January 16th, 2013
“Nostalgic Professionalism” or Actually Caring About Patients?
Ajay J Kirtane, MD, SM
The other night my pager buzzed at 2 AM with a call from the emergency room. I was technically not “on call,” but because I was concerned that the ER was trying to reach me in the middle of the night, I answered the page. It turned out that an emergency physician needed help with one of my patients, beyond what he could derive from our electronic medical record. I assisted the physician, who used what I told him to help treat my patient, and he thanked me.
However, if one of my medical trainees at New York-Presbyterian Hospital answered an off-hours patient call, it might be pejoratively described as a form of “nostalgic professionalism,” according to a recent viewpoint article in JAMA. Among the examples of residents’ practices that need to be remedied are, apparently, staying past the end of a hospital shift to make sure your patients are (to use hospital slang) “tucked in”; remote checking of labs from home; and following up on a patient’s progress while off duty.
The rationale behind eliminating these practices among medical trainees (our future independent physicians) is to limit their work hours, thereby improving patient care. Advocating for a “new professionalism,” the JAMA authors cite the need for systems and processes that are based on optimized “shift work” paradigms from law enforcement and the aviation industry. These changes would (the argument goes) make patient care more efficient and safe.
No one would dispute that, from a systems level, reducing medical errors by “overworked” trainees is desirable. But what happens when those trainees enter the real world? Perhaps it is a sign of changing times that (professional) concern for patients, whether we’re on or off duty, is no longer noble but rather deemed “nostalgic.”
As a physician who cares for — and about — individual patients and families (and as someone with numerous family members who have received such care from other physicians), I hope I never see the day when we as doctors don’t wonder about and help our sick patients when we’re not in the hospital.
A core concept that we strive to instill in all our medical trainees is to care about patients, not just care for them. Call me “nostalgic,” but to me that’s not a sin.
How often do you take off-duty calls? And what’s your opinion of “nostalgic professionalism”?
10 Responses to ““Nostalgic Professionalism” or Actually Caring About Patients?”
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Unfortunately, the time course of acute illnesses, those illnesses response or nonresponse to therapeutic intervention obeys no artificial “shift” boundaries. The natural or interrupted natural history of clinical syndromes requiring hospitalization operates on a continuous time variable and the adverse or favorable effects of applied or overlooked therapies ride along that continuous time variable. We are responsible for recognizing that so as to attain the best outcomes for our patients- whether we are present( so called “on”) or not. Simply put- stuff is happening all the time.
On a personal level, some of my best problem solving occurs away from the chaos of the work ecology whereby I may reflect on a patient profile and clinical data set allowing “things to fall into place” and/or to reconcile that profile or data set with the literature(so called REFLECTIVE LEARNING). This often will lead to a change or enhancement of treatment. The efficiency and continuity with which this is realized has been enabled by the web based environment and the ability to maintain contact remotely.
Woe be we as a profession, if only the things that matter is when we are present for then we have become an itinerant profession.
I am millennial physician that did their internship prior to 2009. I suppose that makes me a “new old-timer.”
In any case, one of the major transitions between Intern year and the second year of residency (aside from the right to wear a long coat) was keeping our pagers on at all times when on an inpatient service.
Whereas intens regularly signed out their team pagers to the overnight call intern, as residents we felt that we should be available at all times to our co-residents and interns should there be any questions. I rarely got called… but almost felt relieved to answer a much needed question on someone that I knew a lot better than the person standing at the bedside.
The funny thing is that the tradition of keeping your pager on at all times wasn’t written in any rule book. Much like the knowledge of where the mess hall was in A Few Good Men, this was just tradition and culture.
When I talk to IM residents that are still in training, things are somewhat different. There’s no doubt that they still feel privileged to provide assistance with their clinic patients, but as most inpatient training programs move to complicated partial-nightfloat systems, pager coverage has been rolled into shift-coverage. Most residents say that when they walk into the sunrise, the pager goes off and is thrown onto the kitchen table.
There is something called the “bystander effect” where no one takes direct responsibility. This I fear is the effect of limiting interns and residents to no extra “shift” work. I think night float is actually a good idea, however the transition to the ward staff in the morning is the critical step in the care of the new admissions as well as the sign out of existing patients in the evening.
I was a salaried physician for 20 years and have been in private practice for more than 10 years. I have always taken calls outside my shifts, made house calls when necessary, followed my patients through home hospice. For me it is a privilege to be permitted the intimate relationship we necessarily have with our patients.
Many of my patients as well as my colleagues have my cell phone number. Patients rarely call me on my cell phone outside regular office hours. I find my knowledge of my patients medical and social history is often critical in their care as inpatients and has been life saving in some instances. I am always happy to speak to the ER physicians from whichever hospital my patients end up at. Given that there is still no interoperability of EHR’s between hospital systems, what I can tell the ER is often critical to the patient’s care.
In otherwise healthy patients with a single problem, the new ethos may work adequately. I do not consider what I do “nostalgic professionalism”. Illness is not like flying an airplane or giving parking tickets though it may be more like detective work in crime fighting. It is fantasy to think we can adequately care for patients if medicine is structured like the aviation industry, especially in its current state.
