A humanities friend of mine asked a question in response to the last post: if the intern workload produces bad incentives and potentially suboptimal care, not to mention emotional burnout/family trauma/car accidents[1]/general crabbiness, why the heck do we do it? There are certainly plenty of people who want to be doctors, not to mention the number of nurses/physician assistants/other providers who'd love to extend their scope of practice. Why would we set this up so that so much burden falls on the most junior (i.e., least competent) doctor? Are we, in fact, just nuts?
This is a question I work on quite a bit in my organized medicine activities. The answer is tricky. There is some of the problem that's good old-fashioned "I did it, I suffered, now it's your turn" mentality. But, there's also good economic reasons for it, and that's really what keeps it going (in my opinion, anyway). The economics from the hospital's side are simple. The median salary for a nurse practitioner in Seattle (if you believe salary.com) is about $90,000. My pay, as conveniently advertised on the web, is half that. I don't have a union, I don't have to be paid overtime when I work beyond 40 hours, and in general, I do perhaps 1.5 times the work (as measured by hours; productivity would be less) of a free-market NP for half the cost. If I save the hospital perhaps $50K a year, and there's at least 400 residents in the hospital, that's $20 million a year. That's not even counting the extra revenue that the surgical residents can generate because of the extra volume in high-reimbursement procedures.
It isn't just one-way exploitation, though. In theory, it's also designed to benefit me. Between the cap on the number of residents Medicare will pay for, and the general tight-fistedness of the accrediting bodies, the residency system acts as a choke on the physician supply. As you'd guess if we're working almost 80 hours per week, the supply is controlled to a level substantially less than demand, and has been for decades. Econ 101 tells us that high demand and low supply equals an increase in the price of the good. Or, in other words: the residency system creates an artificial scarcity of doctors in almost every specialty, leading to recruitment battles and higher physician salaries [2]. One of the major reasons everybody tolerates this system is that (again, in theory), in exchange for getting hosed while you're a resident, you thereafter get to be permanently employed with a salary in the top 3rd to 5th percentile. It also lets you feel a bit prestigious -- sure, you work hard and maybe it messes up the patients, but think about how much better you are than all the people who applied for your job but didn't make the cut!
The interesting thing is that aside from the twin profit motives above, there's a very anti-profit motive that also props up the system. Somewhere along the way, we acquired the notion that excellence in doctoring is comprised mainly of working harder. In general, many physicians' solutions to the problems facing health care as a whole, or individual patients, is simply to throw more of their own person-hours into the furnace. We're quite proud of it, too. We'll regularly boast about how many extra hours we put in to get the job done for that one particular patient. Whoever self-inflicts the most suffering is somehow ennobled. It's hard for me to say where this mindset comes from; as you can guess from my tone, I don't think it's quite right. You can't build a sustainable health care system on the notion of individual heroism. Yes, it's nice to know you've got the doctor who'll go the extra mile -- but do you still want him when, as almost inevitably happens, he burns out and loses the ability to care altogether? More importantly, who among us hasn't been told approximately a trillion times to "work smarter, not harder"?
And that, in the nutshell, is the real reason why a system persists even though it probably doesn't do anyone (except maybe the hospital management) much good. We could design something better, but to do so goes against the #1 survival skill taught during training: keeping your head down, working harder, and just plowing through. Furthermore, everyone's so focused on the short-term gain they expect to get out of the system that they ignore the broader interest. Unless physicians of all stripes get together and make the teaching system more sensible for doctors and patients alike, we're going to be so busy with nobly working harder that we won't notice while all those traditional prerogatives of the profession (prestige, money, the "right" to be "in charge", even being the only person on the team who's called "Doctor") get carved up and carried away by the many other players in the modern health care enterprise.
We willingly and perhaps even knowingly perpetuate a system that messes up our future colleagues, sets us up for economic problems in coming decades, and doesn't do any better by the patients. We are, in fact, nuts, or at least just really dumb. Unfortunately for me and many others, this turns out to be yet another one of those diseases I can't fix -- at least, not yet.
[1] All of the above are, in fact, documented in the peer-reviewed literature. Yes, car crashes. It's in the New England Journal of Medicine. Brings new meaning to "work yourself to death", no?
[2] Econ 102 goes on to explain that supply-demand curves are ironclad unless a substitute good is available at a lower price. And that NP may be expensive at $90K... but he/she is a lot better than the median psychiatrist salary of $200K. (It's about the same for a hospitalist in general medicine.) So in fact, a rationally-acting hospital or health insurer will not pay physicians what they expect, but will instead substitute cheaper products when possible. The storm coming from that particular collision in expectations is another entry unto itself.
