Published in the December 2012 issue of Today’s Hospitalist
IF YOU’RE LOOKING for an example of just how much life has changed for physicians serving as ward attendings, consider the case of attending rounds. While some consider teaching rounds an anachronism in today’s world, others think they are a central part of attendings’ jobs.
Not surprisingly, the divide over the value of attending rounds tends to break along age lines. While old-timers (anyone over age 40 in hospital medicine) might find tremendous value in teaching rounds, many younger physicians would prefer to spend rounding time on patient care instead.
While that debate may seem academic, it gets at an issue that academic hospitalists everywhere are confronting: What’s more important for residents, education or patient care? The answer to that question is critical for hospitalists, explains Robert M. Wachter, MD, because hospital medicine now plays a larger role in medical training than just about any other specialty.
In a Sept. 12 commentary published in the Journal of the American Medical Association, Dr. Wachter examined the conflicts and tensions that now occur on teaching services. He says that as teaching hospitalists attempt to strike a balance between the competing priorities of teaching and patient care, they find themselves in a lonely and stressful position.
That’s because it’s a challenge, says Dr. Wachter, to be an attending in today’s more patient-centered hospitals where graduate medical education has changed. He says that many in academia “both older attending physicians who are trying to adapt their teaching approach to the 21st century and young hospitalists searching for a new normal “sometimes feel "like they are standing on Jello."
A "juggling act"
If academic medicine doesn’t address the tension between education and service, the JAMA article warns, "There is a risk that teaching will be shuffled to the bottom of the deck in the name of efficiency."
Dr. Wachter, who is chief of hospital medicine at the University of California, San Francisco (UCSF) and chair of the American Board of Internal Medicine, says that those competing demands make an attending’s job a "juggling act."
"You are trying to take care of patients clinically and meet all sorts of external standards, and you are trying to teach at all sorts of different levels, and you have time pressures," due to residency duty-hour rules, he explains. "When you throw into that juggling act a little bit of uncertainty, sometimes the plates come crashing down."
The debate is particularly important to hospitalists, Dr. Wachter says, because the specialty plays such an oversized role in teaching, and because so many hospitalists tend to be young. "A really crucial question," he notes, "is how we teach junior hospitalists to manage these pressures."
No more specialist attendings
With so little consensus on the role that attendings should play, Dr. Wachter explains that academic physicians are thirsty for guidance. (He notes that he has received more feedback on the article than on nearly anything else he’s written for a number of years.) While Dr. Wachter says that older physicians (he includes himself in that group) have to scrutinize their nostalgia for the good old days, younger attendings need to make sure they aren’t throwing out what has always worked.
"The job hadn’t changed very much over 20 or 30 years," he says, "but many of the assumptions have recently been thrown out. But they haven’t been replaced by a new set of norms that create a level of stability for all players." Complicating matters, that uncertainty has been magnified by a "generational divide," where older physicians view the job of academic attending as something very different from the job envisioned by younger colleagues.
A good part of that uncertainty, says Dr. Wachter, comes from the fact that the type of physician who serves as an attending has changed. Until the last decade or so, the job was done mostly by subspecialist researchers, who would attend on the wards for perhaps a month a year. These doctors generally took a hands-off approach to the job, and residents “for good or bad “had a lot of autonomy in how they cared for patients. These attendings also had little responsibility for billing, documentation or even providing efficient, evidence-based medicine.
Today, attendings tend to be hospitalists supervising groups of trainees for six months or more, and they are on the wards during the full shift. These attendings have greater hands-on responsibility for patients, and they and their teams are expected to provide cost-effective, efficient, evidence-based care that meets quality and safety guidelines. They’re also expected to make sure residents meet the administrative requirements of their training program.
A new generation
"Any time generations have very different world views, it is an interesting conversation," Dr. Wachter explains. "The older generation tends to romanticize the way things used to be, while the newer generation has new ideas and is figuring things out as they go along. There is a little bit of a culture clash."
To illustrate, Dr. Wachter recalls a dispute he had with one of his residents. At stake was whether trainees had to attend attending rounds. Dr. Wachter wanted all the residents to be there. "That’s the way it has always been," he says, "and I like to think that what I teach them is useful."
The resident, on the other hand, told the interns that they didn’t need to report to attending rounds. "Although she agreed that attending rounds are useful," Dr. Wachter continues, "she had been given the job of helping the team get out the door so they didn’t turn into pumpkins by the time the duty hours clock struck."
"She felt that part of her job now was to defend the team against me, to be blunt," he says. "It put her in an incredible double bind." Dr. Wachter adds that the situation put him in the equally uncomfortable position of having to countermand his resident and demand that everyone attend.
"These are all really good people trying to do the right thing under a new set of rules, but nobody has articulated these givens and how we balance all the new imperatives," Dr. Wachter says.
What’s the solution? Dr. Wachter recommends that each program discuss its priorities and then incorporate decisions into faculty development programs. "Just like being an effective teacher is to some extent teachable, I think learning how to be an effective attending is tricky but trainable," he says.
At UCSF, he explains, "we are trying to work on that now in our faculty development program. I think it is an important part of the onboarding of new attendings." But because you can’t orient people if you don’t know what you want to orient them to, what needs to happen first is to "sit down as a group and come up with a set of shared assumptions that everybody buys into." Then will come "skill-building on the part of faculty so they know how to negotiate and balance all the demands" placed on attendings.
The goal, says Dr. Wachter, is to stave off future conflicts. Those will only continue to flare up if the "rules are being invented on the fly by every resident and attending, with each one having very different ideas."
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.