One of our sciblings, Dr. Signout, is learning the ropes as she struggles (and presumably excels) through her medical residency. As her writing has picked back up, she has brought up some important questions about medical education and medical professionalism. I'm a little further along in my career than she, and I have some thoughts that may flesh out her experiences, and shed some light on the medical profession as a whole.
Her latest posts brought up two particularly important issues, one about how doctors are treated "without the white coat" and the other on what it means to put others' needs before one's own. These, it turns out, are connected.
Even when we shed the white coat, we're still doctors. If we are out to dinner, and we see someone in distress, we respond. If a family member or friend has a problem, they call us up, day or night. Being a doctor is uniquely tied into personal identity. This makes certain situations particularly awkward---being a patient in your own hospital is discomfiting to say the least, and visiting a loved one is often no better.
Both situations are paradoxical---we never really take off the white coat, but at the same time, our role as physician is made secondary to other more immediate roles. It is nearly always the case that taking care of other doctors or their families is a challenge. In extreme cases, many of us have seen doctors reading through charts or writing orders on family members when they really should know better. But most situations are more subtle. A doctor seeing me as a patient may feel like any other patient, or may feel particularly helpless. A doctor taking care of a doctor may feel under special scrutiny. It can be uncomfortable for both, but more important, it can impede good care.
But lets push all that aside for a moment. Dr. Signout described a situation in which a friend was critically ill in her hospital, and she was treated no better than any other visitor.
Issue 1: are we, as doctors, any better than any other visitor? Of course we are. Or aren't. Or maybe we're worse. It's hard to say. Ultimately, the patient's nurse is often the best judge of what is best for the patient, and the patient's doctor can place any visiting orders she wishes on the chart. But to be perfectly honest, in a profession where our ethics preclude any major gifts, tips, or monetary professional courtesy, one of the few perqs is to get a little "special goodness", that is, a little extra help getting through the system. When a nurse shows up at the clinic during a break, there is a greater than 50% chance that she may end up being seen a bit quicker, if the conditions of other patients allow it. If a doctor calls me to get his mom in for an appointment, she isn't going to wait two weeks. It's a small thing we can do for each other. It happens. It becomes problematic when the boundaries blur and people expect "special goodness", or we make decisions that endanger other (sicker) patients. Still, there is something fundamentally unfair about this, and crossing into unethical territory is a real danger. "Special goodness" must be dispensed with care.
Issue 2: whose needs are more important---mine, or my patients'? Both. And neither. We sometimes communicate this poorly to our trainees, as in Dr. Signout's case:
That afternoon [the same day as her friend was critically ill] I was pulled aside by a superior and told that something I had said had caused a patient's family member to raise an eyebrow. A few days prior, I had been post-call--awake for 30 hours--and on rounds, I had mumbled, "God, I'm so tired I can barely stand up." This, he said, had been seen as unprofessional.
Fascinating. Let's look at the message she took away from this:
I turned to face him and marveled at the strange blur before me. No eyes, no ears, no chin--just a building with a big, flapping mouth for a door and an inconvenient parking structure tacked awkwardly onto the back. Flap, flap, flap went that mouth.
Here is the message the hospital was giving to me: I am expected to maintain firm boundaries, refrain from complaining; and provide to patients' families exactly what they want, whether it's reasonable or not. However, I should not expect that when I am the loved one of a patient, I can demand any of the indulgences that families can demand of me--not kindness, not time for my own grief and anger, not a sensation of loss of control. I am a pillar of professionalism at all times, and even when I snap in two, both halves need to stand up straight.
The ethic of "placing the interests of patients above those of the physician" is often misunderstood. It doesn't require us to ignore our basic needs.* OK, really it does. As residents, we are taught to live without sleep, without good nutritional habits, without satisfying our own emotional needs for hours or days on end. This ethic carries through into the rest of our careers. But should it?
