I. INTRODUCTION

Residents are vital to the medical workforce, especially for overnight call duties. Transitioning from junior roles to handling overnight calls as senior residents (SRs) can be anxiety-inducing, leading to decline in cognitive performance and fatigue (Weiss et al., 2016). These pose concerns for patient safety and quality of supervision, as SRs often serve as the most senior staff on-site overnight. However, calls offer valuable training opportunities, fostering autonomy, decision-making skills, and preparation for future consultant roles. The challenge is to ensure that overnight calls are safe for both patients and physicians while being conducive to learning.

During the COVID-19 pandemic, the health system’s reallocation of manpower substantially increased the workload. While there remains conflicting evidence on the optimal on-call arrangement, the Accreditation Council for Graduate Medical Education stipulates a maximum of 24 consecutive hours of direct patient care to safeguard against negative effects of chronic sleep deprivation (Nasca et al., 2010). In our tertiary hospital, two medical SRs performed stay-in overnight calls ranging from 15 to 21 hours (1700-0800h on weekdays and 1100-0800h on weekends). Before each call, SRs started work at 0700h. One SR was in-charge of the intensive care unit (ICU) and the other was on the general medicine floor. During each call, the ICU SR was responsible for supervising 2 stay-in junior residents, 2-5 new patient admissions and 20 existing ICU patients; the general medicine SR was responsible for supervising a team of four stay-in junior residents, 30-50 new patient admissions, and 100-150 existing inpatients. After each call, SRs would continue with the morning ward rounds before ending work. SRs could seek help by calling the duty consultant, who stayed out of hospital.

With limited data on SRs’ call experiences during the pandemic, understanding their perceptions and attitudes would be essential for system improvement and preparation for future challenges. Therefore, we aimed to explore the perceptions, attitudes, and practices of SRs with regards to overnight stay-in calls during the COVID-19 pandemic, as well as avenues for improvements in the call system.

II. METHODS

An electronic survey was conducted via monthly email invitation to SRs in the internal medicine department of a 1,200-bed tertiary university hospital between November 2021 and January 2022. All SRs approached had at least three calls per month. Each email invitation was sent to 40 SRs who consisted of the hospital’s on-call medicine pool. Consent was exempt as this was an anonymised survey (NHG DSRB reference number: 2021/00413). Participants were asked to provide their opinions on various aspects of these calls using a 5-point Likert scale. Monthly prompts to complete the survey were issued.

III. RESULTS

Out of the 40 medical SRs surveyed, 20 responded (50% rate). Their education backgrounds were split between the United Kingdom (n=7) and Singapore (n=13). All trained and worked as SRs in the same hospital group for 4-9 years (median 5 years). The specialties represented included advanced internal medicine (4 respondents), endocrinology (4 respondents), geriatric medicine (3 respondents), neurology (2 respondents), rheumatology (2 respondents), and one respondent each from respiratory and critical care medicine, haematology, infectious diseases. Two participants declined to state their specialty.

In terms of perception, SRs generally agreed that calls contributed to their development as specialists and were essential to their training. They found the learning experience during calls to be valuable for exposure to diverse cases, different from their specialist training which mostly occurred during daytime clinical work. In terms of attitude, most SRs felt prepared and confident for their calls. However, around one-quarter expressed doubts about handling difficult call situations. Many SRs believed that the patient experience overnight could be greatly improved. Nearly half perceived overnight patient care quality as compromised, with 95% noting a decline post-call. While the majority felt safe on-call, fifteen SRs agreed that they would ask for help on-call. Worryingly, only 55% were comfortable doing so and 60% preferred having more supervision during calls.

For potential improvements (Fig 1), SRs were asked to rank various choices on a 5-point Likert scale. These choices were specific to overnight calls. Most SRs agreed that the educational value of calls could be enhanced, and they would prefer to have fewer calls during their training. Around two-thirds disagreed with the idea that certain specialties should have more calls or that consultants should perform stay-in calls. Detailed results can be found in the Appendix.