A Question of Commitment

It is such a common scenario. It might be 4:45 p.m. in a rural, two-doctor office, or 9:30 a.m. Saturday during rounds in the nursery, or 11:55 a.m. in a teaching hospital. You are waiting on just one more lab result before you can finish that last patient encounter of the day, but you are also running late for your daughter’s soccer game. Do you stay and finish up, or sign the problem out to your partner who is on call?

I was taught there are three "coms" that characterize ideal physicians: They are competent, compassionate, and committed to their patients above all else. Those three characteristics are reflected in the mirror each morning. Your reputation is built on them. Your patient trusts you because of them. But you don’t want to disappoint your daughter, either. "So," says the little voice in my head, "just how committed are you?"

Dr. James Gordon reflects on this in the American Medical Association Virtual Mentor column "Sharing the Pain" (Virtual Mentor 2007;9:508-10).

"In the old days, anyone who wanted to go into medicine had to be prepared for a life of exhaustion. Before laws and regulations prohibited one-in-two call, we were rapidly conditioned to accept the idea that the life of a doctor was not only one of service, but a kind of servitude. ... In the first year of residency, the fledgling doctor learns never to leave work for anyone else at the end of the day."

Dr. Michael B. Edmond reflects on how this has changed for today’s newer physicians in "Taylorized Medicine" (Ann. Intern. Med. 2010;153:845-6).

"The marked changes in the way we conduct our business in teaching hospitals have been driven by advances in technology that have improved the process of care. ... But the biggest changes have been driven by the rules of the ACGME on resident work hours and their rigid enforcement.

"Every resident now has an invisible but heavy stopwatch sitting on their shoulder, ticking loudly, constantly reminding them that their task list still has many unchecked items as time slips away."

Dr. Edmond claims that in the past, "part of the maturation process for young physicians was coming to terms with the daily unpredictability and lack of control associated with caring for acutely ill inpatients."

Dr. Gordon claims that in his era, "regardless whether you had been up all night, you did not leave loose ends for your colleagues." He goes on to claim that, "in the end, most of us embraced the pain, which made us a fraternity."

But what I see is that Generation X and Y physicians have developed a different solution with a different work-life balance. These newer doctors don’t and won’t work the long and particularly the unpredictable hours that the prior generation did. They don’t have a spouse who runs the household. They have kids at daycare who need to be picked up on time. Many prefer working 0.8 full-time equivalent (FTE). So they have adopted a different work ethic. They recognize that unpredictable events sometimes – even routinely – make it necessary to sign out work to the on-call colleague. The new fraternity is committed to relieving last night’s on-call person, and expecting the same when it is their turn. Work flow is organized to hand off tasks to ensure that the patients’ needs are always paramount. The technological tools for carrying out these handoffs aren’t working smoothly – yet.

There are advantages to this new paradigm. It reduces the House of God attitudes I saw in medical school, and that will benefit patients. It will also benefit physicians as we balance our professional and personal lives.

Personally, I’m comfortable being cared for by a doctor from the older generation, whose commitment was evident in his long hours. Of course, that assumes that those excessive hours haven’t spawned burnout, substance abuse, or divorce – all of which would negatively impact my care. I have the expertise and wealth to afford such a doctor, if I could find one who isn’t too busy. But Henry Ford reminds me that the horse and buggy aren’t the way of the future.

Dr. Kevin Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He said that he has no conflicts of interest to disclose.

It is such a common scenario. It might be 4:45 p.m. in a rural, two-doctor office, or 9:30 a.m. Saturday during rounds in the nursery, or 11:55 a.m. in a teaching hospital. You are waiting on just one more lab result before you can finish that last patient encounter of the day, but you are also running late for your daughter’s soccer game. Do you stay and finish up, or sign the problem out to your partner who is on call?

I was taught there are three "coms" that characterize ideal physicians: They are competent, compassionate, and committed to their patients above all else. Those three characteristics are reflected in the mirror each morning. Your reputation is built on them. Your patient trusts you because of them. But you don’t want to disappoint your daughter, either. "So," says the little voice in my head, "just how committed are you?"

Dr. James Gordon reflects on this in the American Medical Association Virtual Mentor column "Sharing the Pain" (Virtual Mentor 2007;9:508-10).

"In the old days, anyone who wanted to go into medicine had to be prepared for a life of exhaustion. Before laws and regulations prohibited one-in-two call, we were rapidly conditioned to accept the idea that the life of a doctor was not only one of service, but a kind of servitude. ... In the first year of residency, the fledgling doctor learns never to leave work for anyone else at the end of the day."

Dr. Michael B. Edmond reflects on how this has changed for today’s newer physicians in "Taylorized Medicine" (Ann. Intern. Med. 2010;153:845-6).

"The marked changes in the way we conduct our business in teaching hospitals have been driven by advances in technology that have improved the process of care. ... But the biggest changes have been driven by the rules of the ACGME on resident work hours and their rigid enforcement.

"Every resident now has an invisible but heavy stopwatch sitting on their shoulder, ticking loudly, constantly reminding them that their task list still has many unchecked items as time slips away."

