The Following Post is Written by Dr Deborah Fisher, Associate Professor of Medicine, Division of Gastroenterology at Duke University Medical Center. Dr Fisher is both a brilliant clinician, writer, and researcher…and also happens to be my wife. http://www.durham.hsrd.research.va.gov/cv/Deborah_A_Fisher_MD_MHS.asp
Usually I spend about 65% of my time in clinical Gastroenterology and 35% in research, but 4 weeks a year I put on my General Medicine hat and supervise the housestaff. General medicine is more challenging than ever because of resident time restrictions, multiple patient care hand-offs, and the increased administrative burden for all physicians (in-training and supervising). For readers not familiar with the academic calendar, it runs roughly July to June rather than January to December. This past General Medicine rotation I drew the lucky card of July. Or so several administrators would have me think. “Residents are enthusiastic in July, no burn-out” “They don’t argue with you” “They treasure every clinical pearl you offer” and the like. Perhaps. I must admit that residents rarely argue with me during any month and often General Medicine induces burn-out in even the newest residents.
Nonetheless, I thought it might be less pressure to teach in July. The classic Chalk Talk is all but gone. Allegedly, residents are all self-teaching basic pathophysiology and differential diagnosis during the time carved out by duty hour regulations, but the empiric and published evidence is not obvious to me. My teaching goal is to bring relevant data to the clinical setting in the context of individual patients. Of course, I provide feedback regarding data collection, patient presentations, and plans for management, but I also emphasize the importance of communication: within the team, with covering physicians, with consultants, and with patients and their families. I teach critical appraisal of guidelines. Guidelines can be useful summaries of the available data, but they can also be biased opinions and above all they cannot be applied to any patient without considering how that patient may have complicating comorbidities or other circumstances not addressed in a given guideline. Finally, in all clinical settings, I emphasize that in this age of technology we must connect with our patients and engage them in their own healthcare. I worry when in clinic residents only make eye contact with the computer screen or on the wards when, after morning rounds, they deliver all news to patients via bedside telephone (even when on the same hospital floor and wing). The Mantra from Administration is “Discharge planning begins on admission.” My interpretation is that we are not attempting to discharge as quickly as possible for its own sake, but that we must understand something of a patient’s social situation and other potential barriers to managing their health to start mobilizing resources to address these barriers. The sooner this is done the better. We must tailor the evidence for an intervention with the individual needs of the patient.
To avoid taking myself too seriously in my role as a clinician-educator I will end by sharing my 2 super powers. This is timely as July is also filled with superhero summer blockbuster movies. My best super power is the ability to arrange endoscopic procedures with a single phone call. My second super power is the ability to approve Miralax (polyethylene glycol) for constipation. Oh the might! The glamor! Of a Gastroenterologist on General Medicine.
It is unfortunate, but now medicine is “on the clock”. We now must not only battle disease, but we must also battle time. Physicians are asked to do more in less time. Innovations such as EMR (which in theory are supposed to increase efficiency) sometimes actually slow clinical practice to a halt. Additionally, ongoing debate exists as to how best train medical residents and prepare them for the practice of medicine. Technology and mhealth applications are changing the way in which doctors and patients interact. Training programs have been evaluated multiple times over the last 20 years and sweeping changes have occurred in the way in which the ACGME regulates the working hours of physicians in training. These changes have a significant impact on the way in which physicians practice once they have completed their residency and fellowship commitments.
Medicine, more than any other profession, is best learned through experiential training. “Hands On” contact with patients and families allows residents to immerse themselves in disease and the continuum of care. Studies from the late 1980s (published in the New England Journal of Medicine) suggested that although resident hours were long and arduous, much of their time was spent doing paperwork and tasks such as drawing blood and transporting patients–even in the era of the 100+ hour week for interns only 20% of the work time was spent in direct patient care. In the early 2000s with increasing pressure from politicians and other organizations, the ACGME issued a statement limiting the work hours of housestaff to 80 hours per week. The arguments that led to the limitations in work hours revolved around mistakes and errors during times of sleep deprivation. Citing patient safety and resident “burn-out” advocates for change stressed that care and learning would both improve if rules were put into place to limit consecutive as well as cumulative work hours. However, a recent study in the Journal of General Internal Medicine explored the difference in mortality pre and post reform. Interestingly, there was no overall change in mortality pre and post reform. In fact, when interviewed, residents and attending physicians complained about the dangers of the “patient handoffs”. In the old days, the “sign outs” would occur only once a day–in the evening to the on call team. Lists were prepared from every team and a verbal sign out would occur doctor to doctor and team to team. In the morning, the on call doctors would discuss the overnight patient events with each team and ensure a proper continuum of care. In the new system with trainees coming and going at different times, there are many opportunities for miscommunication and sometimes important patient care issues get lost in translation. Many times the night call team is not even associated with the particular service they may be covering and may only cover a night or two here and there–resulting in zero continuity of care and no investment in the overall outcome of the patient. More importantly, trainees never truly understand the entire course of a disease process as they frequently only see a portion of the span of therapy due to work hour limitations.
Clearly, the current system for training physicians is lacking. Neither pre reform guidelines nor post reform guidelines are adequate. This week in the New York Times, author Pauline Chen provides a nice review of the course of reform in medical education. However, near the end of her essay, Dr Chen makes her most important points–ultimately, by limiting time spent with patients, we are working to eliminate the formation of the doctor patient relationship. In fact, some data suggests that in addition to a training curriculum for residents most institutions also have a “hidden curriculum” that affects the attitudes of physicians toward their patients once in practice. If the institution is heavy on paperwork and intern “scut work” there is little time for direct patient interaction. These training experiences can shape the way in the doctor relates to patients throughout his or her career. It is essential that we continue to teach doctors how to be healers. No matter what the working hour limitations may be in the future, we must continue to foster skills for building healthy doctor patient relationships in our physicians in training. In addition, we must help residents with time management and discover ways to improve the time that they spend in direct patient care while in training. If we do not, we will find that the art of medicine may in fact be lost forever.