Danielle Ofri, MD, PhD is the author of three books about her experiences as a general internist at NYU School of Medicine and serves as editor-in-chief of the Bellevue Literary Review. The following post originally appeared on her blog on June 25, 2010.
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How many hours can a doctor work?
The residency regulators are back. About ten years ago, the national organization that accredits residency programs (ACGME) set out its first guidelines about how many hours a doctor-in-training can work. Interns and residents finally achieved the vaunted 80-hour workweek. (New York State was 15 years ahead on this, having mandated an 80-hour work week in 1989, stemming from the Libby Zion case.)
Every patient wants a doctor who is well rested and alert, but limiting residents to 80 hours per week wasn’t as simple a panacea as it seemed, as I wrote in an editorial in the Resident Hours Perspective NEJM shortly after the ACGME regulations were issued.
Practical issues abounded, mainly concerning the increased number of hand-offs required, as patients had to be cycled between teams of doctors. Less quantifiable, though no less concerning, was the inevitable progression toward “shift-mentality” and a decrease in professionalism.
In fact, the 80-hour workweek did not decrease errors and did not increase sleep time for the doctors. The ACGME has recognized this and has now issued a new report. In essence, they have admitted what all of us who teach new doctors already know, that medicine is far too complex to apply simple formulas. What really helps doctors-in-training practice good medicine, decrease errors, and maintain a high standard of professionalism is good supervision.
It might seem like stating the obvious, but fresh-off-the-boat interns need near-total supervision. These eager new doctors were medical students just an eye-blink ago, and a parchment diploma did not ratchet up their clinical skills overnight. A good supervisor needs to watch closely and teach intensively during this early period.
Over the next several years, as the residents gain skill and confidence, supervisors can ease back, offering more opportunities for independent decision-making. The overall thrust is that the quality of medicine delivered by residency training programs depends heavily on the quality and quantity of supervision provided.
The changes in this area are palpable. When I did my medical residency training almost twenty years ago, senior physicians (attendings) were barely present. The attending showed up once a day to see all the newly admitted patients during an “attending rounds” session, and then returned to his or her private practice. We were on our own for the rest of the patients’ care, even if it lasted weeks.
Now, I am an attending at the very same hospital, but the model is entirely different. When I spend a month supervising a team on the medical wards, I am there full-time. We still have that attending rounds session to talk about new admissions, but we also have the rest of the day. I don’t follow two steps behind my residents and interns every waking moment, but we talk constantly during the day. I also examine the patients independently to make my own clinical assessment. We work as a team six days per week and I can be reasonably sure that we are all on the same page with the patients’ care.
Do errors still happen? Are residents still exhausted? Yes, and yes. But I do think patient care is better for it.
The trick now is to teach them independence and to foster the do-whatever-it-takes-for-your-patients credo that suffused my training years. Not to mention the joys and rewards of medicine.
But that can be done in 80 hours, or at least I am hoping so.
- Danielle Ofri
Sunday, 18 July 2010
Thursday, 15 July 2010
The doctor will "tweet" you now
There’s a lot of evidence that to prevent many serious health conditions, including diabetes, obesity, heart disease, and stroke, making healthy lifestyle changes are just as good, if not better than, taking medications. Lifestyle changes may consist of stopping unhealthy behaviors such as tobacco and excessive alcohol use, or starting healthy behaviors such as moderate daily exercise and eating adequate amounts of fresh fruits and vegetables.
As anyone who has ever tried to quit smoking or make radical changes to their physical activity or dietary routines will be quick to tell you, though, making healthy lifestyle changes is hard! Family physicians do our best to support patients trying to make these changes. Unfortunately, with the exception of smoking cessation (where a few minutes of advice from your doctor can make a difference), doctors can’t provide nearly enough counseling in the limited time available at a typical visit. Patients trying to change their lifestyles for the better are most likely to succeed when they receive supportive messages again and again and feel that they aren’t alone in their efforts.
Social media tools such as blogs and Twitter offer a new venue to promote healthy and discourage unhealthy lifestyle behaviors. In addition to receiving regular supportive and educational messages, patients can share their own stories with a community of people undergoing the same types of struggles. Smokers who are seeking support to quit the habit can exchange tips with thousands of fellow nicotine addicts at http://www.twitter.com/quitsmoking123; patients with alcohol problems can join a “virtual AA group” at http://www.twitter.com/alcoholicsanony; and anyone interested in improving their physical fitness can find virtual lifestyle coaches and trainers at http://wefollow.com/twitter/exercise.
In addition, as recently reported in the Los Angeles Times, there has been a recent explosion in the number of consumer healthcare applications for smart phones. Many of these free or low-cost apps are designed to help improve physical fitness or encourage weight loss. Although their track records are slim, and none have yet been proven to be effective in changing behaviors, it’s probably worth giving them a try. I would recommend checking with your family doctor first to make sure that an app that you are considering provides reliable information.
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This post was first published on my CommonSense MD blog at Family Health Guide.