When we talk to patients, they often miss what we think is important, and remember what we think is trivial. Being a good communicator/physician requires a lot of repetition, and attention to subtle cues. My patient may miss the fact that I just told them their blood pressure is high, but may focus on my yelling at someone on the phone in the next room. The message the patient takes away may be opposite of what I intended.
This is all a long-winded way of saying that Dr. S. was completely correct to take offense at her situation, but it was perhaps an unavoidable Catch-22. While patients sometimes like to see that we're human, they really don't want to believe it, and we feed that. By admitting weakness, she may have made the patient uncomfortable. But we, as medical educators, are the ones who made her feel weak and unsupported. Perhaps if she had been treated better, her needs attended to just a little, she would have been tired, but not dis-spirited.
Given that it is inappropriate to gain emotional strength from our patients, we must give it to each other. Sometimes this involves some "special goodness", or sometimes just a recognition that my resident has had a really bad 40 hour stretch and needs a little support.
___________________________
*It really is intended to guard us from conflicts of interest, that is putting our own financial and other interests ahead of the patient. For example, if I were to buy a CT scanner, and started getting lots of CT scans for mushy reasons, I would be violating this ethical principle. If I cancel my appointments for the day in order to get a little rest, this is pretty much OK.
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Is it true that you never "take off your white coat"?
I doubt it. I've known many doctors who off-work are off-work. Not only does a person need personal space, but the legal liability of being "on" outside of work is very high.
You don't need some "high and mighty" bonus ethics, special demands exception to get special treatment from folks within your own profession. Professional courtesy exists in many fields -- it's just common courtesy and common sense to treat colleagues differently from your other clients/patients/whatever you want to call them.
Please -- you'll get more respect if you give it. You're not the only people working crazy hours with great demands in a productive profession; we're not all used car salesman out here. You're trying to solve an ethical dilemma that simply does not exist, and then inventing a rationalization to solve it; that rationalization is much more offensive than the original problem.
/me counts to ten. Backwards. In German. With the syllables reversed.
OK, maybe I can avoid completely blowing up now.
I deal with this in training first responders. You know, those wild and crazy people who rappel down to someone, or go into a burning building, or stop at auto wrecks where unidentifiable fluids are all over the street. Those people.
It's amazingly hard to drill the first rule into them: the first pulse you take is always your own. The first person you look out for is you. Not because you're more important than that schlub halfway down the mountain who had an argument with the trees, but because (listen carefully) if you don't, he is screwed. If nothing else, we may not have the resources to rescue you both, and we may just figure the odds are better for you than for him. Or maybe because choosing the survivor is one of those undocumented perqs that will never show up in the after-action report.
If I ever catch a caregiver looking at me with that classic "I'm neurologically impaired but compensating" look I am going to scream bloody murder because when someone else is planning to adjust my clockwork, I deserve to have them be in calibration themselves.
End of rant.
As a brief clarification for DC, it isn't *supposed* to make us subsume our basic needs, and the RRC has forced us to improve medical trainees work hours, etc, but there is still a pervasive and unhealthy culture (as you know) of working until you drop. It's getting better...slowly.
And for joe, I actually agree with much of what you wrote, and I think it is the not taking off the white coat that is the basis for some of these conundrums. However, i must respectfully disagree about the nature of being a doctor. Several professions have similar overlays, such as police officer, priest, etc, and I don't think it is entirely avoidable. Doctors from less clinical specialties, such as radiology, are, i think, less prone to this than those of us in primary care.
Sessions, to what degree do you find your rule to be followed in medicine in general, for residents, or even in the special case of first responders? Common, standard practice? Possible, but mostly not followed? Or completely and utterly impractical for residents?
-kevin
I find it entertaining that the patient complained about Dr. Signout voicing the truth. I think patients should be aware that their doctors are forced to work 30 hour shifts and are cognitively as good as being drunk at that point. Perhaps if patients knew that, then they would complain to the hospital and one day the system would change from the archaic and ridiculous call system that exists today to something more educational for the residents and safe for the patients.
