Night Float, Part Two: The Art of Cross-Coverage

In his recent Slate article, Dr. Sandeep Jauhar wrote about concerns regarding Night Float systems:

"Night float is the product of reforms in medical education that limit the number of hours that residents and interns—doctors in training—can work. Because they can no longer rely on the same doctor caring for a group of patients day and night, teaching hospitals have had to arrange more cross-coverage when the primary resident is not on duty. Most have created the position of a resident who works the night shift, usually for a few weeks. The upside is that other residents can sleep. The downside is frequent patient handoffs, which can result in the transfer of faulty or inadequate information. The nightmare of night float raises a central question about work limits for interns: Is it better to be cared for by a tired resident who knows your case or a rested resident who does not?"

The topic of cross-coverage is important to any discussion of Night Float or resident work-hours generally. In this post, I'm going to expand the definition of cross-coverage and lay the foundation for a later discussion of patient handoffs or, as I call it, sign-out.

What is cross-coverage?

Cross-coverage defined:  Temporary coverage provided at night and/or on weekends for a patient's usual daytime physician.  This coverage usually includes receiving phone calls about patients who are already in the hospital, making daily rounds, and responding urgently to changes in patient's clinical status.  It does not necessarily include admitting the patient to the hospital, but may describe any period of coverage by a doctor other than the patient's usual doctor during the course of the patient's hospitalization.  Cross-coverage is essential for nursing staff to know who to call if problems arise in the patient's care.

In other words, when a doctor provides cross-coverage, he is responsible for the care of patients he may never have seen before, and may not see during the period of coverage. Typical questions that arise range from simple ("Mr. Smith needs a sleeping pill or a laxative") to extremely complex ("Mr. Smith's heart rate has dropped from 70 to 30 and he is extremely difficult to arouse"). As you can imagine, cross coverage is an unwelcome burden to the covering physician, operating as she must under limited information, after business hours when services are minimal, and usually during the time when patients unexpectedly decompensate (i.e. the wee small hours of the morning).

The art of cross-coverage consists of several components:

1. The ability to obtain a concise and pertinent history from the physician signing out (i.e. to know in advance what might be important).
2. The ability to obtain additional information from the nurse who calls you about a patient you have never seen before, who has now developed a problem (i.e. how to extract further pertinent history as the need arises).
3. The clinical judgement to know whether the problem being reported to you a) can be observed for a period of time without intervention, b) can be addressed with an intervention, but does not require you to evaluate the patient, or c) requires your face-to-face evaluation before further intervention can be decided.
4. The organizational abilities and responsibility to follow-up on a patient's status and lab results, if applicable, and to prepare either a written or verbal update for the referring physician at the end of your cross-coverage period.

Obviously, the individual skills of cross-coverage take time and experience to develop. The challenge of cross-coverage is how to acquire these skills and refine them so you can ultimately juggle cross-coverage with other call responsibilities such as admitting new patients. As far as I know, no medical school or residency has any specific curriculum to teach the art of cross-coverage, because it is not something that is easy to teach. The learning comes from seeing a lot of patients in the middle of the night, and that experience occurs during Night Float.  Why not during daytime rotations?  Because the prospect of handling new problems and changes of status on inpatients during the day--when all the attending physicians are around, the consultants are easily available, and the lab and X-ray departments are fully staffed--is a lot easier than when these resources are not available and you have to figure things out by yourself.

You must understand: cross-coverage never goes away. Four years out of residency, I still have to face the need to cross-cover patients. If anything, the sign-out process between physicians in practice is sketchier than the sign-outs I received as a resident. I often receive calls about a patient I really have only the vaguest notion about. But I still cover for them. I have no choice, because cross-coverage is a shared responsibility. We all have to participate, or else none of us will ever get a day off.

So when Dr. Jauhar asks whether "an ignorant doctor really better than a tired one?" he implies a false distinction. Residents under a traditional call system may know the details of a patient's case better than a Night Float resident providing cross-coverage, but they are no more likely to be able to anticipate the myriad of catastrophes that will happen to their patients after hours. The choice is not between ignorance and fatigue, but between degrees of preparedness. A good residency will expose young doctors to the demands of cross-coverage in a setting of supportive guidance, but will not shirk from making trainees do the work of seeing patients and refining their skills. Whether or not this educational process occurs during Night Float or traditional call systems is less important, although I think a strong Night Float team provides an excellent setting for residents to learn the art.

Providing good cross-coverage depends on good communication between physicians.  Part of the process of communication involves signing out between day and night residents, and this will be the topic of the next post in this series.