Random Thoughts from a Restless Mind

The law of unintended consequences is alive and well in medicine.

One of my closest friends, my best friend in Cleveland, is a General Surgeon on the other side of town. We were medical school classmates a lifetime ago at the University of Vermont. Although we live in the same city we have done a terrible job of getting together over the years, consumed as we have been with the various duties of fatherhood, husbandhood, and doctorhood. We finally managed to get together for dinner at  what may be the best restaurant in Cleveland, Johnny’s Bar; it’s certainly the best “guys'” restaurant. It figured to be a perfect guy-getaway: my entire family was out of town, and Bill was NOT on call.

As fathers will do we spent the lion’s share of the time we were together talking about our kids. None of my progeny seem destined to follow their old man into medicine, but Bill’s two older kids are hell-bent to be doctors.  He wondered aloud whether they really knew what they were getting into, whether they really understood what it means to be a doctor and what they would go through to get there.  He also mused about the difference in both  the practice of medicine today in comparison with  medicine as it was practice when we decided to be doctors, as well as the apparent difference in the attitude and approach of recently trained doctors. Being old guys we naturally commenced whining and complaining about the newly minted doctors and how different they are from us and our generation. (Note to self: quit acting like an “old guy”)

How are new doctors different you ask? What is it that makes them different and how did that happen? Well, in order to answer that question it would probably be helpful to describe what it was like to be a doctor and to train to be a doctor “back in the day”. There was a time when only doctors possessed medical knowledge, when the canon of disease and disease treatment was the sole purview of those who had gone to medical school and trained to be doctors. Weird, huh? No internet around to google a disease or come up with a novel treatment in order to play “gotcha” at an office visit. Nothing but true quack remedies in the publications of the day, unless it was an article on some amazing cure discovered by a doctor.

Doctors served long apprenticeships in training, spendings years of their young lives as indentured servants, working brutal hours for what would be much less than minimum wage if such a thing existed. This rite of passage not only served to teach the newly minted doctor all that was known about his particular specialty (almost all doctors were men back in the day), but it also served to ingrain certain habits and skills that were characteristic of the profession. Among the most important of these was the ability to perform at a very high level when fatigued or just after being awakened, and the knee-jerk reflexive response to do just that whenever a patient was in need. Every time. The long, endless hours of patient care in training developed generations of doctors who simply didn’t know that there was any other choice but to go to the side of their patient whenever they were needed, day or night, every day and night. I think I’m like this, but my friend Bill most certainly is.

Patients responded by according enormous respect to doctors. A doctor, ANY doctor, was someone to look up to no matter who he was or what kind of doctor he might be. Answering the phone with “this is Doctor White” instantly set the tone for the conversation.

What kind of medicine, what kind of healthcare, and what kind of doctor did we get from this system. This was the day of the paternalistic doctor, the time when patients said things like “you’re the doctor” when asked their opinion about a treatment. Even though there was much less to know the gulf between what the patient knew and what the doctor knew was at least as immense as it is in today’s world of endless complexity. The relationship was not adversarial, though, but was rather very cordial and respectful in part because the doctor behaved as a professional, putting his patient before essentially everything including his own family. To be truthful this lead to some pretty dysfunctional physician families in the days before divorce, and a  pitifully high divorce rate among medical families once divorce became more common. But the primacy of the patient and the profession remained through all of the societal changes occurring around medicine in the 60’s, 70’s and 80’s.

What happened? Why do old guys like me and my friend Bill feel that new doctors are different? What is different about them and how did this happen? Somewhere in the 80’s there was a shift in how Americans viewed their doctors. No longer was the first instinct to trust, to respect a doctor simply because he (or she, now) had earned a degree. It became a little less OK to get up in the middle of the night, to leave the dinner table to take a call once the level of appreciation of the sacrifice involved declined. Add in a steady decline in income and a steady increase in bureaucratic headaches that took time away from doctoring and it was harder to feel good about putting your patient first. Yet doctors of a certain age continued to do just that because, frankly, it was what they had been trained to do and it was all that they knew.

