a true “Holby City” moment. We had been called in to see a young woman in respiratory distress. It seemed to be total chaos as registrars, SHOs, and house officers milled around poking needles and tubes into her and shouting orders as she lay unresponsive. I stood paralysed in a corner, certain that I was watching a person die. The fatigue I felt before ebbed away and an adrenaline rush took its place, which made every sound seem louder, every colour more vivid, and each second much longer. Minutes later the patient was conscious and talking, having been revived by the arrest team.
Discovering the nature of being on call brought to mind some issues I had not considered before. I had never thought that I would get tired of learning and experiencing the marvels of modern medicine; nor did I expect that I would relish so much the pleasure of switching off and heading home.
I realise that, while caring for others, one is more prone to neglecting one's own self. This made me appreciate the importance of having an active life outside the world of medicine. The audit helped me to remember why I chose to study medicine in the first place. It was incredibly heart warming to see patients recover from critical conditions, and equally satisfying to be part of a team working hard to make it happen. I admired the detective-like approach all the registrars adopted when diagnosing patients and the individuality of each registrar in the way they looked after their patients. This led me to wonder what my style of practice would be like.
As I wearily made my way home on the last night, I felt almost guilty at my relief that I could return to my student life. The next time I'm on call will be better, I thought to myself. With my new expectations, I will be ready for anything; I will also be wearing trainers. ■
We thank Thoebe Lo, Astrid Thomas, and Sara Lightowlers.