The Black Cloud Phenomenon in Hand Surgery

Abstract

Background: The term black cloud for a surgeon is generally used to describe someone who is unusually busy compared with his or her counterparts, and it is a superstition that tends to pervade the medical world. The purpose of this study is to investigate whether black clouds exist in hand surgery. Methods: We examined one academic year’s worth of hand surgery–specific call at a level I trauma center and tabulated the number of hand-related patient transfers and add-on cases per surgeon. Each surgeon was given a black cloud rating by the fellows who were in training that year. Correlations were made between the black cloud rating and the surgeons’ call volume. Results: There were 12 surgeons who shared 365 days of hand call, and 5 of them are hand surgery fellowship trained. Those 5 surgeons tended to be busier on their call days, with more cases added on overnight and the next day, and also had worse black cloud ratings than the 7 non–hand fellowship trained surgeons. Conclusions: In regard to hand surgery, while true emergencies occur and require emergent intervention, how busy hand surgeons may be during call may be influenced by a variety of factors not related to their patients’ problems but rather their daily schedules, their hospitals’ ability to facilitate add-on cases, and their rapport with their fellow surgeons to share case loads.

Background

Despite being a profession that prides itself on scientific studies and evidence-based medicine to dictate treatment and patient management, the medical community is filled with superstitious traditions and perceptions that are not founded in objective data.^6,11 Mandell et al showed that although only 23% of medical personnel characterized themselves as “generally superstitious,” medical-related superstitions were still prevalent. As much as 80% of emergency department personnel believe that Friday the 13th and full moons result in an increased amount of trauma cases and patient volume.^6,8,10 Physicians routinely avoid using the word quiet during calm work periods for the fear it will incite an influx of chaos.¹¹

The terms black cloud and white cloud are used to describe those who are perceived to have a larger or lighter than average work load during call nights, respectively.^3,9 Despite many studies demonstrating no objective date to validate these terms,^2,4,5,9,10 medical personnel still hold a widespread belief in these superstitions.⁶ Evaluating whether the “black cloud phenomenon” actually exists in a medical specialty may have an important impact on understanding why certain physicians are given this label. A previous study in pediatrics residents demonstrated a correlation between black cloud residents and decreased sleep while on call, but no increase in actual workload.⁹ Tanz determined that “black clouds come from within” and are self-generated. Those labeled as black clouds slept less and believed they had harder on-call nights compared with their peers, despite no statistical difference in workload.⁹ They demonstrated that black clouds may be more inefficient than white clouds at completing their work in a timely manner.

A paucity of literature regarding the black cloud phenomenon exists in surgical specialties as the majority of black cloud literature has been studied in primary care medicine. Although different specialties have a different definition as to what constitutes a black cloud, in surgical specialties one is generally labeled their specific cloud color based on the number of emergent, unscheduled, trauma cases that arrive on their designated on-call days. Sixty-six percent of operating room nurses and 65% of residents believed that certain medical personnel indeed carried a “black cloud.”^7,10 Once labeled a “black cloud,” this term usually follows the surgeon throughout their career. The purpose of this study was to evaluate a hand surgery department’s case logs at a major trauma center over the course of 1 year to determine whether specific attending physicians were indeed black clouds.

Materials and Methods

A chart review was performed examining 1 year’s worth of hand trauma call among the hand surgeons at 1 Level I trauma center from August 1, 2014, to July 31, 2015. For each surgeon per 24 hour call period (7 am-7 am), the number of cases added on overnight (7 pm-7 am) was tabulated, as well as number of add-on cases the next day (7 am-7 am). Each case was reviewed in the electronic medical record to determine whether it was a scheduled case or the result of a consult that came in during that surgeon’s call period. Scheduled cases were excluded. We also obtained the medical transfer log for this institution to examine the number of accepted transfers from other institutions during each call period by on-call surgeon, as well as how many of those transfers went to the operating room either that night or the next day.

To obtain a “black cloud” rating on the various surgeons, the hand fellows at this institution were surveyed, asking them to rate each surgeon’s “black cloud” level on a 1 to 5 scale, with 1 being a black cloud, and 5 being a white cloud. This survey was performed within 1 year after the fellows had graduated so they could be able to recount their experience for the full year being examined. Throughout the year, each fellow takes an equal share of overnight call alongside the attending surgeon and is usually present to assist for overnight cases. Spearman rank correlation tests were performed correlating each surgeon’s black cloud rating and the number of add-on cases they had overnight and the next day, as well as the number of transfers they had.

Results

There were 12 surgeons who took primary hand trauma call during the examined year. One of these surgeons had 1 call day during the 365-day period with 0 cases, so this surgeon’s data was excluded. Table 1 lists the number of call days, patient transfers, overnight operative cases added on, next-day operative cases added on, and average black cloud rating per surgeon. Out of the 11 surgeons, 3 are orthopedic surgeons who underwent specific hand fellowship training. The remaining 8 are plastic surgeons, with 2 of the 8 having underwent hand fellowship training and are practicing hand surgeons. The non–hand fellowship trained plastic surgeons practice a variety of plastic surgery fields; however, all of the surgeons, both orthopedic and plastic, are trained in microvascular surgery to take care of any potential emergency hand replantation cases. The average black cloud rating was taken from survey results of 5 of the 9 hand fellows from that year who responded to an e-mail survey request. A rating of 1 was considered a black cloud, whereas a rating of 5 was a white cloud. Four out of the 5 hand trained surgeons had black cloud ratings <2.5, considered more on the black cloud end, whereas 6 out of the 6 non–hand trained surgeons had black cloud ratings >2.5, considered more white clouds.

