In Search of a New Rhythm on Today’s Wards

When I was a medical student, I remember wondering what my attendings did when they weren’t on the wards. As an attending now myself, trying to cram three half-month ward blocks into my hyperscheduled life each year, I find that sentiment charmingly naïve. I – like most of my faculty colleagues – am awfully busy these days, both on and off the wards.

But one thing that makes the wards doable is that there is a certain rhythm to the experience. Check that: made and was. Until last year, the ward team (consisting of a resident, a couple of interns, and a med student or two) admitted new patients all day and all night, every fourth day. As their attending, I might have seen a couple of new admissions during the on-call day and chatted with the resident overnight about the most complex cases. But the team was mostly on its own for the first 24 hours, particularly at night. The data dump – from the residents to the legally responsible physician (in this case, me) – occurred on the post-call morning, when I sat down with my bleary-eyed team to hear about all the new admissions – sometimes as many as ten. As we raced from one case presentation to the next, we desperately sought time to accomplish any number of tasks: listen to the third-year student’s cinematic depiction of his patient’s family history, run to radiology to look at some films, talk to a couple of patients and families, and – channeling my inner Abraham Verghese – demonstrate some key physical findings.

Oh yes, all the while trying to ensure that the patients received the best possible care. For the attending, the post-call day was a hellish fire drill, but the work got done, most patients did fine, and the rhythm was predictable, lending a certain comfort to the whole exercise. Moreover, the non-post-call days offered relatively tranquil interludes of 60-90 minutes each morning for attending teaching rounds; in a half-month block, I could count on about 6 “good days” when all the residents and students were around and I could cover some of my favorite topics (diagnostic reasoning, patient safety, decision-making about end of life care, etc.). And – because they were left alone for so much of the on-call day and night – the housestaff learned to be autonomous clinical thinkers.

I just finished my first ward stint since the new ACGME duty hours regulations took effect last July. These regulations, you’ll recall, now prohibit interns from working shifts of more than 16 hours. Like programs everywhere, UCSF was forced to jettison the time-honored 24-hour call system and replace it with some version of shift-work. In our new model, on-call teams now admit from 8 a.m. to 6 p.m. The interns go home at about 9 p.m.; the resident stays overnight to mop up on the new patients and to cross-cover them. But new admissions between 6 p.m. and 8 a.m. are handled by a separate night crew, consisting of housestaff and hospitalists. All these patients have to go somewhere, of course, so the daytime on-call teams receive several new patients who were worked up overnight during an early morning handoff.

You may think that this is the time when the old geezer begins crooning about the “Days of the Giants”: how overnight call made us Strong-Like-Bull, how fraught handoffs are, how today’s housestaff are acquiring a shift-work mentality. I do have concerns. In fact, in this month’s issue of AHRQ WebM&M, we highlight many of them with a thoughtful article by Dine and Myers and my interview with Larry Smith, the founding dean of the new Hofstra/North Shore-LIJ med school and a former residency program director. Both pieces are worth a look.

But, recalling the times I fell asleep driving home after 36-hour intern shifts, I think the new model is an improvement. Even if it isn’t, we should get over ourselves and work on making lemonade. The public finds the idea that we can provide high quality, safe care in our 32th consecutive hour impossible, particularly when good research shows that after such a period of prolonged wakefulness, our cognitive skills degrade to a state that mirrors that of someone with a blood alcohol level of 0.1 – legally drunk in every state. Even though studies on the impact of duty hour limits generally don’t prove that safety is improved, the limits have led to better rested housestaff, less burnout, and greater public confidence in our system. So the duty hour limits are here to stay (by the way, the max in Europe is 48 hours per week), and those of us who run educational programs must accept our new challenges: how to preserve the core values of professionalism, intellectual autonomy, and medical education when the wards have a very different rhythm than in the past.

It’s not an easy task.

The new system has several advantages over the old. For the attending, rather than trying to digest a mountain of information about many new patients on the post-call morning, the task has been shifted one day forward and spread around. Last month, I eventually settled into a routine in which I rounded with my team twice on their on-call days: once at about 10 a.m. to hear about all our old patients and the new admits that they received 3 hours earlier from the night teams (usually 3-4 patients), and again at 6 p.m. to hear about all the additional patients admitted throughout the day as well as any major status changes (remember that they’re done admitting new patients at 6 p.m.). The beat was completely new to me: I saw patients throughout the on-call day and evening, generally leaving the building around 11 p.m. It was an exhausting day, particularly for an Old Timer, but it also felt great knowing that I had tucked in all the new patients by bedtime. The dread I used to feel driving into work on the post-call day was replaced by Zen-like calm; it was now a smooth, predictable day.

