“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Sunday, March 18, 2007

A failure to imagine ...

“Thinking is easy, acting is difficult, and to put one's thoughts into action is the most difficult thing in the world.”
~Johann Wolfgang von Goethe


The other day I was in the faculty lounge and one of our pediatric nephrologists was there. I asked her the basic question you typically ask people from other services, "how's business these days?" We talked about the state of medical care, so forth and so on. You know that "poor me" type of stuff. "I work too hard and get paid too little." Blah Blah Blah. After we got over ourselves, I asked about how call was for her and the state of her subspecialty in our city. She mentioned how reimbursement is bad and there aren't many people going into the subspecialty. I voiced the same concerns with my specialty. Then, she then told me a story that I will share.

At 3pm the day before, she went to complete a consult on a patient that had come in the night prior. This patient had a number of issues, but she was addressing some electrolyte abnormalities. She noticed that a number of labs were out of wack (WBC 40, NA 170 , CXR complete whiteout of left chest). She contacted the resident for the patient and informed her of what she recommended and that some of these labs should be rechecked since it has been greater that 24 hours and nothing had been rechecked and the patient was rather sick. The resident informed her that she was on her way home and to call the resident on call to take care of the patient. This resident had been on call the night before, but her "shift" actually ends at 5 pm. My jaw fell wide open. This was borderline incompetence in my mind. The patient's workup wasn't even complete and the resident left without proper sign out or coverage. Needless to say, the patient ended up in the PICU and in the OR the next day. This brought up a number of other discussions.

Another faculty member came in an we began discussing some of the troubles we are already seeing with the medical students and residents coming through. Many of them have started to develop the mentality of a shift worker. "I work until my shift is over." My colleges brought up the real concern of what are we going to do in 10 years, when people graduating bring that mentality into practices. We all noted that we will need more people to fill in the time voids. The problem is that medicine has taken a major financial hit decreasing the ability to expand practices; and we already have a shortage in many specialties. So what can we do about it?

I previously wrote that I thought that the medical students and residents were "soft". This was said half serious and half in jest. I said it to bring up some issues that we are already seeing. I am sure many took offense to this and a couple of comments were made, which I welcome. When I make a statement like "you all soft," I want you to have a visceral reaction to this statement. I love playing the devils advocate. I like to see how people respond. Truth is there is a real fear for many educators that there is a changing mentality of those who are now training.

There are many things that are changing in medicine. Reimbursement is awful. The hours are still bad. The risks are high. The respect for the profession is down. So, why would you sign up for this bad life. What so many in training fail to realize is that when you begin in practice, depending on the specialty, you will have more than just patient care to think about.

As I speak to my pediatric colleagues, they explain to me how much of their time is spent answering phone calls from patients and doing paperwork. They explained that on call they receive calls from both patients and ER physicians constantly during the night. One of the pediatricians described how his residents have a problem, they have a "failure of imagination." They fail to imagine that even though they are not on the floor, they may have other patient care responsibilities. This failure of imagination is what we fear. There is a belief that when residency is over, life will be much easier.

Unfortunately, the life of a physician is not easy. When you are in your private or academic practice, the patient's care is your responsibility. If something is missed, it falls on your shoulders. The patients don't care that your "shift" is over, you are their doctor. In the end, you will have to stay until the work is done. Some physicians will tell you that they work harder now than they did in residency. Remember, once you graduate, there is no 80 hour work week that will protect you.

“Don’t ask what the world needs. Ask what makes you come alive, and go do it. Because what the world needs is people who have come alive.”

~Howard Thurman

2 comments:

Brent said...

I read this blog everyday, and I love it. I think it's interesting as well because the mentality seems to be that in all of medicine. I was a PA in orthopedics and just returned to see my doc I worked with and how things were going. He was in the OR and I just came down to see everyone and all of the staff, and he's frustrated, because the OR staff is unable to work past 3:30 in the afternoon because their shift is done then. The afternoon people come in, but since there are less cases by that time, less workers are present and thus everything takes longer, with turnover time, patient preparation etc.
It's interesting how if he has a complicated case that runs long, all of the staff starts whining that they have to go home, a new person scrubs in and away they go. However our job is not done until that patient's off the table, into the room, and we've talked to the family. More of a vent then anything, but it's disheartening to hear some of the people talk that are in medical school at the moment, and what there perception of the life of a physician is. Many of them have a reality check awaiting them once they step out into the "real" world of actual practice when the buck stops at them and no one else.

orthonet said...

Many of the new trainees either at the medical student level or resident level do not understand "professionalism".

The following article outlines many of these issues.
http://www.annals.org/cgi/content/full/136/3/243

I am currently at the Mayo Clinic completing a fellowship and one of many aspects that really standout is how the system is actually centered around one theme
"the best interest of the patient is the only interest to be considered".

I must admit that when I arrived and heard this statement or some truncated version over and over again by administrators, staff physicians, nurse leaders and even the odd resident I thought they were brainwashed or just saying it. But the actual system is setup in such a manner that this central concept dictates policy and how individuals from the cleaning staff to management act. I am sure that the staff are sheltered somewhat from some of the pressures of the healthcare system that threaten professionalism. Nevertheless you would never see a resident here signing over an incomplete workup, an OR nurse leaving early if a case runs late. There is a sense of pride and professionalism that is pervasive and that I have not seen in other residency programs.