We all know of doctors and medical students who perform rituals in the hope that they will have a quiet night on call. Is this pragmatism or just plain stupidity? Patrick Davies and Adam Fox investigate and tell us why you should never say, "It's quiet tonight"

Everyone knows that doctors are rational sensible logical people who use science to further the wellbeing of their patients. They tirelessly work extremely long stressful hours, often in the middle of the night. Students have probably heard some of the myths about on-call nights, and some may have experienced them first hand. But what is not well known is the lengths some doctors go to to minimise their overnight workload and maximise their rest.

General behaviour on the ward can strongly influence how much a doctor is called overnight. Generally, doctors fall in to two camps: those who believe that they will not be bleeped if they are never seen on the ward, and those who feel it is better to set the nursing staff's minds at rest. Methods of doing this include a night ward round, either in person or over the phone, which can tidy up any outstanding issues, hopefully ensuring a good night's rest. Asking nurses to "batch" jobs for a night's ward round can minimise the time spent on each ward. More efficient working skills are becoming essential in an ever more stretched health service.

Some doctors, however, rely to a varying degree on more supernatural methods to reduce their workload. For example, some doctors follow elaborate routines in the belief that they can influence how busy they will be during their night on call.

Superstitions are founded in the ancient belief that unseen forces take an active part in our lives. By not tempting fate we can exert an influence over these forces and take control of our destiny. It is a seductive concept. Given that actors say, "Break a leg," sportsmen swear by lucky footwear, and gamblers stake their fortunes on symbolic numbers, why should doctors be any different?

The modern world remains full of superstition. Often, despite their better judgement, intelligent rational people avoid walking under ladders and knock on wood. Hospitals are certainly not exempt from this. Ward 13 and bed 13 are rare in British hospitals. In addition, Friday the thirteenth has been shown to be a dangerous time, with above average rates of hospital admissions due to road accidents.¹ Sceptics may dismiss this as merely the result of altered driving behaviour.

Superstitious patients

As a recent studentBMJ editorial pointed out, many patients hold firmly to their superstitions, which may have inadvertent health effects.² Such superstitions can have a considerable impact on healthcare funding. A Japanese study estimated that patients refusing discharge on "unlucky days" cost one hospital 7.4 million yen per year (£41 000; $63 000; a64 000).³ This is not just an Eastern phenomenon: nearly a quarter of Irish patients said they would refuse discharge on a Saturday on the basis of the "Saturday flit, short sit" superstition,⁴ which dictates that if you leave somewhere on a Saturday, you are unlikely to remain away for long. The added stress of perceiving a day as unlucky can lead to an increase in cardiac mortality among some people and so such beliefs should be taken seriously.⁵ It is worth bearing in mind that the Chief Medical Officer's working parties take patients' anecdotal evidence as seriously as the evidence from randomised controlled trials.⁶

Superstitious doctors

Lunar cycles

There is plenty of evidence to suggest that doctors are superstitious creatures too. Nearly two thirds of emergency doctors believe that the lunar cycle affects their workload, despite evidence to the contrary.⁷ No difference has been found between number of admissions, severity, or likelihood of trauma on the night of a full moon.⁸

Exams

A Swiss study showed that a tenth of medical students took lucky charms with them in to exams.⁹ Even though these students did no better than their peers, future candidates will no doubt keep up the lucky charm tradition.

On call

We conducted a survey of 240 doctors at a large district general hospital to investigate what doctors did to influence the success of a good night's sleep when at work. Although the response rate was low, 47% confessed to some type of on call superstitious behaviour. Interestingly, of the 11 doctors who tempted fate by avoiding their usual superstitious behaviour, 10 claimed to have regrets, as their time on call was busier.

The "Q" word

The most common superstition was avoidance of the "Q" word. By saying that the on call appeared to be quiet was considered to be a sure sign of an impending sleep depriving catastrophe.

A randomised controlled trial set out to measure the influence of the Q word.¹⁰ At the start of each day, a coin was tossed to decide whether the day would be a Q or a "W" day. A Q day began by the medical team all discussing how quiet they expected the day to be whereas on a W day the team discussed only the weather. The study found no significant difference in admissions between Q days and W days. A similar study in the United States also failed to show a significant difference.¹¹

Shoes, socks, and other stuff

Clothing featured significantly in our survey. Many respondents believe that if everything is not laid out ready for a quick getaway, then they are bound to need it in the middle of the night. Odd behaviour regarding socks is common. Some doctors always sleep in their socks and others have to lay "each sock on the respective shoe, longitudinally." One doctor, bravely, never wears socks with theatre shoes. Shoes were also central to many routines. Not only do some shoes have to be ready, some have to be pointing towards the door. Lucky necklaces and even lucky eyeliner were mentioned.

Certain surgeons enter theatres through the anaesthetic room door only and one doctor confessed to believing that if he saw any wildlife on the way home after an operation, then the patient they had just operated on would do better.

The black cloud

Another common superstition is the black cloud--that is, the perception that certain doctors tend to have busier on calls with more admissions and less sleep than their colleagues. A study of 19 paediatric residents in Chicago vindicated this apparent myth. Particular individuals did indeed tend to have persistently worse on-calls than their colleagues. However, the difference in sleep and admissions was more a reflection of the doctor's personal habits and practice than a true difference in the volume of patients.¹²

Adam Fox specialist registrar in paediatric allergy and immunology , St Mary's Hospital, London
Email: adam.fox2@virgin.net