If you talk to most doctors over the age of 40, and certainly any doctor over 50, you will hear them lament that younger doctors do not place enough emphasis on being a doctor. That newer doctors are selfish, too concerned about themselves and their lifestyles and their own comforts. Talk to a patient at 2:00 AM? No way–I’ll be too tired tomorrow. See a patient at 1:00 on a Saturday or on a holiday? Sorry. That’s family time. Is this all bad? Well, from the standpoint of the physician’s family it’s probably a very good thing, and who can blame the young physician if you think about it. Why should they put the patient first when in their minds they no longer get the respect and appreciation for doing so? When they are constantly second guessed by the Google-empowered, and paid less to boot. But if you are a patient and you call YOUR doctor it’s a little less of a good thing.

Why do doctors like Bill not adopt this attitude? I think it goes back to the traditional residency training that doctors of our generation endured. As a general surgical resident Bill routinely put in 100-120 hour weeks learning to function at a high level when tired and learning about how diseases progressed as you watched continually over time.Even more importantly the instinctive reflex to respond when called was indelibly ingrained. In residency training nowadays, not so much.

In the late 80’s I think it was, there was a very famous case in New York, the Libby Zion case. Young Ms. Zion was brought to an ER and was under the care of an intern heading into her second day of work without sleep. A medication error was made (Ms. Zion neglected to mention an illegal ingestation and the intern failed to consider the possibility) and Ms. Zion died. Now, Ms. Zion was the daughter of a rather famous publisher in New York and the case became a cause celebre. The intern was vilified, the hospital was sued, and calls rang out for reform of the medical training system that left a patient under the care an intern who had been awake and working for more than 24 hours. The well-known effect of fatigue on performance was judged to be the cause of the error and a sea-change in how doctors are trained resulted. Every state now has explicit laws that limit the number of hours a doctor-in-training, a resident or intern, is allowed to work in a day and in a week.

Was that it? Is that why Libby Zion died? Because an intern was awake for more than 24 hours and still at work? Did the system fail Libby Zion and rob the Zion family of their daughter? These are important questions because the work rules that have resulted from this case have contributed to the kind of doctoring we are now getting from our newest trained doctors. I believe the system did INDEED fail Libby Zion, but NOT because her intern was working more than 24 hours without rest. In my opinion the system failed because the other doctors who were supervising the young intern left her alone. Her resident, fellow, and attending failed to engage the case as they were obligated to do under the residency system, leaving an intern to fend for herself in a complex case. The senior doctors in the system failed their intern, a systemic failure that was, and would be, independent of the number of hours worked by the intern.

In came the “Do-Gooders” and “Know-Betters” to solve this problem and prevent any other Libby Zions from coming to harm at the hands of an overworked, under-rested intern. We are now training new generations of doctors who never learn what it is like to work under the pressure of fatigue. They never learn that reflex of going to your patient first, last, and every time because they never get called to do so–they have turned over the care of that patient to their relief. Our residency training programs are now turning out medical shift workers who punch a clock and put in their time. Patients don’t stop being patients and diseases don’t respect either the clock or the calendar, but in their zeal to correct the (wrong) problem with medical training that contributed to Libby Zion’s death the crusaders have removed one more cornerstone from the foundation of the practice of medicine: doctors don’t stop being doctors after office hours.

The law of unintended consequences is alive and well in medicine. Reform has come  although it is still quite an open question as to whether this has really made medicine in training programs any safer-the senior residents and attendings still need to show up to back an inexperienced, albeit well-rested  intern. A trend toward less respect for doctors and therefore less satisfaction while practicing medicine is now augmented by a training regimen that teaches our residents that they work on a clock. When they close the clinic door they leave not only the office but their patients behind. Not surprisingly this leads to a public with less respect for doctors and medicine. And on it goes.

So how did our dinner end? Although Bill was not on call the child of an OR nurse was in the ER with appendicitis and she insisted that Bill be called to do the surgery. Mid-way through the veal Bill left with a touch of sadness at the interruption but with no apology. We are, after all, the same age, doctors and surgeons of the same vintage, and Bill knew that I would understand.

I’ve never been happier to pick up a tab.

This entry was posted on Thursday, July 2nd, 2009 at 10:25 am and is filed under Health Care. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.