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Yule Sample

Working in a hospital during the holidays

By CORY FRANKLIN M.D.
    The brilliant film director Billy Wilder loved to use holidays as a recurring theme in his most memorable movies. Christmas was an important setting in The Apartment and Stalag 17. New Year’s Eve was an essential part of Sunset Boulevard (and also in The Apartment), and Yom Kippur, the Jewish Day of Repentance, was central to the plot of Lost Weekend. Wilder knew intuitively there was both drama and a special emotional pull when he placed his characters in holiday settings. That same drama and emotional pull is at work in the hospital on the major holidays, with the joy and sadness, as well as the unstated understanding that the hospital is a different place during the holidays.         
    For obvious reasons, even the best hospitals are not staffed as well on holidays as during ordinary days. Critical areas, like the emergency department, trauma and intensive care, usually have similar nursing coverage as in normal times. The camaraderie between the staff tends to be greater than usual—perhaps a sense of shared misery having to work. It’s not unusual to see staff share holiday gestures with patients and families, such as small gifts on Christmas, a brief midnight celebration on New Year’s Eve or a special meal on Thanksgiving.                       
    Other parts of the hospital are generally less well-staffed during holidays. It varies from hospital to hospital, but there are often fewer nurses on general wards. For major holidays, ancillary personnel like therapists and secretaries often have the day off. Those who have to work must sometimes cross-cover—they staff more than one area or areas they are less familiar with during holidays. Senior administrative personnel usually have the day off and junior administrators are left to deal with problems.             
    Physician coverage is also different. Many physicians come in on holidays (“make rounds”), but some doctors take calls from home. Where I worked it was common for doctors to do religious swapping—observant Jewish doctors would do rounds on Christmas and Easter in exchange for having their non-Jewish counterparts do rounds on the Jewish holidays. In hospitals that employ residents, junior residents are usually the primary workforce on major holidays. Many specialists take the day off, especially if emergencies are uncommon in their specialty.                               
    Does this have implications for patients? In high intensity areas like the intensive care unit, where nursing and physician coverage is reasonably the same as other days, there is not much difference. Radiology, respiratory or physical therapy might be scheduled less frequently depending on patient need. If it happened you needed a particular specialist, unless it was an emergency, the specialist might hear about the case by phone and see you the next day. Lots of specialists have a busy Friday after Thanksgiving.         
    In the general wards of the hospital, the difference in staffing might be noticeable. All things being equal, I counsel patients to, if possible, avoid scheduling elective surgery and admissions around Labor Day, Memorial Day, Thanksgiving, Christmas and New Year’s Eve. Even for minor surgeries it’s better to have a complete staff available—and many operating rooms only do emergency cases on holidays.                               
    Interestingly, the problem of holiday coverage is not confined to the United States. A recent newspaper article in Pakistan noted the problems patients have there when doctors and medical staff take off during the Muslim holiday of Eid, the end of Ramadan. The newspaper quoted an attendant at the Lahore Services Hospital, “Nobody is there to listen to the grievances of patients or their attendants because the entire administration of the hospital is enjoying holidays.” Patients at Lahore General Hospital, Jinnah Hospital and Sir Ganga Ram Hospital were also reported to be suffering from a lack of diagnostic services.                                                            
    The one holiday that is a special case is July 4. Most American hospitals begin their training schedules for new residents on July 1. 
So in their first week of formal training, residents are sent out to work in an environment with less staffing and fewer specialists. Most good hospitals are aware of this anomaly and provide extra coverage accordingly.
     One of the urban myths that frequently circulates is that July is the worst time to be sick due to the inexperience of the staff. Most studies that have looked at this tend to refute it—mortality is not higher in July. In my hospital’s department of medicine, I studied mortality figures for nearly three decades, and there was no July increase in mortality. Some observers have theorized August may actually be a more dangerous month, since the inexperienced doctors are now on their own more often, no longer backed by extra coverage. Others have postulated June as the most dangerous month, since so many resident doctors are leaving at the end of the month and might have a tendency to “slack off.” There is no evidence to support either of these theories.   
    Based on my observations, I believe these theories are invalid because physician experience, while a variable in hospital outcome, is at best a minor factor. Far more important than physician experience in determining hospital mortality is case-mix, the type of diseases and patients who compose the hospital population. The highest mortality in our medical department was usually not in the summer, when physicians had less experience, but in the winter when there were far more communicable respiratory problems such as pneumonia and influenza. For us, the Christmas season was a more dangerous time than July 4. (Of course, mortality soared during the summer heat wave of 1995 when the hot weather was a major cardiovascular stressor.)               
    Conversely, my surgical colleagues did tend to see a higher mortality in the summer, but it was almost certainly due to the increases in blunt and penetrating trauma that occur in the summer months. In the summer, more people are outside and that brings a concomitant increase in motor vehicle accidents, arguments and all the dangerous behavior that results in serious injury. July is a more dangerous time for surgical patients and sometimes even the most experienced surgeon can’t put Humpty Dumpty back together again.                                        
    Holidays change the make-up of patients entering the emergency room. Most people put off the routine problems that would ordinarily send them to the hospital. (One ER doctor once told me he thought the slowest evening of the year was that All-American holiday, Super Bowl Sunday. It sounds good, but I have seen no evidence to confirm it.) What it does present to the hospital on holidays is what you’d expect—carving and cooking mishaps and injuries from outdoor athletic activities during summer holidays. Several studies have noted a greater incidence of depression during the holidays. And of course, alcohol, lots of alcohol.  
    A person who works with organ transplant candidates told me a fascinating story about holidays in the hospital. Transplant candidates often get their organs from victims of motor vehicle accidents, and since there are more fatal crashes during holidays, some of these potential recipients have admitted experiencing a subtle stirring of morbid hope during the holidays. (According to the National Highway Traffic Safety Administration, the five most dangerous holidays for drivers, in order, are Thanksgiving, July 4, Memorial Day weekend, Labor Day weekend and New Year’s Eve/Day.)                           
    However abstract it seems, organ recipients know somewhere out there on Thanksgiving weekend a motorcyclist going too fast or a car versus tree collision will result in a donatable heart, kidney or liver. The flip side is that once the holiday is over and they did not receive a call, they become slightly depressed over the lost opportunity. I have never seen literature to support this phenomenon, but there is a certain logic, however perverse, at work.                                          
    When it came to holidays, drama and emotional pull, Billy Wilder had it exactly right. A long-time colleague told me a poignant story about working in the hospital during Christmas. He was the anesthesiologist working on-call for the operating room one year on Christmas Day. It was slow day; there wasn’t a single case. So everyone—the surgical team, nursing staff and orderlies—sat around the lounge playing Monopoly. As he described it, I imagined lots of Santa hats on people who would rather have been with their families. Perhaps an uneaten fruitcake on the table next to the Monopoly board. Though it happened many years ago, he still remembers it vividly. He confided with a sly wink, “That day I learned the true meaning of Christmas—buying Boardwalk and Park Place.”

Published: December 09, 2009
Issue: Winter 2009 - Annual Philanthropy Guide