Monthly Archives: May 2013

“What A F%$!ing Joke!”

I knew I reached a new level in the blogosphere when I received my first comment with an F-bomb.  Given the author’s passion about the topic, I decided to respond.

What a fucking joke. Someone who in his own words, “rarely worked more than 80 hours a week” commenting on something he hardly knows anything about.

I appreciate your energy and the time you took to respond. My intent was to provoke discussion. Your vitriol, however, obscures your argument.

As to whether I am commenting on “something he hardly knows anything about;” for the first 7 years after I graduated from residency, I worked in a multispecialty group taking hospital call and delivering my own obstetrical patients, so I know something about patient care. For the last 7 years, I have served as faculty in family medicine residencies at a community health center and later a large urban hospital. I am currently president of my state specialty society and serve on the family medicine advisory committee to the state agency which distributes state funding to all Texas GME programs. I think I know a little about residency.

The point I was trying to make regarding my residency work weeks usually being less than 80 hour work weeks was that my residency was largely compliant with the intent of the current rules without the administrative burden of the regulations. I think the ACGME imposed a one size fits all solution that appears to be more needed in New York and Chicago than in rural North Carolina.

“80 hours a week of actual patient care is plenty. I don’t know where you did residency, but at least here in NYC where I am training and Chicago where I went to medical school (but to a less degree) some where on the order of 1/2 of the time spent in the hospital is spent doing non-medical administrative BS. Hospitals (ab)use residents as cheap labor; the issue isn’t 80 hours, it’s spending those 80 hours doing nonsense instead of making decisions. Learning how to call the lab 5x / day to get a test drawn or pestering the nurse / phlebotomist to draw labs is not something that I need training in.”
I agree that more of your time should be spent caring for patients and gathering needed experience.   When my residents worry they will get in trouble because they stay late to complete needed work on patients, then the rules need to be changed. I still feel that the IOM and ACGME impose regulations without adequately considering the unintended consequences on quality of patient care, continuity with patients, and patient safety from the work hour rules. Their approach is to mandate first, study later.

I’m sorry that you had to train in the “dark ages.” Fact is, you did family medicine and still didn’t push 80 hrs. If hospitals had their way, as they once did prior to the massive resident strike in the 60s (not sure about the date, may have been the 50s), Interns were literally in the hospital 24 hrs / day and were unpaid. Maybe we should go back to that?

Your point is a straw man. I am in no way advocating a return to the house officer of the 1950’s who lived in a dorm and was not allowed to marry. To assume that anyone who challenges the work hour rules wants to return to this antiquated structure is to use a cheap rhetorical device to disparage anyone who disagrees with you.

OR maybe we should regular WHAT residents do as well as HOW long they do it for.

Good point.

You’re right, life has no work house rules; you can choose to work more or less, but that’s up to you. If you want to work in a practice that makes you take call all the time you can do that and you’ll be compensated for it; OR you can work less and be compensated less. When you don’t have a choice, there have to rational limits, especially when your salary is being paid by the federal government.

I agree.  I want to make sure that future physicians are well-trained enough to handle the increasingly complex patients I have to manage now.  I see good family medicine residents not push themselves to the limits of their skill because they did not get enough experience during residency. I do not suggest 120 hour work weeks as the solution; but when you try to cram more training and teaching in to less time per week and a fixed residency duration, something has to be left out.

W/ regard to your Rural Medicine friend, I suspect two things have happened:
1. He thinks too much of himself and doesn’t remember how green he was when he first started. Its pretty common amongst mid-career physicians in their 40s and 50s.
2. The quality of the grads has decreased a bit from when he graduated, but not as much as he thinks. Why? While the intention of 80 hrs was to give residents some time off, that’s is not what actually happened; Let’s say for example in the typical 100 hr work week of a resident, 50% is spent on patient care and 50% is spent on administrative bs (in reality I would think it’s more like 10:90, but whatever). If you’re limited to 80 hrs, guess which 20% is going to get cut? The patient care.

Again, I think we can agree that training should focus more on patient care and less on administrative work.

I look forward to discussing this topic further and am glad I was able to stimulate some discussion.

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Four Things I Don’t Plan To Change

Here’s another great post from Waco family physician and friend Tim Martindale:

I hear constantly we are in a new world of medicine, and things cannot stay the same. We must make some adjustments, they say, to survive and cope in this new environment. Well I don’t want to be an ostrich with my head in the sand, and I am very involved with reading articles, attending meetings, and wrestling constantly with this new, changing world. I am active in my county medical society, my local specialty society, and my hospital staff. But there are some things the conventional wisdom says have to, or already have, changed, and I don’t agree.

1. I want to focus on listening to, looking at, and examining the patient. This affects decisions on how many patients I see, how to use my electronic medical record, and how I prioritize my time in the exam room. There is no substitute for the gestalt I get when I see, listen to, review history, examine the patient, then talk it over with them. So I see less numbers, find ways to not be boxed in or directed by my EMR, and make the patient my partner in their care.

2. I want to remain a patient advocate. Insurance, government, employers, drug companies, etc. all want me to consider their agendas, and put obstacles, checklists, prior authorizations, peer to peer reviews, endless paperwork, and threats of lower reimbursement or being branded as a lesser quality doc in my way. But my first priority is the health interests of my patient, and I’ll wade through all that nonsense tirelessly to meet that goal. My staff has the same vision and the perseverance of a bulldog.

3. I want to do complete, continuous, comprehensive, efficient care for my patient. I still do all my own hospital work, as well as nursing home and home visits. By doing this, I maintain the commitment to comprehensive and continuous care, the desire to be there for my patients at their most difficult times, the need for someone who knows the patient best to serve as the coordinator of care, the goal to keep my skills at maximum and not narrow my scope of practice, the pleasure and challenge of complicated hospital acute illness management, the camaraderie with the specialists as we work together, the desire to be a leader in hospital and community medical issues, and the widening of my knowledge base as I work with challenging cases alongside specialists. Yes, I do work harder, but I’m more happy and fulfilled. I should note that I respect physicians who have chosen otherwise, and hospitalists today are excellent.

4. I will continue to make my physical, emotional and spiritual health and wholeness a priority, as well as that of my physician partner and clinic staff. That means I think about it, plan for it, make sacrifices for it, and talk about it regularly with those alongside me. We can’t be victims of this relentless pressure and paperwork so that we push ourselves to the point of disqualification where we can no longer serve our communities in such a powerful way because we have forgotten about ourselves.

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