Sunday, December 13, 2009
Saturday, December 12, 2009
Three More Weeks...
I've been off in a wilderness called "medicine" for the past two months; all psychiatrists are expected to do four months of general medicine training in our first year. Mine is split as one month of adult inpatient, two months of pediatric inpatient, and one of adult emergency (which everyone loves, because it involves neither call nor morning rounds).
As you might surmise from the months of sudden silence, it's been busy. It's not just the call, though. It's taken me a while to adjust emotionally to a very different environment and a different way of taking care of patients. There is, obviously a lot less talking to your patients, and a lot more talking about them -- presenting them to the attending on rounds, telling consultants about them, talking to their nurses, calling radiology about their x-rays and CT scans, calling social work to arrange discharges, and so on. For someone who went into psych specifically because it's the specialty where you get to spend an hour minimum with every new patient, that's less than desirable.
The bigger issue, and the one that constantly frustrates me, is that medicine wards everywhere are basically set up such that my survival depends on taking bad care of patients. The issue is simple: a medicine intern's patient load is not fixed, as it is on psychiatry. In psych, we have a bed shortage, nationwide. As such, the inpatient units are always full. The workload has been calibrated such that taking care of a full unit will be difficult, but still doable while keeping work/life balance (and attending to all the non-patient-care items that constitute "work", such as conferences, research, reading, teaching, etc.) No so the medical floors. Every intern has a variable census. At Harborview, our adult hospital, you can be responsible for up to ten patients. Roughly speaking, you're required to pick up five more every fifth day when you're on call, plus two more in the middle of the call cycle -- seven additions every five days. You keep caring for them until they leave. The problem is simple -- nobody can take competent care of ten adult medicine patients. The paperwork and diagnostic/treatment load required is beyond a junior doctor's faculties. The actual "happy medium" for learning varies, but mine is somewhere between five and seven. At Seattle Children's, where I am now, it's similar but without the cap -- each call night could be anywhere from three to ten patients, and I've had my service hit thirteen[1]. (Thankfully, at that point the senior residents took mercy and did some redistribution before I died.)
In such a system, all your efforts have to focus on one thing: get the patient out the door as fast as you possibly can. When you're on call, the principle is similar: do the minimum necessary work on each new patient, because a flurry of admissions or a serious crisis on existing patients could happen at any minute. It's a constant race to get ahead of the tide. Personally, I feel that this leads to suboptimal care; maybe not actually "bad", but definitely not the care I'd want my own family to get. How can your doctor truly care for you when all his/her incentives are about minimizing contact, minimizing time, and getting you just stable enough to be hustled out the door? It does function -- most patients don't get readmitted, at least not immediately. It just doesn't provide the quality I'd want from the world's most expensive health care.
Of course, it's not all bad. I'm not going to say it's educational; the actual amount of learning about medicine is minimal. Mostly I learn how to do paperwork and what this particular hospital's protocols are. At best, it's an exposure to ward workflow so I can be more helpful in second year, when my primary role will be consulting psychiatrist for those medically ill patients who also have mental health needs. What it does do is really make you appreciate your free time. I find myself being more efficient in my days/hours off, because I know the clock is about to start again. I also think I will never again complain about psychiatry's less-than-once-per-week call schedule.
The other nice thing is occasionally getting one of those medical patients with psych issues, because for once, I can take care of someone from both angles. The average medical resident tends to be profoundly uncomfortable with someone who's suicidal, or majorly drug-addicted, or psychotic. I'm no expert on any of those, but at this point I've seen them enough to not panic. What I don't yet have is enough experience in the management of the many kinds of toxic overdose, or the infections that result from IV drug use, or the complications of rampant diabetes. Having someone teach me about those while I get to also treat the psychiatric problems is profoundly satisfying, and almost fun. I've daydreamed about trying to find a way to make more of our "medicine" time focus around that scenario, but haven't quite come up with it. It'd require having a kind of dual-attending med-psych service and the underlying administrative structure; a great project for a chief resident to undertake, but not really doable by an intern (at least, not one on medicine months).
In the long run, mostly the past two months have confirmed to me that I picked the right specialty. Some of the patients were interesting, the pediatric ones are cute, and a few have even been grateful. Still, if you told me I was going to spend the rest of my life managing electrolytes and infections, I'd quit and go back to the lab for good. There's only three (ish) more weeks and six more call nights before I get to put off the white coat, mothball the stethoscope, and get back to shrinking heads. It's good to be in the home stretch.
