When Home Call is a Bad Call

I like my bed. That's one of the reasons I chose urology as a specialty.

In certain disciplines, like General Surgery, Medicine and Ob-Gyn, the norm is "In-house" call, meaning you're stuck in the hospital for 30 hours, period. This makes sense for these specialties - if a woman's having a difficult labor and needs an emergency C-section, she can't wait twenty minutes for her Ob-Gyn to drive in from the suburbs. Same thing for Surgeons when traumas come in, or medicine residents when a patient has a heart attack or stroke.

Up until about a decade ago, when the backlash against 120 hour weeks began, urology residents had the same dreary hours in the hospital that their cohorts did. As work hour restrictions got tighter and tighter, however, residency programs had to resort to creative measures to do the same amount of work without violating the conditions their accrediation agencies placed on their slave labor.

For urologists, ENT doctors, and plastic surgeons, this takes the form of so-called "home call", where you're available for phone calls and consults, but are able to physically leave the hospital. This you do at your own risk, knowing that any minute you can be called back. And unlike people who are on in-house call, there's no guarantee of going home early the next day post-call, even if you had a bad night.

It ends up being a kind of a russian roulette model of work.

To understand how great of a paradigm shift it is for residents to take home call, you have to remember back to the Good Old Days of the Iron Men, when doctors stayed awake for seventy-two hours, approximately sixty of during which they were doing chest compressions on dying patients (Of course, through the patina of time, the proponents of the Good Old Days forget that length of stays used to be much longer and patients were thus less generally sick. During the old days, residents were as likely to be doing grunt work like drawing blood or paperwork as anything.)

The bottom line is, they were there for their patients, whether they liked it or not. They were essentially prisoners, with no hope to escape, nothing better to really do. So why not actually do their job?

Home call, on the other hand, is like parole. Yeah, you're at the beck and call of patients in need of a sleeping pill or nurses who can't get a foley catheter in, but the promise of freedom beckons - the relative paradise of a non-cafeteria meal and a Tempurpedic pillow.

It's the expectation of respite that kill you. The minute, the second that you start dreaming of being able to go home to take a shower, or lay down on the couch to take a nap, you're doomed. Because it's at that critical point when you turn away from your patient towards an outside life that could be, that you start down the slippery slope of Bad Medicine.

You look for ways to stall. Or "temporize", as the jargon goes. This sounds more official, like a legitimate treatment course.

When you're two doors away from a patient who needs a foley catheter, it doesn't take much motivation to walk the two doors down, even if it turns out that the nurse could've done it with a little bit of advice. But sometimes you get calls about little things - things that seem like they could be handled over the telephone. Yes, the apologetic ER doc says, that sounds reasonable, after you ask him to describe the situation and give him some tips. You don't have to come in and see him, he says.

But looking as you are through the eyes of others, you never really know if you've said the right thing. Your guilty conscience wonders, what if he missed this subtle sign? What if he misread a film?

In the end, it's better to go in. And it feels, at times, like entering the lions den, leaving the heaven of home for the uncertainty of purgatory.

Even when things are clearly not urgent enough to require motor vehicular action, the calls can kill you. At 10:30 you get ready for bed. Right after you turn off the light, a nuse calls and asks for a verbal order for a sleeping pill. You wish you could self-prescribe. At 11:10, when the barest details of a dream are just about to form, you get another call requesting an order for tylenol. Just after midnight, you wake up with a snort to answer a page from a nurse telling you that Mr S's heart rate is up, and you order some IV fluids. You incorporate the page at 1:30 into your dream (sounds like a truck backing up), and your bedmate has to wake you up. "Honey, you pager's beeping." Groggily, you tell the ER doctor that you're not actually covering patients by private urologists. The 2:45 wake-up is just plain cruel, a patient at home who's concerned because he hasn't had a bowel movement for two days. Is it okay for him to take some over the counter suppositories?

You're so upset over this one that you can't fall back into slumber until after 3:30. And your alarm goes off at 5:50.

But lest you think that my life is hell, I do have to tell you about those glorious nights, those "freebies" where you fall asleep at 10:00 and don't once hear your pager go off. Then there are the evenings where you friend is in town and you're SO worried you'll get called in, but are happy when you are able to squeeze in a two hour Thai dinner without interruption.

Ah, the slings and arrows of Home Call.

I like my bed, and in the end I do see more of it than my friends in Surgery or OB-gyn, so I think I chose wisely. I just have to remind myself of the choice that underlies all of this: the choice to serve my patients, not my bed. But you can't fault me for wavering once in a while before I make the right decision...