I also like the fact that my input into the cases was much more timely. In the old days, for a patient admitted at 6 p.m., I might have heard a thumbnail sketch by phone five hours later, a full presentation late the next morning, and not gotten around to meeting the patient until that afternoon, nearly a day after admission. Now, sick patients admitted at night are “staffed” by one of my colleagues, a nighttime hospitalist (“nocturnist”). I usually saw all of them by noon. And I saw those admitted during the day within six hours of admission, sooner if they were acutely ill.

So far so good. What’s the bad news?

First, this just-in-time attending involvement carries a potential cost. You may recall me sharing some of Dr. Cindy Fenton’s observations when she returned to academic medicine after a decade’s absence. Perhaps the most memorable were her comments about housestaff autonomy:

…The more involved role of the attending was striking. My resident, who was superb, asked for and seemed to appreciate my involvement in holding family meetings and moving care along, especially on post-call days. She wanted me to round with the team in the ICU daily at 8:30 am. I realized I had no idea how to function as an attending on work rounds (this was something I pretty much never did in the “old days”), so I had to develop these skills. 

That was written before the new rules make things worse – or better, depending on your perspective. On call days, I was much more of a presence, and offered my input much sooner, than in the past. On the post-call day, the resident (who is allowed to stay overnight but can work for only 28 consecutive hours) had to leave by 11 a.m. When she left, I morphed into the team’s res-attending. My interns were terrific, as was my resident, but, with each look to the attending for guidance on decisions that residents used to make completely independently, I could see the team’s autonomy slipping away.

Is that good or bad? Both. (And not just from the attending perspective – this superb essay, written by one of our 3rd year residents, Chris Moriates, and published in JGIM, offers a residents’-eye view of the new system.) Learning from one’s mistakes is fundamentally unethical when you have a human life in your hands. But an environment in which the housestaff are trained to read the attending’s body language before making a tough call can’t be right either, particularly when our third-year residents morph from resident to attending on June 30th each year. I often had to push myself to say, “Tell me what you’d like to do,” but it isn’t easy when you’re so busy, the duty hours clock is ticking, and the quickest path to the right answer is to offer it up yourself. As midnight draws near, Cinderella doesn’t have time to discuss the pathophysiology of pumpkins. She just needs to know where the staircase is.

A second worry is the relative dearth of patients being followed by a single resident from admission to denouement. Our teams inherited nearly half their patients as handoffs from night admitters. While some trainees forced themselves to rethink their patients’ problems and actively ward off anchoring bias, others didn’t, accepting what they were told as gospel and never coming to know the handed-off patients as well as those they admitted themselves. So many emergency admissions traverse a trajectory in which an early assessment is followed by a period of data gathering (tests, consults), followed by an initial patient response, which is evaluated in context. In a system in which half the patients are cared for by two sets of doctors during these crucial stages, neither group fully sees this arc play out, and their education suffers. While some handoffs are inevitable, I wonder if there is some way to drop the handoff percentage to more like one-third of all admissions. This feels like an intricate math problem – tough but soluble.

The other thing that worries me about the new schedules is the palpably limited time available for education. In the 16 days I spent as attending in January, I recall only two in which the entire team was available for our traditional hour-long teaching rounds. Sometimes I felt that my resident believed part of her job was to protect the rest of the team from the attending so that the interns could get their work done. I completely understand why that would be, but this is a terrible position for residents – and attendings – to be put in. We simply have to figure out how to bake in structured teaching rounds – maybe at 6 p.m. rather than 10 a.m. – lest we lose something very precious. And perhaps the hour-long chalk talk is no longer the optimal teaching forum for the Twitter generation; today’s trainees may need to learn through multiple small feedings rather than 500cc boluses. If so, that’s fine. But I’m confident that if we don’t hard wire teaching times into the daily schedule, then formal teaching will sink to the bottom of the priority list in the name of efficiency and duty hours. That would be a terrible loss.

Let’s not romanticize the old days. My schedule during internship was inhuman and dangerous. While the old rhythm had the virtues of continuity and more time for teaching, the costs in patient safety, housestaff burnout, and the credibility of the enterprise to a skeptical public were too high. A new system is welcome and needed. But those of us trusted to teach the next generation need to seek ways to mitigate its harms. If we don’t, we will have traded off some old problems for some powerful new ones – and the latter outcome could pay itself forward for generations to come.

