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“On duty, not on call: time to rethink Neonatal Intensive Care Unit attending hours”

Journal of Perinatology volume 43, pages 1453–1454 (2023)Cite this article

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There is a tradition in medicine of physicians working long shifts in the hospital, often in excess of 24 consecutive hours. A generation ago it was determined that this practice is unsafe, both for patients and for physicians. Work hour restrictions were therefore codified in the U.S. for physicians in training. Ironically, no such restrictions were put in place for attending physicians, who are commonly older and carry more responsibility than trainees. More than a decade ago we argued that working continuously for over 24 h is inappropriate and unnecessary for neonatologists, as the data and reasoning that led to work hour restrictions for trainees were, and are, relevant to attendings as well [1, 2]. In this issue of Journal of Perinatology, McAdams provides an excellent review of relevant data, and persuasive arguments to limit attending shift duration based on patient safety and physician wellness [3]. Each argument is compelling, and in combination they make a strong case against prolonged neonatologist work hours.

It is worth considering how we got here, to a situation in which prolonged attending work hours are accepted, particularly in large academic Neonatal Intensive Care Units (NICUs), and why things have not changed. In the 1960s and 1970s, in-house NICU medical coverage was provided primarily by pediatric residents, who worked long shifts in the NICU, just as their counterparts elsewhere in the hospital. The residents were supervised during the day by neonatology fellows and/or attendings, backed up at night by fellows from home or in house, and by attendings commonly on call from home. Attending neonatologists on service during the day might cover the NICU overnight, and often for several nights in a row, but were usually at home and able to sleep for at least part of the night. Over the years, NICU patients became increasingly smaller and sicker. Resident time in the NICU was significantly reduced, which led to less resident and junior fellow expertise and ability to care for these patients. This, in turn, led to attendings spending more time in the units at night to optimize patient care and safety. Now, commonly, busy NICUs are covered by an attending neonatologist in-house around the clock. An attending might work all day in the unit, stay in-house all night, and possibly work much of the next day. Sometimes they get to rest at night; sometimes they do not. For attendings required to be in the hospital working the overnight hours, the term “on call” still lingers, but a more appropriate description would be “on duty.”

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References

  1. Mercurio MR. A day too long: rethinking physician work hours. Hastings Cent Rep. 2008;38:26–7.

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Authors and Affiliations

  1. Yale University School of Medicine, New Haven, CT, USA

    Mark R. Mercurio & Steven M. Peterec

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  1. Mark R. Mercurio
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  2. Steven M. Peterec
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MRM wrote the first draft of the manuscript. MRM and SMP made substantial revisions to the manuscript and approved the final draft.

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Correspondence to Mark R. Mercurio.

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Mercurio, M.R., Peterec, S.M. “On duty, not on call: time to rethink Neonatal Intensive Care Unit attending hours”. J Perinatol 43, 1453–1454 (2023). https://doi.org/10.1038/s41372-023-01776-4

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