Has Medicine Gone Soft?
Medical training is becoming more humane. Is that bad for patients?
Posted Jan 20, 2017
I still had some sesame seeds from the bagel stuck in my teeth when rounds started on Saturday morning in the Cardiac Care Unit. The weekend crew was motley. The overnight intern began rounds by presenting the woman who had been admitted last night after a cardiac arrest. She was enjoying a stroll in a park when she collapsed to the ground still clutching her cell phone. She had no pulse. Her family called 911. Four times she was shocked with a defibrillator before she regained her pulse and was immediately transferred to our hospital. In the hospital, she was intubated, paralyzed, and cooled to help preserve brain function. No one really knew why this happened to an otherwise healthy woman but it was presumed to be from disease in the vessels supplying the heart. Five minutes into the intern telling the senior cardiologist about the patient, he was interrupted.
“So when was the aspirin given?” the senior cardiologist asked.
“Well, when she first came in, it wasn’t clear if she had a head bleed, so we didn’t give it then.” (Aspirin can worsen bleeding)
“So does she have a head bleed?”
“Well we eventually got a CT scan that ruled out a bleed.”
“So did you then give the aspirin?”
An aspirin had not been given. The senior cardiologist told the team gently that while given the extent of damage that had already occurred, it was unlikely to have changed the patient’s course, aspirin was an essential medication that the patient should absolutely have received. He then looked at me and I quietly entered the order. Twenty years ago, the team would have been berated. But not today. Not in today’s medicine.
Changes in the American workplace have filtered to the traditionally rigid ways of medical training. Hierarchies, while still ever present, are less impenetrable. One of medicine’s venerated traditions, “pimping”, which involves the attending physician posing a series of difficult questions to a resident or medical student, continues to fight extinction. The culture in medicine has become less prickly, more furry. Having to tell an intern or student about doing their job well now has to be layered in a warm and toasty feedback sandwich, with slices of critique buried deep inside fluffy loaves of praise and adulation. Before one can remind trainees about all the things they failed to do in the appropriate fashion, one must be able to tap into a fund of goodwill. The Cult of Self Esteem has already ruined our children, but are we too late to save our in-utero physicians?
During the final year of my medical school, I was approaching the end of my two-week cardiology rotation. The past two weeks had been grueling but my whole group had been working extra hard to meet the soaring expectations of our supervisor. He was an extremely competent and compassionate physician, frequently waiving his fees for patients who couldn’t afford some of the more expensive interventional procedures. On the very last day of our rotation, we were all giddy with the hope of getting a great grade, a letter of recommendation even. Just as we were about to sign off, he asked our group, “Name at least five different causes of ST elevations?”
ST elevations are signs that show up on patient’s electrocardiograms that indicate damage to the heart, most notably in patients undergoing a heart attack. However, there could be other causes of ST elevations, and though most of us knew three or four, none of us could name all five. His eyes narrowed and his impressive mustache bore down on us like a theater curtain closing prematurely. He proceeded to destroy us and we ended up barely passing the rotation. It seemed like two weeks of hard work had vanished. But now that I think back, even if I am pinned down under a pick up track in the middle of a desert, in sweltering heat, going without water for a week, I will probably be able to tell anyone who cares at least five different reasons why a patient who comes to the emergency room with chest pain could have ST elevations on his electrocardiogram.
One of the cardinal aspects of medical training is the physical examination. The need for physicians to be better at diagnosing conditions based on their physical exam rather than blanket, indiscriminate testing is critical at a time when unnecessary costs are crippling health care. However, data reveals that not only do residents and interns have very poor abilities to diagnose common conditions based on their exam, this skill actually disintegrates over time, with medical students faring better than more senior residents. Furthermore, graduates from foreign medical schools appear to do better than their American counterparts.
At the policy levels, one of the biggest reforms to residency training recently has been to reduce residency work hours. This notion was borne out of the idea that residency working long hours were more likely to commit medical errors and exhibit more burnout. However, large assessments of these reforms have conclusively shown that those likely to benefit from these reforms (interns and residents) themselves believe that restrictions diminish both training as well as the continuity and quality of patient care.
To me, expectations from residents have never been lower, and much of this is driven by how residents get accredited. The current system is great at setting a minimum safe standard but doesn’t incentivize excellence. It is almost taken for granted that the age of patient ownership has expired given the number of shift changes, handoffs and signouts that characterize resident services. One of my attendings in the intensive care unit recently asked the team to present patients from memory without cheating off the computer screen. That simple request sent a shudder through the team. We were so used to presenting patients by reading from our notes that it only highlighted what the attending had intended to put across. At a time when the need for documentation only keeps increasing, what is actually known about patients with complex medical histories appears to paradoxically diminish.
I might be the victim of primitive thinking, and I confess that just writing this makes me feel like a dinosaur. No one needs to tell me about how long and stressful residency training can be. I entered medical school in 2004 and still have several years of training to go. But I never forget that the reason I get paid, and the reason I train, is to one day provide quality care under all sorts of circumstances. While, I am sure patients care about sleep-deprived residents, I can bet no one is willing to trade a well-rested resident with a more competent one, and data does not suggest the two to be necessarily the same, even if that wouldn’t hurt.
Older physicians are known to ruminate ad nauseum about their days, and how everything was different back then. Medicine has evolved greatly from the time when William Halsted, the founder of resident training, could power his residents through 362 days a year of work on a cocaine-fueled frenzy. Patients today are sicker, more complicated and the amount of work per patient has risen astronomically. The sheer body of medical knowledge has, and continues to, rise exponentially. But even as demands of students and residents increase, there is little indication that they haven’t kept pace. Current trends may represent a swing in one direction but there is data to suggest that adversity, as demonstrated during the recession, and increased supervision, can both increase productivity. The current blanket implementation of work hour limits are useful for certain rotations but leave a lot of holes in care in other settings such as the intensive care unit. I feel privileged to work in a program where I am universally treated with respect and dignity. But the real world has consequences, should residency?