Learning from the lessons of night float

No medical resident looks forward to working night float. The initial glamour of doing chest compressions in the rising light comes up against a litany of administrative tasks. As the glamour wanes, the gulf between the objective curriculum and actual practice widens. On paper, residents learn how to manage acute emergencies and learn deeper clinical reasoning. Actual practice, or the “hidden curriculum” of training, can be a different experience, involving mountains of paperwork and distractions to clinical care. My confessions come from two overnight cases, and lead me to two conclusions. First, the hidden curriculum is not all bad. Second, recognizing its limits can help us understand how to train better residents and doctors.

The first case of the night is a 45-year-old obese female presenting with chest pain and concern for a heart attack. It is a slow night and I grab a chair to sit next to the patient and her son to take a detailed history. It becomes clear the pain is likely non-cardiac, though there are significant barriers to health literacy. The tasks of admitting this patient are increasingly electronic and performed behind the scenes: ordering EKG’s, assigning an appropriate diet and reconciling medications. Despite this, I linger awhile and discuss her compliance with medications. Meanwhile, her son picks up the phone to order her fast food (a hamburger with fries) over the phone, which leads to a rich discussion about diet and exercise. In one sense, my lingering was the antithesis of quality care: time-consuming, inefficient, and not amenable to electronic quality metrics. On the other hand, it was the paragon of care, both for me and the patient.

The second case of the night is a 50-year-old man also presenting with chest pain. He has heart failure and is set up to get a cardiac catheterization in the morning. I examine him, lump him into the “stable” category, and fill out his paperwork. I also tell that if I were a betting man, I would say his coronary arteries would be “clean.” The next evening the intern informs me of my two errors. Mistake one: He had multi-vessel disease and will need surgery the next day. Mistake two: He had disease of his carotids and may needs further imaging. The first error was due to lack of experience, the second lack of competence.

In the first case, the hidden curriculum pushed me to be efficient over humanistic. This was hidden in that all forces, including electronic ordering, multiple competing time-demands, and interruptions to patient care incentivized efficiency. The lesson here is not to malign the hidden curriculum as soulless or inhumane, but rather for hospitals and residency programs to create equally compelling incentives for quality humanistic care.

In the second case, while the objective curriculum asked for competence (correctly identify a carotid murmur), the hidden curriculum asked me to stake a claim on a diagnosis. Again, this was hidden in that over time, declaring one’s diagnosis boldly is praised more than admitting uncertainty.  The lesson here is that competency-based training is not enough: Training doctors involves teaching to competency and providing sufficient experiential learning to be able to predict the right diagnoses.  As my second evening of night float looms close, I have given up on glamour and hope only for more cases and fewer hamburgers.

Tom Peteet is an internal medicine resident.

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