As anyone who has ever tried to quit smoking or make radical changes to their physical activity or dietary routines will be quick to tell you, though, making healthy lifestyle changes is hard! Family physicians do our best to support patients trying to make these changes. Unfortunately, with the exception of smoking cessation (where a few minutes of advice from your doctor can make a difference), doctors can’t provide nearly enough counseling in the limited time available at a typical visit. Patients trying to change their lifestyles for the better are most likely to succeed when they receive supportive messages again and again and feel that they aren’t alone in their efforts.
Social media tools such as blogs and Twitter offer a new venue to promote healthy and discourage unhealthy lifestyle behaviors. In addition to receiving regular supportive and educational messages, patients can share their own stories with a community of people undergoing the same types of struggles. Smokers who are seeking support to quit the habit can exchange tips with thousands of fellow nicotine addicts at http://www.twitter.com/quitsmoking123; patients with alcohol problems can join a “virtual AA group” at http://www.twitter.com/alcoholicsanony; and anyone interested in improving their physical fitness can find virtual lifestyle coaches and trainers at http://wefollow.com/twitter/exercise.
In addition, as recently reported in the Los Angeles Times, there has been a recent explosion in the number of consumer healthcare applications for smart phones. Many of these free or low-cost apps are designed to help improve physical fitness or encourage weight loss. Although their track records are slim, and none have yet been proven to be effective in changing behaviors, it’s probably worth giving them a try. I would recommend checking with your family doctor first to make sure that an app that you are considering provides reliable information.
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This post was first published on my CommonSense MD blog at Family Health Guide.
Tuesday, 13 July 2010
Medical homes and the meaning of "P.C." - Part 2 of 2
In my last post, I discussed the high hopes many have for improving health care through the medical home and the sobering results of the AAFP's National Demonstration Project, which fell short of fulfilling those hopes. The "PC" in PCMH stands for "patient-centered," which means changing primary care practice to better meet the needs of patients rather than allowing patients access to care only when convenient for the practice (which I'd call a "practice-centered" approach). Some ways that the AAFP's demonstration practices did this were to offer same-day scheduling and phone or electronic mail consultations in lieu of face-to-face visits.
The potential of primary care teams will not be achieved if medical homes are too "physician-centered." This point requires some clarification. Physicians have the most education and training of any person in the practice, and they should be doing primary care tasks commensurate with their training and ability, and no more. But the primary care team that succeeds will expect the same from all of its members, including the nurse practitioner, the physician assistant, the health educator, the medical assistant, etc. and just as importantly, be responsive to their input about improving inefficient or inadequate processes of care.
Reflecting in the Annals of Family Medicine on the lessons from the AAFP's attempt at creating a sustainable patient-centered medical home model, my friend and colleague Dr. Larry Green from the University of Colorado, Denver makes several valuable observations:
The PCMH is useful, even galvanizing, but limited, as a political construct and is best understood as the rallying point for robust, modernized primary care that now necessitates a new mind model from all of medicine, policy makers, and especially those wonderful clinicians and staff members taking care of most of the folks in the US today. PCMH is really not a thing, a collection of techniques; it is presently a journey toward a destination not yet crystal clear. ...
I am not at all concerned about all the "hoopla" around patient experience getting worse during a 26 month period and small effect sizes. ... What would one expect from a traffic survey of travelers on a road under repair if asked, "Does this ride delight you? Are you getting exactly what you want from this road the way you want it when you want it?" And to lament small effect sizes is akin to lamenting less than gorgeous blossoms on roses planted in a desert, with the gardener having only a cup of water each day.
Well said, Larry.
The potential of primary care teams will not be achieved if medical homes are too "physician-centered." This point requires some clarification. Physicians have the most education and training of any person in the practice, and they should be doing primary care tasks commensurate with their training and ability, and no more. But the primary care team that succeeds will expect the same from all of its members, including the nurse practitioner, the physician assistant, the health educator, the medical assistant, etc. and just as importantly, be responsive to their input about improving inefficient or inadequate processes of care.
Reflecting in the Annals of Family Medicine on the lessons from the AAFP's attempt at creating a sustainable patient-centered medical home model, my friend and colleague Dr. Larry Green from the University of Colorado, Denver makes several valuable observations:
The PCMH is useful, even galvanizing, but limited, as a political construct and is best understood as the rallying point for robust, modernized primary care that now necessitates a new mind model from all of medicine, policy makers, and especially those wonderful clinicians and staff members taking care of most of the folks in the US today. PCMH is really not a thing, a collection of techniques; it is presently a journey toward a destination not yet crystal clear. ...
I am not at all concerned about all the "hoopla" around patient experience getting worse during a 26 month period and small effect sizes. ... What would one expect from a traffic survey of travelers on a road under repair if asked, "Does this ride delight you? Are you getting exactly what you want from this road the way you want it when you want it?" And to lament small effect sizes is akin to lamenting less than gorgeous blossoms on roses planted in a desert, with the gardener having only a cup of water each day.
Well said, Larry.
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