8 Responses to “In Search of a New Rhythm on Today’s Wards”

  1. David Tribble, MD February 8, 2012 at 5:08 pm #

    I have loved the days and hours spent educating residents on clinical medicine services, and have likewise observed the change in ethos. My own training notwithstanding, I have to agree that I would not want to be cared for by any physician in his 30th consecutive hour of being awake.

    That said, I agree as well that we need to solve what appears to be a developing shift-worker mentality. It falls to us who do the teaching to hold our trainees accountable, to make a specific point of not simply accepting what the last physician said, but taking ownership of the patient’s care, regardless of how long that patient will be in a specific physician’s care. It has to do with what each of us is willing to have his/her name attached to, the development of a sound internal professional/ethical compass.

    Among other things, that means that we need to be sure those who teach possess such a compass themselves.

  2. vinny arora February 8, 2012 at 10:10 pm #

    Great post Bob -I def agree that attendings definitely need a new rhythm with the new system. One other thing that’s interesting with the EHR and cell phones is you are always connected. And there is a lot of communication (text, email, phone) and care going on outside of the hospital between covering residents and primary residents. As an attending signing notes late at home, its not uncommon for me to see something and call back to the night team. Initially, I thought this would be an unwelcome disturbance but residents who are cross covering and floating for your teams are often relieved when you call in and offer guidance. welcome back to the US too! vinny

  3. Menoalittle February 8, 2012 at 10:15 pm #

    Bob,

    I have not been able to determine from your presentation if you, or anyone, understand how to mitigate the harms in the new system, in which accountability is depreciated, and superficiality becomes the standard of care.

    Alas, do not worry. Help is on the way. Computers to the rescue.

    EHRs loaded up with clinical decision support and algorithms with universal order sets enable anyone (even chimpanzees) to click to provide the bare bones of medical care and meet the quality standards of CMS.

    These state of the art medical care directing machines are reputed to be so safe and efficient that the residents should have many extra hours to sit with you and pontificate the nuances of delirium.

    Best regards,

    Menoalittle

  4. Chris Johnson February 9, 2012 at 5:59 am #

    I’ve just turned 60, and was part of the generation that never saw an attending in the hospital after sundown. Or, with some attendings, after lunch. I agree with Bob that 36 hours in a row, which is what happens when an intern is on every other 24 hour period, is brutal and dangerous. I wasn’t married at the time and more or less lived in the hospital.

    But. But . . . now we are asking residents to learn more than we had to learn in the course of a residency that is, in effect, half as long. We’ve cut duty hours, but nobody wants to talk about extending residency to make up for the lost patient contact hours. And procedural skills really suffer. I’m an ICU doc, and by the time I finished residency in 1980 I could resuscitate pretty much anybody who could be resuscitated, and never missed getting an airway. Now residents can finish their training having personally intubated and gotten central vascular access on maybe a handful of patients. I see the difference in the patients I get sent from outside hospitals: the youngster docs (say under 40 or so) just can’t do that stuff reliably. This is a problem. Either we extend residency, or we figure out some way to teach procedural skills — maybe the newest simulation equipment will help.

  5. Adam February 12, 2012 at 5:27 pm #

    Bob-

    Our program has had this sort of structure for several years (resident teams admit during the day, night float takes over, then lots of handoffs in the AM).

    As you mention, in this new model the presence and input of the attending is much tighter with the team and dosed throughout the day. While there is certainly reduction in autonomy, I find the opportunity to mentor residents in operational issues (rather than just clinical decision making) is a huge benefit.

    As hospitalists, we have a relatively unique position within teaching hospitals. Many of us work on quality / operational performance improvement projects, EMR optimization, or organizational leadership roles. Thus, we have a great opportunity to transfer this experience with its insights to a new generation of docs who seem to understand the need for both operational and clinical excellence.

    I find real time teaching – bolused in 5-15 minute blocks – to be much more tolerable and effective for the residents. I like to get them in the habit of pulling up articles or UpToDate in real time to help make decisions, or think through ways to improve operations when a workaround presents itself. I’m convinced this is actually more effective and higher impact than the 1 hour teaching sessions of the past.

    Developing resident autonomy has in some ways been replaced with developing resident ability to get work done more effectively in the complex and changing hospital environment. Net-net, this is good.

    Best,
    Adam

  6. Brian Clay February 16, 2012 at 7:55 pm #

    Bob —

    A wonderful post (and Christopher’s essay in JGIM deserves high praise as well).