I can't comment on residents -- they're out of my circle. As for the first responders, a few observations:
1) Out of a very small set, I could argue that the worst are the ones who are also MDs. They zoom too quickly to the "I must save this person" and lose situational awareness in the process. (Mass casualty drills are very enlightening.)
2) Behavioral psych works. The urban EMTs are very, very good at scene safety. Traffic roaring by an auto wreck will do that to you. Always working in teams ain't bad either.
3) Nonurban responders, for better or worse, are often in situations where responses are routine and unthreatening, or, almost as bad, threats are obvious. Peer reinforcement and drill outside of required CEUs are essential.
4) I don't know anyone who doesn't talk a better line than they practice in terms of making sure that we're alert, hydrated, etc. And, yes, I am at least as bad as anyone else at not practicing what I preach.
I wouldn't say that's universal. Here in Georgia we have so-called "Good Samaritan" laws that limit your liability if you give first aid etc.
However I'm not a lawyer, though if Chris H. wants to go over it I'm all ears.
I do remember reading a book on first aid (rescue breathing, CPR, etc.) and it did cover it briefly to say that one should use their common sense. Which is really just a cop-out.
There is a national law, but it's pretty basic. States are free to add protections on top of it.
I know in Arizona you're pretty safe as long as you're acting uncompensated and within your training.
For some perspective, I'm basically on call 24/7. There is supposedly a law hereabouts about practicing while impaired...i don't know much about it, and I don't risk it. I rarely drink (just don't happen to like to) so it doesn't affect me that much, but given that i rarely sign out my pager to anyone, i have to be prepared to take professional calls at any time. I really am always "on".
Thanks for the insightful post, and the interesting discussion that has followed.
To be clear, I was treated worse than a visitor that first time I went to see Jack. I wouldn't have minded being treated like everyone else--I don't expect special treatment, especially not from nurses, and especially not around here. But to get treated worse because of my status really sucked, especially when I'm expected to treat the loved ones of sick people with great tenderness. I don't expect hugs and kisses when I walk into a medical situation in which I am not involved, but I expect more than a big "fuck you." Especially when I'm there in grief.
About the tiredness thing--the best part of the story is that other family members of this same patient had pulled me aside during call nights and expressed sympathy for what they identified as my crazy schedule. I always said, "Oh no, it's no big deal, I'm used to it by now." Apparently, that was the only right response.
"I find it entertaining that the patient complained about Dr. Signout voicing the truth. I think patients should be aware that their doctors are forced to work 30 hour shifts and are cognitively as good as being drunk at that point."
This part disturbed me too. If I have a doctor who is so tired they can barely stand, that is valuable information. I don't want to be touched by a doctor that hasn't slept in the last 30 hours. I want them to leave immediately, go home, go to bed and on your way out send in a doctor who is awake and rested.
Recently, I visited a close relative who was ill. She was in the hospital that I have been on staff at for 17 years. I was still dressed up "like a doctor" and wore the badge of the institution. My relative asked me some questions about what was going on with her. I knew her doctor well, so I picked up her chart (with her permission) and looked to the latest notes.
Now I have looked in countless thousands of charts over the years, but never have I been chastised by a nurse for doing so. Her nurse (must be new) immediately told me that I could not look at the chart unless I was officially consulted. I obliged begrudgingly. I then walked over to her very own nursing station, and looked up the information on the hospital computer. This, apparently was fine.
I was stunned to find out that I was just a visitor like any other, badge or no badge.
Humbling.
While I agree with pretty much everything, I find the whining coming from Signout oh-so-rich as she has been venomous and vicious in her attacks on another blogger.
Here's but a sample:
That was from another sanctimonious whining rant of hers. Please. Find someone with credibility to use as an exemplar. Signout is but a hypocritical predatory fraud. Thankfully, there aren't many on the roster of ScienceBlogs..
