Looking Back to See What’s Ahead

AM Rounds Slider Master-20

By Jack Ende, MD, MACP, chief, Department of Medicine, Penn Presbyterian Medical Center

Being 65 years old is not without its advantages, and I speak here not just of Medicare benefits, reduced prices at movie theaters, and the occasional vacated seat on a bus (although admittedly that rarely happens, so perhaps I really do still look 50). No, I speak of the gift that years of experience gives to all of us geezers, and that is perspective.

Perspective is the setting on the mind’s camera that controls the ratio of figure to ground. Young, and your view of what is actually happening is dominated by what is taking place now. Old, and you see things differently.

I see the current resident-attending relationship from the perspective of an internist trained in the ‘70s (interestingly, at the University of Chicago where Roshetsky and her colleagues gathered their data on attending physicians’ workload before and after implementation of the 2003 duty hours regulations.). Housestaff in the ‘70s often worked 36 hours straight, and attendings, many of whom were outstanding clinicians and memorable teachers, thought little about standards of supervision. Competency was a term we used for our psychiatric patients, while milestones were mentioned at graduation, if even then. The truth is, houseofficers in my day did a lot that was unsupervised. Great stories now, but not such great patient care.

But the Roshetsky study and the Wong commentary recently published in Academic Medicine focus not on patient care or resident experience but on the workload of the attending. So what are the lessons for the attending whose life clearly has changed since the advent of ACGME rules on resident work hours and the growing expectations for greater supervision? I have thoughts on three relevant issues, and I’ll get these out quickly because, at my age, I may not have much time, and as I write this I am “on service” so I need to get back to work.

First, reduction in housestaff hours is a good thing. I see no adverse effects on residents’ learning or professionalism. But as these changes have impacted expectations for attendings, it is critical to understand that the real battle now is not to fight to roll back the clock (both metaphorically and in terms of work schedules) but to focus on safe transitions of care, as Dr. Arora, one of the authors of this study, has so effectively done in her previous work, and to put limits on service size, both in terms of admissions per day and total census. Non-teaching services are the key to having a service that can teach. So attendings, program directors, and chairs need to stand firm on this issue.

Second, perhaps less time for didactic teaching is also a good thing. I have no data on this, but I do have several decades of experience urging me not to spend too much time in the conference room. Teach at the bedside. Learn to think out loud. Learn to encourage your learners to do the same. This is academic medicine’s most precious two-fer: care for patients and teach all at the same time.

And third, what about burnout? Maybe that’s a good thing too. Everyone, at times, feels burned out. The sense of burnout is life’s egg timer, letting you know you are about to get hard boiled. For me, two weeks and I’m done. But burnout is also a stimulus to think about what you value most in teaching students and residents on the wards, i.e. why you chose to do this in the first place. That’s how we refine what Brookfield refers to as our organizing vision of teaching, which is a fancy way of reminding us why we chose to be an attending physician in the first place.

So, at the risk of sounding avuncular, which probably is better than sounding grandfatherly, let me urge my younger colleagues to not forget what an exhilarating privilege it is to be an inpatient attending but also to encourage them to think about it in a different way. You are not there to spend a lot of time in didactic teaching or to spend hours observing housestaff apart from what you glean from joining them in patient care. You are there to use your knowledge, skills, and attitudes for the benefit of your learners and for the benefit of your patients. And regarding the latter, I, for one, hope you do it well. At my age, I might need you soon.

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One Comment

  1. Kemi Tomobi
    August 1, 2013 at 9:28 AM

    Great post, I am glad there was time while at work to reflect on changes in the attending and resident role in both medical education and patient care.  Having some understanding of history of how medicine has evolved allows one to sharpen focus on goals what what is done today and what is important moving ahead.  An understanding of the foundations and history of how the health professionals trained in the past, compared to how they train and practice now, is very useful to this discussion.  Yes, the terms of competency, licensing, accreditation, and the like are increasingly used today.  One cannot discuss practice and training without these terms.

    I have heard mixed results, directly from attending physicians, as well from as findings in the literature, about the benefits of reduced resident work hours.  Reduced work hours sound beneficial for the residents, but what about the continuity of care, the issues that occur at patient signout/handoffs when handing off patients to the next team, and the like?  I am glad to see the perspective from someone that reduced work hours is good, and that for more effective patient care, organization skills and communication skills are crucial.

    Increase in bedside teaching with the reduction of didactic teaching may also work.  Is it not better to learn a concept in the context of work (learning on the job)?  It is necessary in health professions training. Most busy services, such as on a surgery or OB/GYN rotation, have no choice but to increase clinical bedside teaching, whether it is in the operating room, the anesthesia recovery room, the birth delivery room, or elsewhere while patient care is occurring.  bedside teaching should not be passive, but active and involve participation, therefore the learning is more effective.  While listening to murmurs of a patient with PDA in the NICU is more effective than casually hearing about the characteristic murmur in the classroom, there are teaching opportunities that will be more valuable at the bedside than from sitting in a lecture hall.

    Of course, much learning comes from M and M sessions, grand rounds, and other discussions of patient care, but clinical teaching (at the bedside) should be encouraged more.

    As for burnout – again, having an appreciation and understanding of history of medicine helps to maintain focus in the toughest times of training and practice.

    Thank you for sharing this post.

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