Guest Editorial: Go to Sleep, Grandpa

Back in the early 1980s when I was in training, night call was not a major event. We had no work-hour rules and regularly worked 120-hour weeks as residents and fellows. In August 1987, I remember my first week as an attending, I was in the ICU for about 100 hours. My wife said, “I thought it got better as an attending.” For decades to follow, I would take a lot of calls, initially from home but later in-house and the next day I would go to sleep at the usual time or a little early, sleep through the night, and would be refreshed by the next morning. I would get up and go about my usual day. Work hours have improved for trainees and attending physicians. Trainees now have their hours appropriately restricted from ridiculous to somewhat less than ridiculous. There weren’t a lot of people in the pediatric critical care world back then and, as many more people have entered the field, the number of people in an average ICU group has grown and diluted the number of nights on call. I was on call every 3^rd or 4^th night in my first 10 years as an intensivist. Overall, around the country, it is better. In addition, many ICUs pay additional amounts for the in-house call.

Until a few years ago, the concept of me taking more than one night to recover was unthinkable. Frankly, I never thought about getting old. I was proud of the fact I could be awake for 36 or 40 hours, go to sleep in the evening, and be fine the next morning. As I am going to be 65 years old next month, I have had to accept the fact that I can’t recover as quickly anymore. My ego hates it.

I will admit, it is getting more difficult to get through those 24 hours and then the next day. I think I can still take good care of my patients at night, but there are numerous studies that show a decrease in mental functioning at night with older age.[1,2]  Increasing age is generally associated with a decreased tolerance of shift-work cycles and a greater tendency toward late-night errors.[3]  The tendency toward “morningness” and difficulty with nocturnal sleep makes elderly people better suited for early morning shifts and less well suited for late work or 24-hour calls. Older general practitioners report a decreased ability to recover after night shifts, with a disproportionately adverse effect on the next day’s work.[4] Moreover, studies show that the top two causes of burnout in the ICU are too many bureaucratic tasks and too many work hours.[5] Since this pro-con debate is about call or no call after age 60, what about 65 or 70? At what age should night call absolutely stop? This is important because 29% of practicing physicians are 60 or older.[6] Am I a relic who should just retire because I am older or am I a valuable resource who is still important in the life of a busy cardiac ICU? That is an important question to answer. Most of us still have active academic and clinical lives and have much to contribute.

Four years ago, I was scheduled to recertify in my pediatric critical care boards. I was going to study over the summer. Unfortunately for me, five members of my group deservedly received opportunities to be leaders in other CICUs around the country. That meant we were down five people in our group, as replacements had not yet arrived. I ended up being on call nine times per month in the months of July and August, just before taking my boards in September. I told my wife I finally understood what burnout felt like. I was exhausted and depressed. I was also upset because I didn’t tolerate being on call so many times per month like I used to be able to do. By the way, I did pass the boards.

The downside of someone in your group not taking night calls is that everyone else must take more calls. The upside, (and the younger people reading this should take note), is that this creates a precedent for the group, and eventually, you will be there as well! Based on 34 years as an intensivist who has paid his dues in terms of night calls, I am in favor of allowing those over 60 to reduce or eliminate night calls. It will keep us in the field longer, so our experience and accumulated wisdom can contribute to the clinical and academic well-being of the CICU.

1. Yana Puckett, Beatrice Caballero, Sharmila Dissanaike, Robyn Richmond, Catherine A. Ronaghan. Surgeons Maintain Better Focus Working 12-Hour Shifts Compared to 24-Hour Calls, Journal of Surgical Education, Volume 78, Issue 4, 2021, Pages 1280-1285
2. Kane, Leslie Death by 1000 Cuts’: Medscape National Physician Burnout & Suicide Report 2021. Medscape Critical Care Newsletter January 22nd 2021.
3. Mitler MM, Carskadon MA, Czeisler CA, et al. Catastrophes, sleep and public policy: consensus report. Sleep 1988; 11: 100-109.
4. Harma MI, Hakola T, Akerstedt T, Laitenen JT. Age an adjustment to night work. Occup Environ Med 1994; 51: 568-578.
5. Martin, Koval   Medscape Intensivist Lifestyle, Happiness & Burnout Report 2021, Medscape Critical Care Newsletter. February 19, 2021
6. 2016 Federation of State Medical Boards Census of Physicians.