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On-call: making the best of a not-so-bad situation

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01 October 2015, at 1:00am

GARETH CROSS ponders the results of the latest survey of the profession and in particular the provision of out-ofhours care, something that seems to keep veterinary surgeons on edge and yearning for time off

BEING on call is without doubt one of the most stressful and most hated parts of our jobs. According to the most recent “Survey of the Profession” published by the RCVS in 2014, 56% of UK practices still cover their own out-of-hours work.

So 44% of you can enjoy reading this month’s column with a glass of wine and dose of Schadenfreude, and the 56% of us who jump and whose heart rate goes up every time a mobile phone rings with the same ringtone as the duty phone can hopefully gain some solace from the fact that you are not alone.

At this time of year there are many recent graduates in the first few months of their first job experiencing the peculiar stress of being on call too. I thought I would share some of my own thoughts on how to deal with the stress of being on call and what has worked for me over the years. I have also found a few good reviews on the subject, notably “Environmental Health: A Global Access Science Source 2004, 3:15 by Nicol and Botterill”; it’s a free to access article available on pubmed.

Human nature seems to be able to deal with good news very well and also deal with bad news in a rational way. What we don’t cope well with is uncertainty and that is the prime stressor of being on call.

If on my next weekend on call the on-call fairies would tell me: “Right, this weekend at 4pm there’s an RTA cat coming in, nothing over Sat night then a stitch-up and pts after teatime. 3am call to see a coughing dog the owner is worried about. Back to bed for a few hours then nothing till Sunday evening pts old cat. By the way as a heads-up, during that weekend in November on call coming up there’ll be a Saturday midnight GDV that dies”, then I would sleep well and arise at the appointed hour to do my job. As it is, we get to lie there looking at the phone wondering if it will ring, or not…

A neat summary of some of the stress factors I found was: Before you can deal with on-call stressors, you first have to identify them. Although the disruption in your day is one source of stress, there are usually several contributing elements. These include the challenges of defining an emergency, dealing with patients whose conditions are outside your area of expertise and your comfort zone, allocating on-call duties among the physicians in a group practice... Every surgeon and every speciality has a different definition of “emergency” ... Because “call” is an add-on episode, it can create anxiety, fear and irritability. For example, how does a specialist in spine surgery handle foot, hand or knee problems when on call? When subspecialists are on call, their stress levels increase as they anticipate having to deal with skills and decision-making in areas where they are no longer competent or comfortable.

Different strokes

The above is obviously from the human field and I had to smile about the specialists who deal with spines but have to see a foot out-of-hours – try seeing a whole new species! But in practice we do acquire niches and I am happy dealing with some things that are quite major in one field and that my colleague would baulk at, but something she can handle easily would be extremely challenging for me.

This stress is transformed into an extreme irritant when you are with someone who has never experienced being on call and they say something like, “Oh are you on call, how long can you stay?” Do not slap these people and yell at them telling them they really don’t get it.

This uncertainty can occasionally be harnessed for your own benefit. If you have any sort of hobby that requires some degree of precision and physical exertion then doing it while on call does kind of heighten the experience.

Zen archers have a practice which involves getting all your kit together and travelling to the practice field, setting up your target, stringing your bow, nocking an arrow and then just firing one arrow. Pack up, go home.

Doing something similar while on call means you sure as hell make sure every moment is your best. My current application is sabre fencing on a Friday when on call.

You just hack and slash with a little more care and precision when you know it could all be over at any random moment when the phone goes off. You don’t waste any time messing around.

The good bits

There are other advantages to working on call. OK, on balance I would still rather not do it, but here are the good bits. I find it is a very pure distillation of why I became a vet and what I want to do.

It’s just me, the owner and an animal who is in genuine (usually genuine) need of my services. There are no routine boosters, no cats to spay or dog food to sell. You are genuinely needed and appreciated and no one else can do what you do. So my usual thought process when on call runs a bit like this:

  1. The phone rings. Wake up (kind of) and speak to nurse on phone.
  2. Look at clock and decide that I hate my job and my way of life and why didn’t I just become a teacher and be surfing by 4:30pm and have 13 weeks paid holiday? Resolve to quit tomorrow.
  3. Phone owner and try not to sound grumpy/asleep/patronising/depressed or any or all of those.
  4. Drive to work and wake up a bit. Start to run through differential diagnosis, etc.
  5. Meet client and observe the golden rule of on call: once you have got this far always be polite and professional. You are all here now so let’s get on with it. They are paying quite a lot of money for this service (even if you don’t get to see it) so be nice to them.
  6. Make a very ill animal a bit/a lot/ completely better. Hey, maybe this job isn’t so bad after all.
  7. Go home, lie in bed wide awake and full of adrenaline until the alarm goes off then feel really tired all of a sudden.
  8. Repeat every nth night of your working life…

