Senior attendings like to quip that the medical students seem to be getting younger every year. They’re not.
But the attendings on the wards of American teaching hospitals actually have gotten younger. At UCSF Medical Center, for example, about 90% of our ward attending-months are now staffed by hospitalists, about half of them physicians in their first six to seven years on faculty. When I was a resident in the mid-1980s, the vast majority of my attendings were senior faculty, mostly subspecialists.
Not only has the cast of characters changed, but the nature of being a ward attending has also been transformed by a series of forces, including resident duty-hours regulations, increased supervisory expectations, sicker patients, and electronic health records. Because everyone is so busy and the stakes so high, my sense is that all of those on the wards are a bit uneasy, searching desperately for a new normal. We’re actors in a play and have just been handed a new script.
Several months ago, I was chatting with my friend Abraham Verghese, the acclaimed author and a professor at Stanford, about how much more challenging being a ward 
attending is these days, and we got a bit nostalgic. Not that the old days were so great, mind you – residents were exhausted, the degree of autonomy that trainees enjoyed was probably unethical, the pressures to improve quality and safety were largely nonexistent, and writing notes and orders in indecipherable chicken-scratch on dead trees was ludicrous. But at least everyone understood the way things worked, and that lent a certain comfort and calmness to the enterprise.
Abraham and I decided to write an article about our observations, and it is published today in JAMA. I won’t say much more about it here, in the hopes that you’ll read the article itself. But here is one key paragraph, which I hope will whet your appetite:
… opportunities for misunderstanding abound. Given time constraints, should the team sit in a conference room, discussing the virtual construct of the patient in the computer – the iPatient – or should they be rounding and seeing patients together? If the senior resident prioritizes “getting the work done” over attending teaching rounds, is that an acceptable tradeoff? All of these questions have made clear how fragile the old attending-trainee ecosystem was and how much of the daily work (and harmony) rested on a bedrock of unspoken assumptions and powerful traditions. The magnitude and rapidity of today’s changes have left all the species groping for a new and more stable habitat.
The article is accompanied by a podcast of an interview that JAMA’s editor, Howard Bauchner, conducted with Abraham and me.
In writing this piece, our goal was not to bring back the Days of the Giants (truth be told, I think the quality of care is better today; as for the educational experience, I’m not so sure) but to start a conversation among leaders, attendings, trainees, and patients about what needs to be done to improve the ward experience for everyone involved. I’d welcome your comments.
Bob,
You speak with forked tongue on the EHR issue.
Last week, you stated: “In other words, I couldn’t figure out what was going on with the patient.”
This week, you stated: “…and writing notes and orders in indecipherable chicken-scratch on dead trees was ludicrous.”
However, you did not mention the cut and paste progress notes so prevalent in the modern era, not did you mention the number of minutes that the trainees spend clicking in orders while ignoring their patients.
What is more astounding is how you, a thought leader, sit back and read the script without questioning it and IT; and avoid the sensitive issues, like who approved EHR and CPOE devices as being safe and efficacious, and who wrote the script.
Best regards,
Menoalittle
Bob
I enjoyed the commentary immensely. I dont see the forked tongue. 🙂
http://blogs.hospitalmedicine.org/SHMPracticeManagementBlog/?p=5865
Brad
Bob:
The article is behind a paywall. Like the majority of physicians in America, I don’t belong to the AMA (because it doesn’t speak for me).
Is you article going to be anywhere else?
But I agree with your encapsulation of what things were like back then: patients got spotty, and sometimes dangerous care; but resident teaching was probably better. The ownership and pride over their patients’ care that residents felt then appears now to be mostly gone. It’s not the residents’ fault, it’s just the way things are now.
I am also disappointed to find that this article has limited access. I hope it will be published elsewhere. I think many of these “young attendings” you speak of have not joined the AMA for similar reasons as stated above. It does not speak to our generation of doctors.
This article brought back memories of clinical rounds as a medical student in the ’70’s – surgery made rounds in 20 minutes or so, concentrating solely on what needed to be done in the short term for the patients – then off to the OR. Medicine spent a couple hours on rounds, often veering off course to some wild tangent where references on obscure diseases were thrown at each other in an incessant unproductive game of one-ups-manship. (I eventually chose pathology.)
Surely there is some happy medium where teaching can be accomplished but patient care needs are also met.
The difference between the attendings of a generation ago and the current attendings is that the former needed to only consider the patient and his/her problem. Unfortunately, attendings of the present generation have offer to consider the payment before the problem or the patient. One can debate the morality of such practice but it is acceptable often for the preservation of the institutions that will train future physicians.
Your hospital’s medical library will get you a copy of the article. Often at no (or reduced) cost.
This of course assumes your hospital has a medical library, with a medical librarian, to provide this basic service in support of knowledge- & evidence-based practice. But that’s a different topic I’d like to see Bob cover another day. I find it interesting that your JAMA article is such a clear example of the need for hospital medical libraries if there is to be wide discussion of articles on improving healthcare.
Bob- Interesting idea about co-attending role for the sub-specialists. Maybe it is time people take a closer look at the Columbia two attending approach?
Having spent several days rounding last week I was struck by your article. Having spent the past number of years as a CMO at a sister UC hospital I have witnessed the rise of the hospitalist and intensivist. In your article you speak to the issues of quality and efficiency and that is clearly how hospitals can justify the salary suport. I also agree that the patients in hospital are sicker, more complex than years ago and their average length of stay is less than four days and on many surgical services they are measured in hours. It is clear that the advent of CT’s MRI’s , Ultra-sound studies and multiple laboratory tests have greatly enhanced our ability to diagnose patients. My impression from talking to residents and students is that what has been lost is in fact perhaps the most important thing a physician does and that it to communicate well. All one has to do is look at HCAPS scores at most institutions to realize that patients perception is that less than 80% of the time do doctors or nurses communicate with them. In the old days physical exams were more extensive and you spent that time talking with patients. In addition with longer lengths of stay you had more time to speak with patients and get to know them better. All to often in academic medical centers the silo mentality of multiple consults leaves the patient confused by often conflicting recommendations. At the end of the day communication is perhaps the most important part of the doctor patient relationship and we need to figure out with the multiple competing missions how we continue improve our outcomes both from a patients perspective and from the trainees perspective
Forked tongue? You make me laugh Menoalittle, stop taking things out of context and actually re-read what was written.
As an attending I’m not all that senior, but I too remember the hours of rounding on the medical service when I was an intern, before the work hour restrictions. I remember there was so much work to do, and I was so tired, that those valuable educational hours at the patients bedside were lost on me. Now the work hours are better but the volume of work remains and production/economic pressures, while they don’t affect residents directly in medicine, definitely drive some of the fast turn-over and decreased communication noted by Dr. Spiritus.
The EHR in my opinion makes things worse since everyone is distracted by or staring at computers most of the time. When I was an intern in the ICU I was so busy entering orders in the computer that I missed alot of the discussion. Until doctors in training are treated as something other than data entry specialists this state of affairs is likely to continue.