Non-Residents On Call are doctors covering part of a shift off-site, being available over the phone for advice or available to come in for emergencies.What is commonly refer to as being on call – taking referrals and dealing with emergencies during the day or at night, while based on site, is, in terms of NHS contracts, is being “on-take”.
This is the first in a three-part series. Read Part #2 here, and Part #3 here.
Who Gets the Call?
Currently only a few specialities run a registrar NROC service with the majority working a resident day/night shift pattern. Most consultants, however, will cover their on calls from home. The idea of NROC is that specialities with traditionally lower on call workloads can cover 24 hour weekday shifts – and often 48 hours of the weekend – and still achieve sufficient rest during this period. NROC has the benefit of reducing the impact on training exposure that a full shift pattern and subsequent days off would bring.
I have been working a NROC for several years and have taken for granted some of the aspects involved that are different from a full shift pattern. I was speaking to an ITU consultant one weekend when I was still in the hospital late into the evening. She told me how she sees a lot of junior consultants struggling with NROC for the first time as they have always on site as registrars. NROC does require a slightly different mind-set and employs slight different skills to being on site.
Give Me Some Details!
During a 24 hour NROC, a doctor will usually work a normal full day, often running the on call on top of normal clinical duties. Once they leave the hospital site, even though they might be at home, or at least not at work, it’s very difficult to relax completely. They have to be accessible at all times; dinner plans, gym sessions etc have to be carefully considered as they might be called back into hospital at any time. Going to the loo, having a shower? Better make sure you have your phone on loud! Do you have enough petrol in your car, whats the traffic like? Live with someone else? They may well get woken up in the middle of the night, too. They also have to plan for the occasions where they are not able to leave work at all, emergencies in the evening and through the night meaning they stay on site working for up to 24 hours straight. Sure, sometimes there won’t be a single call through the night, and NROC usually provides a half day off the day after, but the shifts involving working 24 hours straight without sleep can really encourage a career evaluation.
I Can Sleep, Though, Right?
Sleep during NROC is not like restorative sleep. Its not like switching off and relaxing after a day at work, instead its often fitful and interrupted even without phone calls. To wake up from sleep and give advice over the phone can be difficult. Sleep inertia needs to be overcome and the mind needs to go from a state of relaxation to working coherently and logically. Being woken up in the middle of the night gets the adrenaline flowing and the heart racing. Do I need to come into work? Will I need to operate? Is this something I can handle? So, do please, have a quick think as to whether that 3am call to ask how to arrange follow-up for a well patient is necessary!
So… Not a First Resort Option?
When calling someone who is NROC, be it registrar or consultant, bear in mind that they may be exhausted, in deep, deep, sleep and maybe even still asleep when they speak to you. Take a minute to think before you call them and try and start off by stating what you want from them, and get to the point straight away. Let them know early on if you want to talk over a problem and ask how to manage a patient or if you need them to come in. “What would you like to do?” is not the most sympathetic or productive question to ask someone about how to manage a patient when you’ve just woken them from sleep.
That Would Bug Me, Too…
When you are NROC and get called, once in a while you’re brain wont wake up and function. If you need to, take their number, go splash your face with cold water and call them back when your brain works. Its horrible trying to get back to sleep after a call and running through the details, realizing you can’t remember asking them about a detail like urine dip or if the patient is diabetic. Its worth taking a number in case you do wake up in a cold sweat and need to call them back.
Another skill is knowing when you can safely give advice over the phone or if you need to go in to see someone yourself. With any luck you will be taking a referral from someone you know and have developed a working relationship with and know whether you can trust their judgment. However you will often be called by someone you don’t know and need to make a judgment call. Sure, the safest option is always to come and see the patient yourself, but in reality, waking up, travelling in and seeing a patient my end up being a 2 or 3 hour round trip and in the middle of the night after a full day of work and with work again the following morning, this can be far more of an ordeal that it seems.
Surely, the More Time in Hospital the Better?
Yes, if you do go and see every patient you get called about in the night you are far less likely to miss something, but you will very quickly run yourself into the ground and will be useless during your normal working day. The key is to be able to learn when you need to go in and when you can advise over the phone. This takes trust in those calling you and trust in your decisions making in the middle of the night and an ability to read between the lines and often hear the words not being said by the person on the other end of the line.