Tiring tests

Sleep disturbance is a major negative factor when doing out-of-hours. The review mentioned above found that: The third study, conducted on a small sample (n = 5) of ship engineers in Sweden, measured sleep during on-call periods using electroencephalogram (EEG) and electrocardiogram (ECG) recordings and subjective ratings [23]. This research found, like the others, that the sleep quality and quantity of the ship engineers was affected by the interruptions of being on-call. In their subjective assessments, the engineers reported being more drowsy during the day after being on-call, a finding similar to that of the transplant co-ordinators. But, the authors also found that the apprehension associated with the possibility of being awakened for call duty also negatively impacted sleep. On-call sleep registered less slow wave sleep (SWS) and rapid eye movement (REM) and a higher heart rate than when workers were testing during their normal sleep. Many of these conditions occurred prior to being awakened for call duty.

Earlier research by the same authors examined the sleep patterns of Swedish merchant marines at sea. This population also found it difficult to fall asleep on nights when they were on watch. The anticipation of alarms that would wake them up was seen as an obstacle that prevented workers from relaxing enough to allow for normal sleep patterns to develop.

So that explains why even after a quiet weekend on call when you are not woken from your sleep by the phone, you still feel tired. It’s no surprise to those of us who do it, but even if not woken up you just don’t sleep as well when on call. Most of us who work a full weekend feel pretty worn out by the end of it even if it’s a quiet one.

I was lucky enough to be taught by the late great Barrie Edwards, an equine surgeon. When he finally announced he was retiring and was asked what he was going to do in retirement, he replied that he was mainly looking forward to getting a decent night’s sleep.

Another factor to bear in mind is the stress inflicted on your partner, especially if you have small children. When babies arrive suddenly your partner is as tied into the on-call rota as you are. Being married to someone on call when you have small children is almost as bad as being on call. And you equally can’t go out or drink when they are on duty.

How can we make this better?

There is not much on this that I could find so for those of you new to being on call I will end with a few things, in no particular order, that help me. Any other ideas please email to garethcross@hotmail.com and I will collate them and print them.

  • The uncertainty is the big stressor here so start the night/weekend by thinking what your average call-out rate is and that it will probably be a bit like that. Over the year you will be about right! Sounds daft but giving yourself some sort of reference can help.
  • Look on the positive side as detailed above – you may get to actually help a sick animal and do some interesting work.
  • If you are new to it, remember that most call-outs are not that dramatic. Emergency medicine CPD is great but obviously skewed towards the tricky stuff. Most call-outs are minor RTAs, PTSs, stitch-ups, etc. If new to all this, go through the cases seen over the last six months with an experienced vet.
  • Get good at it during the day, especially for farm animal and equine work. Make sure you get sent on calvings, colics, etc.
  • Don’t commit to any social/family goings on. We have over the years developed a weird parallel existence for weekends on call with the family doing their stuff and me occasionally appearing and then disappearing during the day. I will join in if I can but equally can disappear without a drama.
  • Remind yourself that you are not the only one doing this. Lots of other vets as well as engineers, doctors, midwives, military personnel, mariners, police, etc., do on-call and many people work longer hours than you do for less pay. Reading forums and the letters page of the vet press, you would think that we had the worst deal ever. This week for example I had a client in who was an electrician and was advised to have minor surgery on his dog two months ago. “Sorry I didn’t come in then,” he said. “I got called into work and had to spend five weeks on a ship.” Suddenly my bank holiday on call doesn’t seem so bad.
  • Remember that most “No Out of Hours” vet jobs will require more late evening and Saturday shifts than most jobs that involve on-call. Many friends of mine who do no on-call work more Saturdays in a month than I do for the privilege and finish later in the evening.
  • Save up all your DIY/housekeeping, etc., jobs for the weekend on-call. Take your kids to B&Q to share the misery. Last time I did this as we pulled into the car park the liveried SUV of the local equine vet pulled out of B&Q with his daughter in the passenger seat.
  • If you are doing farm animal work and driving a lot, get a dog to keep you company! Peg and I spent many hours racing around Exmoor between farms and stopping off for short dog walks in between. My record was 350 miles in one weekend.
  • For new graduates remember that what is expected of you is to do what an average vet would have done in those circumstances, not what your lecturer who was a Specialist could do.

To sum up then, we all hate it but remember you’re not the only one doing it and it’s not that bad really. The RCVS’s recent ruling on home visits has just about edged the welfare of vets above that of dogs and cats, so do yourself the same favour. Keep on keeping on and don’t let it grind you down.