“I’m sorry. Did I wake you up?”

“No, that’s OK. I had to get up to answer the phone anyway.”

It’s an old joke. It’s also 3:16 a.m. Someone’s potassium is low; or someone’s urine output is flagging; or they have a fever; or their blood pressure is dropping; or their chest drainage is rising; or they’re not waking up; or they have one more CFU on their urinalysis than the lab swears is normal. Or maybe they need a sleeping pill or a laxative. Or maybe it’s every one of these things.

It doesn’t matter.

It’s 3:16 a.m. and you’re on call.

Which, like most of us, you are (or you were) a lot. I was on call upwards of ten thousand nights in my career, so I know of where I speak.

It doesn’t matter.

You can only take them one 24-hour day at a time.

There’s an old saying in medicine: It’s not the work, it’s the worry. And even if we work hard to exude confidence on the outside, we really worry a lot on the inside. If we’re lucky, we have residents to worry for us; but then we have to worry about the residents. And whether they’re worrying enough; or worrying about the right things. We worry while we’re operating and every minute after. There’s so much that can go wrong; so much that can’t be controlled, so much that can change from minute to minute, from hour to hour, day to day. We worry about every decision we make – even the small ones.

Spoiler Alert: there aren’t really any small ones.

Call.

Just say the word to most physicians and you induce the thousand-yard stare.

Call.

Because that’s what they do. They call – and when they call, they call you.

Pager, home phone, cell phone, office phone, satellite phone, ship-to-shore, tin cans on a string – if someone can call it, they will.

Because that’s their job. It’s what you want them to do, what you told them to do, and what you simultaneously hate them for doing.

Call isn’t a yoke or a set of manacles. Call is a backpack. Full and heavy. And you can’t take it off unless someone else puts it on. It’s bulky and it's cumbersome and the straps cut into your shoulders no matter how you wear it.

How many patients do you have in the hospital? Drop a brick in the backpack for each one. Is one of them a little sick? Add a brick. Is one of them unstable? Add a cinderblock. Now carry this loaded pack while you do your day job. Discharge somebody? Take a brick out. Discharge everybody? Not in this lifetime.

As the end of the workday approaches add a few bricks and the occasional cinderblock from your colleagues’ backpacks. Listen to their sigh of relief. Sometimes you need a second backpack just to accommodate everything. Wear it when you walk through the door to greet your family, stooping a little now under the weight. Try and find a comfortable position in your favorite chair with it on. Try having a conversation with your spouse while you’re ruminating on how all the bricks are doing in there. Try playing catch with your daughter or reading a book to your son while it pulls you down. Then carry it up the stairs or down the hall. Tuck it in bed with you after the late news.

You don’t sleep the same when you’re on call, do you? Not with one eye open exactly. More like with both eyes not completely closed. Even after many years, you learn to never fully relax. It’s like knowing there’s a panther padding silently around somewhere outside the hut. But not an anaconda – that’s another story.

There are those occasional nights when all the bricks nestle snugly together and let you sleep. But most nights the corners and the edges nudge and bump you awake. You toss, you turn, and you make adjustments so they fit better. Then you find the least uncomfortable position and try to doze. Some nights you have to go back to the job site. Something is leaking, something is broken, or sagging, or maybe hanging by a thread. And usually, while you’re there, someone hands you yet another brick.

Call is also an equal-opportunity abuser. Are you a woman? Are you a parent? It doesn’t care. It treats you the same during any stage of pregnancy and through every phase of child-rearing. It doesn’t think to synch the low urine output call with the three-o’clock feeding. It doesn’t care about the school play, the Little League game, the father-daughter Sweetheart dance, or the romantic evening. It’s no accident there’s no Take Your Daughter On Call Day. Call changes you – in direct proportion to how much of it you take. It runs your life. It determines whether you take one car or two or whether you even go at all.

If you’re lucky enough to have partners, you can look forward to the morning light and the bittersweet process of transferring the weight to their backs. If you don’t, you just hope your colleagues can help you shoulder the load for a while, like Simon of Cyrene, until you have to put it on again.

And yet.

And yet, call is perhaps the most ennobling thing we do.

We drop what we’re doing, no matter how important, and we respond. We commit to putting the welfare and the needs of complete strangers ahead of ourselves and those closest to us. We assume that responsibility because someone’s well-being has been entrusted to us. Not infrequently, someone’s life is at stake. Maybe, when all is said and done, call is the most satisfying thing we do.

It just never seems that way.

Sit in any Doctors’ Dining Room at breakfast and you can pick out who’s been on call. Ever so slightly disheveled, ever so slightly unfocused, gathering their resolve to tamp down the terrors of the night and marshal their resolve for what the new day has in store.

And call is what ultimately wears you down, inexorably carving a Grand Canyon in your everyday existence. Spouses learn to adjust their schedules; children subconsciously adapt their expectations. We knew all of this when we signed up for this life but it is the submerged bulk of the iceberg that most people don’t see. The part that sinks ships.

When they call, you will answer. You will do what needs to be done; you will go see who needs to be seen. It’s what makes us different. We don’t just “provide” care – we deliver it. Wherever and whenever.

It’s 3:16 a.m. and the phone rings.

“Did I wake you?”

“No,” you say. “It’s OK.”

But what you mean is, “I was never really asleep.”

Daniel Waters, DO, MA recently retired from active practice after three decades in cardiothoracic surgery and medical education. Dr. Waters is a 2019-2020 Doximity Fellow.