Friday, November 05, 2004
Who Would You Want as Your Doctor????
The New York Times brings us : Defining a Doctor, With a Tear, a Shrug and a Schedule
The New York Times brings us : Defining a Doctor, With a Tear, a Shrug and a Schedule
I had two interns to supervise that month, and the minute they sat down for our first meeting, I sensed how the month would unfold.Medical training is at a crossroad, which way will it go?
The man's white coat was immaculate, its pockets empty save for a sleek Palm Pilot that contained his list of patients.
The woman used a large loose-leaf notebook instead, every dog-eared page full of lists of things to do and check, consultants to call, questions to ask. Her pockets were stuffed, and whenever she sat down, little handbooks of drug doses, wadded phone messages, pens, highlighters and tourniquets spilled onto the floor.
The man worked the hours legally mandated by the state, not a minute more, and sometimes considerably less. He was seldom in the hospital before 8 in the morning, and left by 5 unless he was on call. He ate a leisurely lunch every day and was never late for rounds.
The woman got to the hospital around dawn and was on the move for the rest of the day. Sometimes she went home when she was supposed to, but sometimes, if one of her patients was particularly sick, she would sign out to the covering intern and keep working, often talking to patients' relatives long into the night.
"I am now breaking the law," she would announce cheerfully to no one in particular, then trot off to do just a few final chores.
The man had a strict definition of what it meant to be a doctor. He did not, for instance, "do nurses' work" (his phrase). When one of his patients needed a specimen sent to the lab and the nurse didn't get around to it, neither did he. No matter how important the job was, no matter how hard I pressed him, he never gave in. If I spoke sternly to him, he would turn around and speak just as sternly to the nurse.
The woman did everyone's work. She would weigh her patients if necessary (nurses' work), feed them (aides' work), find salt-free pickles for them (dietitians' work) and wheel them to X-ray (transporters' work).
The man was cheerful, serene and well rested. The woman was overtired, hyperemotional and constantly late. The man was interested in his patients, but they never kept him up at night. The woman occasionally called the hospital from home to check on hers. The man played tennis on his days off. The woman read medical articles. At least, she read the beginnings; she tended to fall asleep halfway through.
I felt as if I was in a medieval morality play that month, living with two costumed symbols of opposing philosophies in medical education. The woman was working the way interns used to: total immersion seasoned with exhaustion and adrenaline. As far as she was concerned, her patients were her exclusive responsibility. The man was an intern of the new millennium. His hours and duties were delimited; he saw himself as part of a health care team, and his patients' welfare as a shared responsibility.Who would you want as your physician? |
This new model of medical internship got some important validation in The New England Journal of Medicine last week, when Harvard researchers reported the effects of reducing interns' work hours to 60 per week from 80 (now the mandated national maximum). The shorter workweek required a larger staff of interns to spell one another at more frequent intervals. With shorter hours, the interns got more sleep at home, dozed off less at work and made considerably fewer bad mistakes in patient care.
Why should such an obvious finding need an elaborate controlled study to establish? Why should it generate not only two long articles in the world's most prestigious medical journal, but also three long, passionate editorials? Because the issue here is bigger than just scheduling and manpower.
The progressive shortening of residents' work hours spells nothing less than a change in the ethos of medicine itself. It means the end of Dr. Kildare, Superstar - that lone, heroic healer, omniscient, omnipotent and ever-present. It means a revolution in the complex medical hierarchy that sustained him. Willy-nilly, medicine is becoming democratized, a team sport.
We can only hope the revolution will be bloodless. Everything will have to change. Doctors will have to learn to work well with others. They will have to learn to write and speak with enough clarity and precision so that the patient's story remains accurate as care passes from hand to hand. They will have to stop saying "my patient" and begin to say "our patient" instead.
It may be, when the dust settles, that the system will be more functional, less error-prone. It may be that we will simply have substituted one set of problems for another.
We may even find that nothing much has changed. Even in the Harvard data, there was an impressive range in the hours that the interns under study worked. Some logged in over 90 hours in their 80-hour workweek. Some put in 75 instead.
Medicine has always attracted a wide spectrum of individuals, from the lazy and disaffected to the deeply committed. Even draconian scheduling policies may not change basic personality traits, or the kind of doctors that interns grow up to be.
My month with the intern of the past and the intern of the future certainly argues for the power of the individual work ethic. Try as I might, it was not within my power to modify the way either of them functioned. The woman cared too much. The man cared too little. She worked too hard, and he could not be prodded into working hard enough. They both made careless mistakes. When patients died, the man shrugged and the woman cried. If for no other reason than that one, let us hope that the medicine of the future still has room for people like her.
