Cross Cover and Sign Out

Although most people view the "difficult" stuff in medicine as making that astute diagnosis, responding to emergencies, and finessing treatment plans, the most dangerous part of next year for me will be navigating a process called sign out. In sign out, one physician transfers the information and responsibility for care of a patient to another physician. This occurs a lot. At the end of each day, teams sign out their patients to the on-call doctors. At some point in the evening, a night resident (called a "float") comes in and receives sign-out from the on-call team. While most patients have no issues at night, if something does happen, the doctor who responds won't be the doctor who knows them best. This is a necessary part of the system; otherwise, all residents would be at the hospital all the time. Furthermore, sign outs are becoming more prevalent because of work-hour restrictions. Residents aren't allowed to be at the hospital for more than 30 hours at a time (or 80 hours in a week) so at the end of a 30-hour shift, someone else must take responsibility for the care of the patients. (Cross-cover, which is in the title of the post is a similar sort of situation).

Interestingly, I got a talk about sign-out from UCSF at the end of our last block "Coda" and a talk from Stanford during our orientation; this is how important that process is. It's compounded by so many more difficulties; outgoing residents are exhausted and want to go home, on-call residents are swamped with work; patients are extraordinarily complicated. Most medical students have seen the "there's nothing to do on my patients" sign-out and that's simply not adequate, though it's tempting. Communication is central to so many preventable errors. Thus, it was great to get two recent lectures on this process (and good to know that the key points were the same at both places) and hopefully I will keep this in mind as I start later this week.