Table 1.

Characteristics of Hand Surgeons’ Call Volume and Black Cloud Ratings.

Surgeon	No. of call days	No. of patient transfers	No. of overnight add-ons	No. of next day add-ons	No. of transfers taken to operating room	Average Black cloud rating
T.A.	22	18	2	1	1	3.6
J.F.a	79	44	22	26	21	2.8
M.G.	26	10	0	3	0	4
R.G.a	34	19	1	12	8	1.6
J.G.	26	21	4	0	4	4
R.K.a	46	37	12	19	14	2
V.N.	31	15	5	1	2	3.6
J.R.	19	14	2	5	3	4
M.S.	26	22	4	2	2	3.4
A.S.a	36	28	17	16	13	2.2
K.W.a	18	18	3	4	3	2.2
Total	364	246	72	89	71

^aHand fellowship trained surgeon.

Black Cloud Rating and Hand Trauma Call Volume

Figure 1 depicts the average number of patient transfers per surgeon against their black cloud rating. There was no correlation between average number of transfers and each surgeon’s black cloud rating (r = −0.124, p = .675). Figure 2 shows the average number of transfers that were added on to the operating room schedule either that night or the next day per surgeon against their black cloud rating. This correlation was significant (p = .012) with r = −0.724. Figure 3 shows the overall number of cases that we added on overnight and the next day against each surgeon’s black cloud rating, with a significant correlation at r = −0.760 (p = .007). Higher black cloud ratings were associated with both increased number of transfers and increased number of add-on cases.

Figure 1.

The average number of patient transfers per call day plotted against the average black cloud rating for each hand surgeon on call.

Figure 2.

The average number of patient transfers taken to the operating room (OR) within 48 hours per call day plotted against the average black cloud rating for each hand surgeon on call.

Figure 3.

The average number of add-on cases both overnight and the next day per call day plotted against the average black cloud rating for each hand surgeon on call.

Discussion

A number of factors can influence how busy a surgeon may be on his or her respective call day, not just the “emergent” nature of the consults that come in during his or her call period. In our study, we looked at 1 academic year of call from August 1, 2014, to July 31, 2015, to see if there were any correlations between the hand surgeons’ perceived “black cloudedness” as rated by their fellows and how busy they were on their call days.

The number of hand-related patient transfers was relatively evenly spread out among the 11 surgeons’ call periods. Generally, someone trained in a specific field will likely want to operate on cases specific to that field. We found that in our study that the surgeons who were generally considered more black clouds by their fellows tended to be the hand fellowship trained surgeons. These hand-specific orthopedic and plastic surgeons overall took more call periods than the non–hand trained surgeons (Table 2), with 213 call days among 5 hand surgeons compared with 151 call days among 6 nonhand surgeons, and had more overnight add-on cases (55 vs 17) and next-day add-ons (77 vs 12). The average number of overnight add-on cases and next-day add-on cases per hand trained surgeon in 1 year was 11 and 15.4, respectively, compared with <3 and 2, respectively, for a non–hand trained surgeon. Averaged by call days, the hand trained surgeon had 0.26 overnight cases added on per call compared with 0.11 cases for the non–hand trained surgeon. These data signify that on average the hand surgeon can expect to add a case on overnight about every 1 in 4 calls, compared with 1 in 9 calls for the non–hand trained surgeon. For next-day add-ons, the hand surgeon added on an average of 0.36 cases per call compared with 0.08 for the nonhand surgeon. This amounts to about 1 next-day case added on for every 3 call days for the hand surgeon versus about 1 next-day case for every 12 call days for the nonhand surgeon. This analysis demonstrates that hand trained surgeon tends to be busier than the non–hand trained surgeon.

Table 2.

Comparison of Case Volume Between Hand Fellowship Trained Surgeons and Non–Hand Fellowship Trained Surgeons.

	Call days	Overnight add-on cases	Next day add-on cases
Hand trained surgeon (5)	213	55	77
Average per surgeon	42.6	11	15.4
Average per call	—	0.26	0.36
Non–hand trained surgeon (6)	151	17	12
Average per surgeon	25.2	2.83	2
Average per call	—	0.11	0.08
Total	364	72	89

Most hand consults are likely not emergencies and likely do not require the expertise of a hand surgeon. A study by Bauer et al looking at the emergency room referrals to 2 receiving Level I trauma centers showed that out of 296 transferred patients for hand-related complaints, 48% were seen by a hand surgeon, and only 39% were taken to the operating room within 24 hours of presentation.¹ The numbers at the institution we examined demonstrated even less need for a hand surgeon’s expertise: There were 246 transfers in 1 year and only 71 of them, or 29%, were taken to the operating room either that night or the next day by the surgeon who was on call. The truly urgent or emergent nature of the cases that go to the operating room may also be subjected to factors other than the patient’s diagnosis. Scheduling a case more urgently could also be influenced by a surgeon’s daily schedule and nature of his or her practice, such as an operating room’s flexibility to add on a case when it is not considered an emergency or having to travel to other hospitals or clinics that are not in the same location as the hospital where call takes place.

Conclusion

A black cloud in surgery is generally considered someone who is unusually busier than others and brings in more emergencies on his or her call day. The creation of black clouds may be related more to surgeon factors such as training experience and work schedule rather than the number of emergencies that occur during a call period.