Night and day: The dual personalities of a hospital

Dr. David J. Shulkin works in two hospitals.

His day job is president and chief executive of Beth Israel Medical Center in New York. His night job is president and chief executive of the same institution, but once he began going on administrative rounds after midnight, he saw them as two different hospitals with one address, as different as night and day.

During the daytime, the hospital was fully staffed with administrators, department chairs and nurse managers, but senior managers were mostly absent at night, and staffing levels in general were lower.

The discrepancy is important, he writes in the New England Journal of Medicine, because research shows that outside the weekday, daylight hours from about 7 a.m. to 7 p.m., patients suffer more deaths, hospital readmissions, surgical errors, and medication mistakes.

“We should be establishing equal standards for staffing and service and striving for acceptable outcomes for every hour of the week,” he writes.

Rules limiting the hours worked by medical residents mean fewer doctors are on hand at night, ending the days when residents ran the hospital, as Shulkin recalls from his own training 20 years ago.

But two Boston doctors say that since the implementation of the 2002 hour limits, hospitals have had more supervision on nights and weekends than before, and declines in hours are balanced by assigning some residents specifically to nights.

That’s good for patient safety but may be less than ideal for learning, Dr. Marie Clark, pediatric chief resident at Boston Medical Center, said in an interview.

“The advantage is that you have skilled help at the bedside available exactly when you need it, which is clearly best for patient care,” she said. “The disadvantage for trainees is that residents have traditionally felt that they learn the most during these periods of relative autonomy.”

Dr. Adam Wolfberg, a fellow in maternal-fetal medicine at Tufts Medical Center, said increased supervision and better systems to prevent errors have made care better since 2001, when he was working 36-hour shifts as a resident.

“Those are the bad old days,” he said. “Residents running the hospital at night, working 36 hours straight, was not good. We can always do better, but all of the improvements we have made [since then] mean hospitals, day and night, are getting better.”

Dr. Joe Wright, who blogs on Hemodynamics about his first year as an intern in Boston, said the healthcare workforce is stretched too thin to contemplate equal staffing all the time anyway, so in his view, except for emergencies, the point should be to make sure the slower periods are as safe.

"At night we are responding to things that happen during the day, not necessarily moving care forward," he said. "We maintain by night and advance by day."