Tuesday, August 05, 2008

Physicians learning to be shift workers?

In a recent Medscape edition (July 1,2008) we find a disturbing essay by a practicing academic pediatrician who expresses concern about some of the unexpected consequences of the restrictions placed on medical house staff work hours. I find it disturbing in part because what the author describes could not be further from the notion that the physician (house staff) should not leave until his patient is taken care of.

Dr. Jane R. Gilsdorf, from the University of Michigan Medical Center, pulls no punches with this sentence:

The current system is creating a legion of shift-worker physicians who leave when the clock strikes a certain hour rather than when the job has been completed.

In discussing this with a former partner, who taught internal medicine residents for over 30 years and retired one year after the work rule changes were implemented, he had this cynical comment to make:

"Maybe it is good that the residents learn that approach early on because it seems that most docs are becoming shift-workers. Consider how things often work. You have a primary care doctor who has defined office hours and when you call his number after hours you either get a "triage nurse" or a recording that basically says call back tomorrow if it is not an emergency or go to the ER if it is an emergency. At the ER you see an ER doc who is working a shift and if you are admitted you are likely seen by a hospitalist who also is a shift worker. The notion of a personal physician whose role transcends duty hours is dead in the water."

Dr. Gilsdorf opines that more funds are needed to help correct the problems brought about by the ACGME work restriction rules. Basically, someone needs to be paid to do much of what the house staff used to do and now cannot. Dr. R. Centor discusses some of the problems brought about by the ACGME work rules and suggests with good planning,teaching and hard work many of them can be at least to a significant degree mitigated and I believe he is probably right.

However,how the broader "shift-workerization" of physicians can be reversed is another matter.Major shifts in the economic forces regarding physician and hospital compensation have brought that about and that big ship will be hard to turn around.

9 comments:

Martin said...

Unrestricted work hours have done much bad on doctors and patients and there's a wealth of literature on bad performing physicians on extended schedules, including serious driving errors on their way home to theri families.
Retired doctors and officials tend to forget about that as it does not longer affect them.
In the EC, German doctors fought bravely against long workinghours, but it seems the EC wants tu turn back the wheel to save money.
Additional training is required to document conciesly and hand over all poatients safely to the next shift.

jb said...

In a recent Medscape edition (July 1,2008) we find a disturbing essay by a practicing academic pediatrician who expresses concern about some of the predictable consequences of the restrictions placed on medical house staff work hours.

Fixed it for you.

dr_dredd said...

With all due respect, lamenting about "the days of the giants" isn't very helpful. Medicine was different; there just weren't that many things that could be done for a patient. (My medical school mentor once told me that he never failed in a code -- he never did one!) Now, there are a dazzling array of diagnostic and therapeutic choices available. Furthermore, there is an incredible amount of pressure to admit and discharge quickly. 40 years ago, you could keep a patient in hospital for weeks while working him/her up. That's a luxury we no longer have, and this just adds to the workload of the housestaff. Now, if they wait to leave the hospital until all the work is done, they'll almost never go home!
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And that brings me to my next point. Is it so horrible to want a life outside medicine? We need to be able to pay attention to our own wellbeing as physicians; otherwise, we both endanger our own health and set a bad example for patients. From the immortal House of God: "How can we care for patients if'n no one cares for us?"
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All of us have multiple competing priorities: our work, our patients, our families, our leisure pursuits. I doubt that the spouses of physicians who "live" in the hospital are too happy with the arrangement. We need to make sure all of our priorities are balanced. If shift-work is what it takes, so be it. Let's now work to figure out how to optimize this new model.

james gaulte said...

JB,
Your are right -the consequences were predictable but I doubt that the planners at ACGME predicted them.

James G.

james gaulte said...

Yesterday there were 4 or 5 comments posted. Today they are all gone.I did not delete gthem.I do not know what happened.Does anyone know why or how comments just disappear from blogger?
James Gaulte

james gaulte said...

My comment section appears to not be working properly.Several other comments were made,approved,appeared on line and then disappeared.These included a comment made yesterday by me commenting on the situation.Then one of the deleted comments reappeared.Anyone have any information on disappearing comments from blogger.

James Gaulte

Michael Rack, MD said...

In the old days, insurers generously reimbursed doctor for office visits. As part of the unwritten bargain with society, docs provided call coverage. These days, insurers (including Medicare) pay docs as little as possible for office visits and society expects docs to provide call coverage basically for free. Many younger docs aren't willing to do that.

Anonymous said...

I am not sure how putting the patient's interest first would "set a bad example" for patients nor does it preclude a "life outside of medicine" and to claim it "endangers our own health" is quite a reach.
It is all about the current system-non-system of physician compensation.That is the driver, all of the touchy-feely talk about life work balance is just faddish fluff.

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