The Nightfloater's Prayer

Mincha with tallis and tefillin.

Distress and disease: inextricable

The important lesson to be drawn from studies of medical-psychiatric comorbidity is that distress and disease both produce physical symptoms. It is not productive to dichotomize symptoms as "somatogenic" and "psychogenic" because physiologic and psychological processes are involved in all symptom production and perception. "Rule out" diagnostic strategies that search for either a medical or a psychiatric cause of a physical symptom are not supported by epidemiologic findings of high rates of medical and psychiatric comorbidity.

-from Katon W, Sullivan M, Walker E. Medical symptoms without identified pathology. Ann Intern Med 2001;134:917.

I remember last year when I started the night float rotation; the interns passed around a handout, compiled a few years ago by some previous interns who were now attendings, about how to diagnose common inpatient complaints. Anxiety languished far at the bottom of the list for diagnoses explaining chest pain. "This is a diagnosis of exclusion!!" said the handout - the implication being that no one should ever diagnose anxiety (or other psychological complaints) on the hospital floors. The cultural supposition is that chest pain is either a heart attack, or an aortic dissection - or else it's "bullshit." (No one would write this, of course . . . it's understood.)

Floating at night

The hospital, with all its activity and mad transformation, is subdued at night. A cover is dropped over everything.

But it is not as if everything goes to sleep. The activity is dampened but not stilled, like music heard outside a soundproofed room.

Even those events that happen in a mad rush - the resuscitation, the emergency surgery - feel slower. It is night's recognition that daytime matters. Not every shift is like every other.