Dr. Edmond claims that in the past, "part of the maturation process for young physicians was coming to terms with the daily unpredictability and lack of control associated with caring for acutely ill inpatients."

Dr. Gordon claims that in his era, "regardless whether you had been up all night, you did not leave loose ends for your colleagues." He goes on to claim that, "in the end, most of us embraced the pain, which made us a fraternity."

But what I see is that Generation X and Y physicians have developed a different solution with a different work-life balance. These newer doctors don’t and won’t work the long and particularly the unpredictable hours that the prior generation did. They don’t have a spouse who runs the household. They have kids at daycare who need to be picked up on time. Many prefer working 0.8 full-time equivalent (FTE). So they have adopted a different work ethic. They recognize that unpredictable events sometimes – even routinely – make it necessary to sign out work to the on-call colleague. The new fraternity is committed to relieving last night’s on-call person, and expecting the same when it is their turn. Work flow is organized to hand off tasks to ensure that the patients’ needs are always paramount. The technological tools for carrying out these handoffs aren’t working smoothly – yet.

There are advantages to this new paradigm. It reduces the House of God attitudes I saw in medical school, and that will benefit patients. It will also benefit physicians as we balance our professional and personal lives.

Personally, I’m comfortable being cared for by a doctor from the older generation, whose commitment was evident in his long hours. Of course, that assumes that those excessive hours haven’t spawned burnout, substance abuse, or divorce – all of which would negatively impact my care. I have the expertise and wealth to afford such a doctor, if I could find one who isn’t too busy. But Henry Ford reminds me that the horse and buggy aren’t the way of the future.

Dr. Kevin Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He said that he has no conflicts of interest to disclose.

It is such a common scenario. It might be 4:45 p.m. in a rural, two-doctor office, or 9:30 a.m. Saturday during rounds in the nursery, or 11:55 a.m. in a teaching hospital. You are waiting on just one more lab result before you can finish that last patient encounter of the day, but you are also running late for your daughter’s soccer game. Do you stay and finish up, or sign the problem out to your partner who is on call?

I was taught there are three "coms" that characterize ideal physicians: They are competent, compassionate, and committed to their patients above all else. Those three characteristics are reflected in the mirror each morning. Your reputation is built on them. Your patient trusts you because of them. But you don’t want to disappoint your daughter, either. "So," says the little voice in my head, "just how committed are you?"

Dr. James Gordon reflects on this in the American Medical Association Virtual Mentor column "Sharing the Pain" (Virtual Mentor 2007;9:508-10).

"In the old days, anyone who wanted to go into medicine had to be prepared for a life of exhaustion. Before laws and regulations prohibited one-in-two call, we were rapidly conditioned to accept the idea that the life of a doctor was not only one of service, but a kind of servitude. ... In the first year of residency, the fledgling doctor learns never to leave work for anyone else at the end of the day."

Dr. Michael B. Edmond reflects on how this has changed for today’s newer physicians in "Taylorized Medicine" (Ann. Intern. Med. 2010;153:845-6).

"The marked changes in the way we conduct our business in teaching hospitals have been driven by advances in technology that have improved the process of care. ... But the biggest changes have been driven by the rules of the ACGME on resident work hours and their rigid enforcement.

"Every resident now has an invisible but heavy stopwatch sitting on their shoulder, ticking loudly, constantly reminding them that their task list still has many unchecked items as time slips away."

Dr. Edmond claims that in the past, "part of the maturation process for young physicians was coming to terms with the daily unpredictability and lack of control associated with caring for acutely ill inpatients."

Dr. Gordon claims that in his era, "regardless whether you had been up all night, you did not leave loose ends for your colleagues." He goes on to claim that, "in the end, most of us embraced the pain, which made us a fraternity."

But what I see is that Generation X and Y physicians have developed a different solution with a different work-life balance. These newer doctors don’t and won’t work the long and particularly the unpredictable hours that the prior generation did. They don’t have a spouse who runs the household. They have kids at daycare who need to be picked up on time. Many prefer working 0.8 full-time equivalent (FTE). So they have adopted a different work ethic. They recognize that unpredictable events sometimes – even routinely – make it necessary to sign out work to the on-call colleague. The new fraternity is committed to relieving last night’s on-call person, and expecting the same when it is their turn. Work flow is organized to hand off tasks to ensure that the patients’ needs are always paramount. The technological tools for carrying out these handoffs aren’t working smoothly – yet.

There are advantages to this new paradigm. It reduces the House of God attitudes I saw in medical school, and that will benefit patients. It will also benefit physicians as we balance our professional and personal lives.

Personally, I’m comfortable being cared for by a doctor from the older generation, whose commitment was evident in his long hours. Of course, that assumes that those excessive hours haven’t spawned burnout, substance abuse, or divorce – all of which would negatively impact my care. I have the expertise and wealth to afford such a doctor, if I could find one who isn’t too busy. But Henry Ford reminds me that the horse and buggy aren’t the way of the future.

Dr. Kevin Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He said that he has no conflicts of interest to disclose.