Um, Annie, who the fuck are you (rhetorical q,pls don't ans), and why do you feel the need to hijack a perfectly good and interesting thread? (also rhetorical).
I think this thread is turning into a good discussion of some of the problems with our profession. Since your comment is a direct personal attack devoid of any other discernible content, please kindly piss off.
WRT Annie:
Silver lining department: I Google'd for the post over at signout, and am glad I did. Good discussion, even if it did get hijacked (and, yes, Annie: piss off.) With two NICU survivors and 25 years married to a NICU nurse ex-wife, there's lots to be said there -- if the subject ever comes up again.
Meanwhile, a few page hits to signout. Good on ya, lass.
I can certainly understand why a hospital might regard it as "unprofessional" for a physician to disclose to a customer (and that is the applicable term in this context) that the hospital is allowing doctors to work longer hours than is compatible with patient safety.
The "profession" in question, of course, is not medicine, but the retailing of medical care.
As a resident I found a lot of the problem was that people didn't know that we did 30+ hrs of call. I'd be upfront about it and say things like "If there are any problems, I'll be in the hospital all night." After hearing that, they'd be shocked when I showed up the next morning and they realized that I was still working. In Signout's case, the family probably didn't realize *why* she was so tired and were blaming her choices instead of the hospital system.
Blogging brings together a wide variety of people.
Some blog to hurl 'flames' or vent their frustrations.
I think of blogs much like psychotherapy. It is a relatively impersonal venue for venting your spleen, seeking emotional and/or intellectual support Some like to 'freely associate'.
Most of it is very good, some are artsy, some literary,
all or most all can be read by ordinary folks..
It gives many of you who are away from academia or perhaps practicing in rural areas a chance to socialize with others in your own specialty.
Overall I think it is a good thing, sharing cases, challenges, sharing emotions, etc.
Just remember 'we are not the enemy"...more on this later.
GML
Some anonymous type wrote "Blogging brings together a wide variety of people."
It is through the Usenet, forums and blogs that I learned that doctors were just regular people.
It was through the local newspaper that I learned that my family doctor had more issues with his kids than I ever had with mine! He had to send his daughters to a boarding school in Canada!
So it is with a smirk on my lips that I bring my teenage kids in for their annual checkups. Because while they get their needed vaccinations and out of earshot discussions of embarrassing topics... I can rest assured that whatever my kids do, does not warrant sending them to boarding school out of the country.
(and yes, Dr. L... I am more than willing to send you the link to the news article, the young lady they interviewed was born about half a day after my second son was born (she got the 9/9/90 birthday!)... my son who is now at Fall band camp, who is a lifeguard and is a favorite swim teacher, and plays Dungeons and Dragons, and, while not being a Merit Scholar... is a pretty cool nerdy kid taking the second year of AP Calculus in high school)
D. C. Sessions, there's a community over at Ning you should check out. Disaster Responders, a support community for first responders. It's small, growing, and has had some good success stories pulling some people back from the edge.
(Sorry if this is OT, PalMD. I'd have set it direct if I could & figured there may be others interested.)
Annie is the pseudonym of the former N=1. She/he has also written me harassing emails under a different name in the year (YEAR!) since the post noted above. There is no point in engaging this person--better to just ignore, block, or delete.
I heard about these 30+ hour calls many times from physicians. In my case from German ones. The situation does not seem to be much different in Germany.
Is this really necessary? Can't there be shift plan to avoid such overwork. I, as a technology Geek (applied mathematician/physicist), can't quite get that. We don't operate air traffic control or nuclear power plants at this level of fatigue. We're not even allowed to (in many countries).
So why is different for physicians?
best regards,
Eike
Very interesting; and thanks for your MD/DO comments at JREF.
Your emphasis on the white coat, including your old blog, reminds me of my Post-Doc years in biochemistry. An internationally renowned professor, in his 60s, always wore a white coat. Most scientists only do that when a) it is cold, or 2) we are using something really, really nasty.