Very well put. I transitioned from academic medicine to private practice 30 years ago. I have always answered calls when off duty, and consider it a privilege and obligation of the profession. Would you accept a medical school applicant who made it clear that they would only care for and about their patients during duty hours? Should we hold other professionals to the same account? How about the President? The difference between a professional and a provider is the moral obligation that the professional has to always put their patient’s welfare above all others. We should not lose site of this.
Can’t we have the best of two worlds? Clear, concise patient records and well-structured handovers AND the possibility of following up on a patient (which I often do out of unbearable curiosity, and to see if I got it right, i.e. purely selfish motives). Handovers should be well structured, so nothing essential gets overlooked, but also allow for time to relay one’s doubts and feelings and mull over the case with the colleague who takes over – who might have an new insight on a clinical problem.
Michael Katz points out that when you are new and not directly responsible – an intern is often the department gopher – it seems logical to cast off your pager at dawn, but as soon as you graduate into clinical decision-making, it is good practice to be available. It goes without saying that colleagues should respect your needs for rest and recreation, and only call when your input is expected to make a difference in the patient’s treatment strategy.
I agree 5/5 (speaking as a pilot) with dr Kirtane arguments.
We are not pilots of a brief moment in the patient’ life, (except if the patient choose another physician!)
I wonder if pilots continue (under the shower for example) to think of passengers’ well being after their travel!
I personally consider that having the patient’s confidence impose a specific relationship which is taking care of him whatever the time. (Sometimes I remember the discussion of the Fox and Petit Prince in St Exupery’s novel)
Nobody can work 24/7 and a rest time is necessary.
I do not wear any superman suit (I am probably as everyone occasionally irritated by phone calls or SMS or e mail… and, it happens, I disconnect the phone, be sure ) I frequently ask my colleagues’ opinions, in taking care of a new patient I need help from his GP.
Pilots do not know passengers’ life but we do so in some situations (difficult ones or not) simply speaking or briefly answering to a patient or a colleague may be a great help.
When I was an intern a long time ago (not so long!) seeing the patients I admitted few hours ago was so important for me and for the patient (sometimes)
Continuing off-duty calls is one part of our work even if 90% of them are unnecessary and can wait the day after.
Do you think I am a nostalgic megalomaniac?…
I don’t believe in this Nostalgic Professionalism a better definition is Classic Professionalism. It is very easy to practice medicine if you are not full responsible. If something goes wrong you are at best, partially responsible. I you call a human been “your patient” his heath is also your professional responsibility. This notion of new professionalism, e records, protocols writing in stone and 99% hospital base medicine are only industry tactics to take the physician out of the equation. The physician is not important, any one in this hospital can give you the same attention. The institution is the important, the individual doesn’t matter. The problem with this New Professionalism is that you will never develop a good patient – physician relation and if you create any prestige it will stay with the institution. You will be at best a part on the machine, used until you give up, and very easy to exchange.
Ajay,
In this era of shift work and limited patient exposure, I worry. I worry that, in order to make sure that the internal medicine program does not get negative reviews from it’s residents, the program director limits to 20 the number of patients that 8 (!) medicine residents and interns are allowed to take care of. That is not 20 patients each, that is 20 patients total for 8 physicians. I routinely carried more than that when I was a resident. I worry because the most important day a patient spends in the hospital is often the day they are admitted, because that is when the information pours in (consults, radiology tests, and others), but the resident who admitted the patient is not there. I worry that the residents, despite not having more than two patients each, still don’t know their patients like I know them. I worry that as residents are trained as shift workers, they no longer own their patients. I worry that since they are spending some fraction of the time we spent in the hospital, but the number of years they spend in training has not increased, the absolute amount of training they have has decreased. I worry because I see my residents have free time to do many other things, but still don’t know the literature as well as I do (and, isn’t that one of the reasons why the change in duty hours was put in the first place?).
As an interventional cardiology trainee, we often started elective cases at 10pm, and continued until the cases were done. We were professionals learning a skill set. This concept has not followed through.
I am building a program, so my patients and referrings have my cell phone number, and I accept being called or receiving texts 24/7. Regardless, those who we train today will be our partners (pardon the pun) tomorrow, and our caregivers soon thereafter. I fear that those who write the rules in the ACGME long ago lost contact with taking care of patients and training housestaff, but that if they haven’t, they have had a far different experience than the one that I have experienced.
O tempora, o mores! Has it indeed come to this, that we are seriously trying to school OUT of new physicians a sense of concern for and obligation to their patients, extending beyond their designated “shift” hours? The NURSES at my hospital were positively APPALLED a few years ago when a supervisor suggested that they avoid overtime by behaving like cashiers at the supermarket–simply pulling out their cash drawers and departing at end of shift, rather than staying to ensure a safe transition for their patients. Now we are advocating this for PHYSICIANS? The nursing supervisor in question was forced to make a quick departure. Hopefully the position advocated by the authors will be met by all the derision and disregard it deserves.
My partner in practice calls me for advice from time to time when I am off duty. And I call him.