[1] The astute will note a potential upside -- if you are REALLY lucky and get just the right kind of simple admissions a given call night, it is possible to actually discharge everybody before your next call. This has happened to me twice in my three months; it's a magical feeling.
As you might surmise from the months of sudden silence, it's been busy. It's not just the call, though. It's taken me a while to adjust emotionally to a very different environment and a different way of taking care of patients. There is, obviously a lot less talking to your patients, and a lot more talking about them -- presenting them to the attending on rounds, telling consultants about them, talking to their nurses, calling radiology about their x-rays and CT scans, calling social work to arrange discharges, and so on. For someone who went into psych specifically because it's the specialty where you get to spend an hour minimum with every new patient, that's less than desirable.
The bigger issue, and the one that constantly frustrates me, is that medicine wards everywhere are basically set up such that my survival depends on taking bad care of patients. The issue is simple: a medicine intern's patient load is not fixed, as it is on psychiatry. In psych, we have a bed shortage, nationwide. As such, the inpatient units are always full. The workload has been calibrated such that taking care of a full unit will be difficult, but still doable while keeping work/life balance (and attending to all the non-patient-care items that constitute "work", such as conferences, research, reading, teaching, etc.) No so the medical floors. Every intern has a variable census. At Harborview, our adult hospital, you can be responsible for up to ten patients. Roughly speaking, you're required to pick up five more every fifth day when you're on call, plus two more in the middle of the call cycle -- seven additions every five days. You keep caring for them until they leave. The problem is simple -- nobody can take competent care of ten adult medicine patients. The paperwork and diagnostic/treatment load required is beyond a junior doctor's faculties. The actual "happy medium" for learning varies, but mine is somewhere between five and seven. At Seattle Children's, where I am now, it's similar but without the cap -- each call night could be anywhere from three to ten patients, and I've had my service hit thirteen[1]. (Thankfully, at that point the senior residents took mercy and did some redistribution before I died.)
In such a system, all your efforts have to focus on one thing: get the patient out the door as fast as you possibly can. When you're on call, the principle is similar: do the minimum necessary work on each new patient, because a flurry of admissions or a serious crisis on existing patients could happen at any minute. It's a constant race to get ahead of the tide. Personally, I feel that this leads to suboptimal care; maybe not actually "bad", but definitely not the care I'd want my own family to get. How can your doctor truly care for you when all his/her incentives are about minimizing contact, minimizing time, and getting you just stable enough to be hustled out the door? It does function -- most patients don't get readmitted, at least not immediately. It just doesn't provide the quality I'd want from the world's most expensive health care.
Of course, it's not all bad. I'm not going to say it's educational; the actual amount of learning about medicine is minimal. Mostly I learn how to do paperwork and what this particular hospital's protocols are. At best, it's an exposure to ward workflow so I can be more helpful in second year, when my primary role will be consulting psychiatrist for those medically ill patients who also have mental health needs. What it does do is really make you appreciate your free time. I find myself being more efficient in my days/hours off, because I know the clock is about to start again. I also think I will never again complain about psychiatry's less-than-once-per-week call schedule.
The other nice thing is occasionally getting one of those medical patients with psych issues, because for once, I can take care of someone from both angles. The average medical resident tends to be profoundly uncomfortable with someone who's suicidal, or majorly drug-addicted, or psychotic. I'm no expert on any of those, but at this point I've seen them enough to not panic. What I don't yet have is enough experience in the management of the many kinds of toxic overdose, or the infections that result from IV drug use, or the complications of rampant diabetes. Having someone teach me about those while I get to also treat the psychiatric problems is profoundly satisfying, and almost fun. I've daydreamed about trying to find a way to make more of our "medicine" time focus around that scenario, but haven't quite come up with it. It'd require having a kind of dual-attending med-psych service and the underlying administrative structure; a great project for a chief resident to undertake, but not really doable by an intern (at least, not one on medicine months).
In the long run, mostly the past two months have confirmed to me that I picked the right specialty. Some of the patients were interesting, the pediatric ones are cute, and a few have even been grateful. Still, if you told me I was going to spend the rest of my life managing electrolytes and infections, I'd quit and go back to the lab for good. There's only three (ish) more weeks and six more call nights before I get to put off the white coat, mothball the stethoscope, and get back to shrinking heads. It's good to be in the home stretch.
[1] The astute will note a potential upside -- if you are REALLY lucky and get just the right kind of simple admissions a given call night, it is possible to actually discharge everybody before your next call. This has happened to me twice in my three months; it's a magical feeling.
Subscribe to:
Posts (Atom)