I asked one of his students if he still worked in the lab. The answer was "no," the reason he wore the white coat was he had an MD, not a PhD. It seems that he was finishing his training just as the Korean wore broke out; to avoid being drafted, he signed-on as a post-doc in a chemistry lab. I don't think he ever practiced medicine.
The "profession" in question, of course, is not medicine, but the retailing of medical care.
My understanding is that, in the United States, the latter has more or less overwhelmed the former.
I learned that doctors were just regular people.
And so it should be. "Always remember that doctors and lawyers are exactly as good at their jobs as you are at yours." Otherwise they become a priesthood. And priesthoods really do not have my interests at heart.
usagi
In the USA, that list includes commercial trucks. In Arizona, fatigue can get you a Driving While Impaired citation (and loss of license) just like being drunk.
Forcing residents to take patients' lives in their hands when they're not even legal to drive does sound a bit strange, doesn't it? I would think that the lawyers would have capitalized on this one long ago.
Indeed it does sound strange. And I guess it is quite political. Anyone who will try to correct this, has first to admit, that something has gone terrible wrong.
One other point may be that there simply are not enough Physicians. So enforcing a maximal call length by law might result in absence of emergency service at some hours in some areas. However, I think that this should be solvable by proper organisation and assistance technologies. But this might be quite expensive.
But there is an other problem. At least here in Germany. Bureaucracy. There a laws that enforce a certain treatment/medications, for several "standard" diseases/injuries. Well, it's a bit more complicated, but Physicians are in general not allowed to do what they think is indicated. That seems very odd to me. If you want to motivate people to act cost efficient you should install some kind of controlling by an equally qualified peer. There are simply issues that are too complex for the legislator too handle in detail.
D. C. Sessions:
I think in NJ driving after being awake for 24 hrs is considered the same as drunk driving. What did the hospitals say to the post-call residents that had been up for 30+ hrs? Take a 10 minute nap before going home. Awesome plan.
I worked as a lab tech at a small hospital in rural Pennsylvania. In the community, the doctors were treated like celebrities. Everything they had to say was treated as gospel. Many of them served on the town board, school board, and PTA board. Unfortunately for the town, the distribution of ineptitude in business and in public policy is the same in the physician population as it is in the general population. So we had some pretty bad town administrators doing some weird and wacky things (like having Main Street be one-way only every other day) only because they were doctors.
And what can I say about the hospital? On more than one occasion, I had to stand up to a doc or two when they were hell-bent on having things done as if we were Hopkins or Mayo. We weren't, and no amount of screaming was going to have that gene test that had to be sent out to Virginia back to them any faster at 3am on a Sunday morning... Nor was it going to make that O+ dad be the father of a B negative baby by the A negative mom.
Ah, the pompous asshats stick together.
Just feel the sense of entitlement and righteous indignation.
To the nurse referenced above who rightly withheld a patient's record from the physician who had no business looking at it since the person wasn't a patient and hadn't given permission, that's the spirit. That's called patient advocacy.
And fuck you, too, sanctimonious docs, since that's the only language you understand.
Any person who makes a crack to a patient that he or she can barely stand up is barely thinking and is a danger to self and others.
Good on the patient. Should have thrown you out on your arse.
Grateful, indeed.
Rich. Mightly rich.
hmmm...i'm not sure i read the same post and comments as you did...
PalMD wrote "hmmm...i'm not sure i read the same post and comments as you did..."
It takes powerful beer-goggles. There is a brew-pub here that sells them.
That's some weapons-grade crazy, right there.
"so I picked up her chart (with her permission)".
A nurse objecting to that is not "patient advocacy". Sorry.
"If we are out to dinner, and we see someone in distress, we respond."
The cultural belief that off-duty medical doctors are quick to respond to anonymous emergency situations is the very first myth that went bye-bye when I began working for doctors 9 years ago.