Thursday, September 19, 2013

Night Float - The Bad Beginning

A few years ago my family medicine residency program, realizing that duty hour changes(*1) were coming soon, decided to start a night float system (*2).  The new duty hour limits were not in place, so residents worked 14 hour shifts for 14 nights in a row (*3).  (Then we got one day and one evening off in preparation to return to work - on day shift.)

In case you were wondering, this was a horrible idea.

Just a few generalizations about night shift - when you work nights, you never, ever feel good.  You always feel tired, like you need to go to bed, or like you just got up from an ill-timed nap, or like you desperately need a nap regardless of the timing.  You feel disconnected from society – just as people are going to work, you are headed to bed, and just as the kids are getting home from school, you’re trying to wake up again and get ready for another workday.

I know that six nights in a row can be difficult and taxing but 14 were just monstrous (*4).  By the second week, I started to lose perspective.  I was crying every night on the way to work.  I left home with my child in tears as well and my husband frustrated at being thrust into single parenthood with a very angry roommate.

I was angry – initially at the program directors, but gradually at the nurses, the other residents, and ultimately the patients.  I wondered why I was getting so many stupid pages, and why none of the other residents could do their own work without dragging me into it, and mostly why all these stupid people had to choose tonight for their shortness of breath/chest pain/drug overdose.   Not a good attitude.  Add to that the directors’ insistence that no one ever, EVER nap on nights even if all the work was done (“Because you have all DAY to sleep”) and their refusal to consider putting a day off in the middle (“Because it would disrupt the sleep schedule” (*5)).  By the end of that two weeks, I honestly hated my program and was wishing heartily that I’d gone with my second choice.

Then I reverted back to days and life improved tremendously.  I still had a chip on my shoulder for a while, though.

*1) No longer allowing interns to work 30 hour shifts.
*2) “Night Float” means that a handful of residents take care of the hospitalized patients all night so that no one has to work a 30 hour-shift.
*3) Yes, this means a 98-hour work week.  As long as they averaged the first week of night float with the week before it and the second week of night float with the week after it (and each of those weeks were electives), we still satisfied the ACGME requirement of <80 hours per week average.
*4) I don’t want to sound like I think I had the most difficult job in the world –  I just want to make a few points about how badly it went for me personally.
*5) By this logic, no one should ever take weekends off, because most people sleep in on those days thus disrupting the sleep schedule.  However, the program directors did not forego their own weekends off.


  1. I agree wholeheartedly with your assessment of how awful night float can be, although when I wasn't on night float I was very thankfully for it (and for not having to do nearly as much call). In my program, we worked no more than five nights in a row with weekends off, and I think it was way more civilized than your program. Some people went back to sleeping at night on the weekend and others (like myself) maintained the awake at night/sleep during the day schedule, but we all managed to adapt somehow. I can't imagine how exhausted I would've been if I'd had to do 14 nights in a row.

  2. I actually kind-of missed having the post-call day, actually. Not that call was so great, but it usually just wasn't all that bad for us.

  3. I had the EXACT SAME EXPERIENCE. Thank you for posting.

  4. My experiences with night float are before the most recent work hours restrictions, but I did my residency in NYS which has always had fairly strict requirements.

    We did night float when I was an intern, and on some of my rotations as an anesthsia resident. My intern night float was one month straight with 1 res, 3 interns on nights. You covered Sun night - Thurs night. Each intern covered one teams worth of patients and we rotated admissions. It was pretty doable.

    My resident night float was one week a month at two of our sites (we rotated at 6 hospitals). In both cases you worked Mon night - Friday night. Each resident at a site had to do a 24h Sat and Sun, the Sat was usually before the week of nights and the Sun was after. We could sleep if we wanted to, but at one of the sites (our children's hospital) we had L & D to cover for epidurals and c-sections, so they recommended we not sleep on slow nights so you could get some sleep during the day in case you worked all night long. It was not unheard of to be in c-sections from the beginning to the end of your 7-7 night shift.

    1. I don't really understand the advice not to sleep at all at night. In the past I've been sleep deprived enough to take as long as a 4h nap overnight, and still been totally able to sleep for 7 more hours during the day when I got home.

  5. We have six weeks of night float here. Intern year (before hour restrictions) was four weeks; once you're pgy3/4 you have to do two rounds of SIX weeks. sunday is 28 hour shift that can be dragged into a 30 hour shift. monday morning by 9am you go home. back at hospital 5pm monday night. home by 9am tuesday, back at hospital tuesday 5pm, home by 10am wed bc of conference back by 6pm, thursday home by 9am, thursday back in at 5pm friday home by 10am--more conference. off friday night and all day/night saturday only to return for the "30" hour sunday/monday shift beg at 9am. we got screwed and had 7 weeks both times this year because of "how the schedule worked". we were ALL LOSING OUR MIND. and people were tanking at the same time. surgical emergencies--we cover ALL services. we were allowed to sleep BUT after a few nights your body gets into a night routine and you CAN'T sleep. no deaths but pretty close, lots of regrets, some crazy thoughts on our behalf and we are still so bitter have no idea how to stay positive for the next 20 months. also major chest pain, hallucinations, colicky babies, families thousands of miles away, flakey babysitters--you name it what could go wrong DID go wrong at home and work. don't know how it's legal. good news is we are done with night float FOREVER. bad news is our marbles are scattered on the ground and it's impossible to get them back upstairs for a moment of peace and sanity. amen to your post. night float is evil.

    1. Sounds horrible. So sorry you had that experience. Hopefully time will dull the ill effects.

  6. I actually don't mind night float. I'm a pediatric intern. We take 6 nights of night shift out of each of our core hospital months (13 hrs per shift). I like it because I'm able to see my daughter TWICE a day (come home from hospital, eat breakfast with her before she's off to daycare then she comes into my room at 5pm, wake me up, we read books, eat dinner, and I go back to work). I also like that on night float half your day isn't eaten up by rounding on patients--you structure your time as you see fit. Yes there have been some absolutely busy nights where I was slammed with admission after admission after admission, interspersed with kids requiring rapid responses and codes, but you always know each night will come to an end. I often look at the clock and tell myself, "ok, just 4 more hours til the day team comes in. I can do this." I also feel like having had a kid, I'm more well adapted then some of my childless co-interns of sleeping whenever the opportunity presents itself and being able to flip my night/day schedule.

    As a comparison, when I work days on a busy hospital rotation, I'm out the door a couple of hours before my daughter wakes up. And (on late stay days), if I'm lucky I get home just in time to tuck my daughter in bed (though often I'm so tired, I end up falling asleep while reading to her in her bed). You have a lot of work to do, plus you spend sometimes more than half the day rounding. There's not as much effort to "get you out on time" when you're on days like there is to get the night intern out on time in the morning, so often your work spills hours over when it is supposed to.

    I'm sure it varies greatly by institution, but personally I like the night float system at my hospital and always have to pep myself up for transitioning back to days.


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