Diurnal Dichotomies By Neal E. Flomenbaum, MD, Editor-in-Chief

Writing in the May 15, 2008, issue of the New England Journal of Medicine, David J. Shulkin, MD, president and CEO of a New York City hospital, describes the two different hospitals that he heads. The first hospital operates between 7 am to 7 pm on weekdays and is fully staffed by physicians, nurses, senior administrators, department chiefs, and experienced nurse managers. The second hospital, which is at the same address, operates during evenings, nights, and weekends. It rarely has either senior managers present or the same number of nurses and physicians as the day hospital, even though people get sick 24 hours a day and 50% to 70% of patients are admitted to hospitals on nights or weekends. The results of these day/night disparities are higher mortality and readmission rates and more surgical and medical errors during off hours.

That two very different hospitals share the same address is not news to emergency physicians, who might reasonably wonder why it took so long for others to notice. In fact, others did notice years ago—and the creation and rapid growth of emergency medicine as a specialty is due in no small measure to recognition of the need for the same level of excellent medical care 24/7, at least somewhere in the hospital.

But the problem with relying on the emergency department to compensate for the diurnal variation in hospital staffing is that emergency physicians alone cannot address all of the needs of patients who require care during off-hours. No matter how good we are at what we do in the emergency department during the night, we still live in a 9-to-5 world. For the patients who can be diagnosed, treated, and discharged from the emergency department, we can provide that otherwise missing level of expert care. But if instead we need to send a patient to the operating room or to an inpatient service for immediate and continuous care, or if we need to call a consultant to provide a level of expertise beyond our training or abilities, there may still be a problem.

What appears to have changed recently—as evidenced by Dr. Shulkin’s article and the increasing utilization of hospitalists, “nocturnalists,” and “nighthawk radiologists”—is both recognition of the problem and acceptance of the need to address it. Also, better training, more-humane residency hours and working conditions, and a night differential in attending pay can remove much of the sting of heavier night assignments during the first few years of post-residency practice, thereby ensuring greater patient safety.

There are, of course, a few advantages to working night and weekend shifts, when almost everyone else on duty in the hospital seems to be more focused on medical issues, and there is a welcome relief from distracting phone calls, noise, memos, and extraneous paperwork. At night, emergency physicians sometimes feel as if they have been given superpowers. The same specialists and subspecialists who during the day routinely come to the emergency department as consultants to treat patients—or ask that they be sent to their offices—at night seem much more comfortable with having the emergency physician manage the problems alone. But given a choice, most emergency physicians would happily give up those few hours of being a “superdoc” each night for a more consistent diurnal response to patients’ needs.

Emerg Med 40(6):8, 2008