Published in the August 2012 issue of Today’s Hospitalist
IT’S EASY TO SAY that doctors should always act professionally, but what does that really mean? Is chatting with a colleague in the hallway about your dinner plans unprofessional? What about bad-mouthing the decisions of emergency and primary care physicians to your fellow hospitalists? And how about introducing a medical student to patients as “doctor,” celebrating a blocked admission or coming to work when you are sick?
The first example might not seem that unprofessional “and, in fact, hospitalists from three Chicago health systems who were surveyed about their views of and participation in unprofessional behavior didn’t consider chatting with colleagues problematic. (They rated it midway between unprofessional and professional behavior, and more than two-thirds admitted to doing so.) The survey asked questions about a range of behaviors from borderline to egregious.
Survey results, which were published online in May by the Journal of Hospital Medicine, indicated that hospitalists’ behaviors are overwhelmingly professional. But according to Shalini T. Reddy, MD, a hospitalist and associate professor of medicine at the University of Chicago, hospitalists’ responses also highlighted areas where the stresses and culture of modern medicine make it hard for hospitalists to act as they might like.
“As a profession, we are going to be faced with systems issues and difficult situations,” she says. “Being professional means carrying ourselves the way patients depend on us to behave: cool-headed, compassionate and competent, and we have to be those things all the time. That’s a tall order.”
Surveyed hospitalists, for instance, rated disparaging other physicians to colleagues as fairly unprofessional. According to Dr. Reddy, what that really illustrates is how deep-seated the problem of “Monday-morning quarterbacking” is in American medical culture.
Common sense says that such behavior can’t be best for patient care either. The first step toward changing such a culture, she notes, is “raising awareness” through surveys such as this one, which illuminate the distance between perception and action.
“Some of us aren’t even aware that we do this,” says Dr. Reddy. “It’s important to hold a mirror up to ourselves.” Once Dr. Reddy and her research team identified common behaviors, “our group started conducting workshops using videotaped scenarios to raise awareness and get us all thinking about how we work.”
Blocking and turfing
Physicians don’t want to be unprofessional, Dr. Reddy explains. Instead, unprofessional behavior may crop up when doctors are trying to cope with an exasperating or stressful situation.
Take “blocking” and “turfing,” behaviors that surveyed hospitalists both rate as unprofessional but also admit to participating in. “Blocking” an admission was defined as refusing to take an admission that would be appropriate for that doctor’s service, while “turfing” is the practice of transferring a patient who could be cared for on your service to another, to reduce your census. Survey results indicated that 8% of hospitalists reported “blocking,” 9% admitted they have “turfed” and 21% said they have celebrated a blocked admission.
What those findings highlight, Dr. Reddy explains, is the mismatch between workload and workforce. It’s not that hospitalists don’t like taking care of patients, but that they “may be responding to the frustration that they don’t have enough time to see the patients they have,” she says. “If you can have a patient go to a different service, you can spend more time with the patients you already have, and you celebrate that.”
Workload and time pressures
The survey also found that hospitalists with more clinical duties on top of administrative work were more likely to report participating in unprofessional behaviors, like turfing, that relate to workload management.
Hospitalists with night work duties, on the other hand, were more likely than others to report participating in behaviors related to time pressure. Those included not answering nonurgent family questions on a cross-cover patient when doctors had time to answer.
Dr. Reddy also notes that the hospitalists surveyed all worked in academic centers, and that the thoughts and actions of community-based hospitalists could be very different. She speculates, for instance, that physicians in community hospitals may speak ill of colleagues in other disciplines much less “because there is a lot more interaction” between specialists and “it’s a lot easier to disparage someone you don’t know.”
The results of the current survey build on findings that Dr. Reddy and her colleagues published in Academic Medicine in October 2010. That earlier work surveyed interns on their perception of and participation in unprofessional behaviors. It concluded that “learning environments may promote participation in unprofessional behaviors, with participants perceiving the behavior as appropriate in order to resolve cognitive dissonance.”
Finding similar results among surveyed attendings, Dr. Reddy says, shows how important role modeling is in promoting professionalism. “If we are making fun of our colleagues, it’s going to feel OK for the residents to do so,” she notes. One behavior she personally is trying to model, for instance, is not passing off medical students to patients as physicians, a behavior that the surveyed hospitalists ranked as fairly unprofessional, but which 4% admitted doing. Not understanding the roles of various caregivers, Dr. Reddy points out, can confuse patients.
Dr. Reddy also noted that survey results help focus on ways to “improve the environment.” Consider the practice of doing signouts over the phone. The survey found that hospitalists consider such signouts to be less than professional, and only a minority admitted to doing them.
“Maybe we need to build in time for a handoff to take place,” Dr. Reddy says. Or if blocking and turfing are prevalent, “we need to think about what is the right number of patients to take care of.”
The survey also helps clarify the line between unprofessional and unethical behavior. For instance, surveyed hospitalists overwhelmingly ranked several behaviors as “very unprofessional.” Examples include reporting patient information as normal when in fact the physician doesn’t know the true results or discharging patients before they are ready to go home simply to reduce the doctor’s census. In the survey, only a tiny minority of hospitalists (less than 5%) reported such behaviors.
“Even that is an unacceptable number,” Dr. Reddy says. “But I am reassured by the fact that most hospitalists are ethical.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.