    The new paradigm basically forces attending physicians on the teaching service to be more mindful of the autonomy-supervision balance; overnight call without attendings in-house was more of an “autonomy by default” structure. I think we are all learning how to walk this tightrope, but I am still confident that resident autonomy can be developed under the new regulations.

    To those would say that the new rules have cut residency training time in half (or whatever your favorite percentage is for this statement), I have data: in moving from a traditional Q5 overnight call structure to a day team/night team structure (our residents do not stay overnight on the ward rotations), the average number of hours per week worked by interns went from 74 to 70. In addition, the teams are admitting the same number of patients as before; on the positive side, the peaks and valleys have been smoothed out, but on the other hand, more of the patients come to the team as holdovers admitted by the night team.

    One aspect of the new system that I think is quite favorable often goes unmentioned: for complex medical patients requiring consultative input or advanced testing the morning after admission, the team is actually around in the afternoon to discuss the recommendations with the consult team, or to see the MRI results, etc. All of that “first wave results” information that came in on the Post Call afternoon under the old system went to the res-attending, or to a float resident, but not to the primary team. Although people bemoan the new system because there is less ability to watch sick patients “evolve” over the first 12 hours of hospitalization, in reality most patients are relatively stable and unevolving, and many key decisions are made the afternoon of hospital day #1, when the primary team would previously have been gone, having reached the 30-hour limit.

    As to whether we can drop the handoff percentage to one-third of patients or fewer, this will not be possible unless we are willing to structure resident shifts to match admission patterns. I would imagine that at most hospitals, the bulk or peak of admissions comes during the evening hours. Unfortunately, it is also true that most hospitals have most of their ancillary and support services available during usual business hours. Usual business hours are also when patients expect to be discharged. The math problem is even tougher than you think.

    We are coming up on the point when the first crop of interns trained under the new rules are going to move on to be junior residents. This will be the real proof of the pudding. I, for one, am optimistic.

  7. steve walerstein February 20, 2012 at 3:20 pm #

    >Bob
    This blog certainly hit home. Having been an academic Hospitalist for twenty years before going to the dark side of administration, it was with both excitement and anxiety that i approached being on service in early february 2012 for the first time in a few years. The juices flowed, the bedside skills were rediscovered, and I learned about a whole bunch of new medications. When I read your blog on the ebb and flow of the new system, I was struck by how similar our experiences were. Being with your team while they are doing their admissions in the ER at 10PM was eye opening. And where were attending rounds, radiology rounds, and visits to pathology? All are relics of the past.

    As the CMO, I was hoping that being in the trenches would allow me to see first hand the inefficiencies and frustrations faced by the docs. Unfortunately, my presence contaminated the system. On our first day of call, our team admitted a patient w active RA who had eye pain. We discussed the Ddx and I said we should consult ophtho. The house staff rolled their eyes as their experience in obtaining ophtho consults was not exactly positive. So I emailed the chair, and 30 minutes later she emailed her impressions! In short order my team learned that once radiology heard a test was for my patient, it would done immediately. I think they are still using my name even though I am off service.

    Some other observations:

    – I think the physical exam is dead. The residents, and the mostly junior faculty, don’t have the skills and I see no reversal of this fact–and although I have been accused by at least one former trainee of being from the day of the leeches, I’m not sure if this is something we should fight. Despite my demonstration of egophony, valsalva affected murmurs, and shifting dullness, I’m not sure if any important diagnoses or decisions were based on these findings. I think the utility of the physical now lies in its ability to assess pre test probabilities, and to aid decision making as to the need for imaging.

    – bedside, handheld sono training should now be routine. My wife is an ER doc and uses sono daily to look for fluid, assess volume status, r/o pericardial dz and acute right heart strain, etc.

    -in contrast to the physical, history taking and communication skills are, if anything, more essential to the practice of medicine than ever. whether it be eiicting subtle cues, educating patients, coordinating with the health care team, or discussing advanced directives, our interpersonal communications determine quality, cost and outcomes

    -along those lines—-in our hospital 33 pct of the patients are non English speaking. That is typical of any hospital in the country. Having an English- only speaking physician community impairs the quality of care provided. Proficiency in a second language should be an admission requirement for medical schools. It is certainly more important than calculus.

    -the house staff are aware of the pressures of short LOS, but I am concerned they approach this with blinders and don’t “get” the big picture. They were puzzled for the first few days when I insisted all discharge presentations include an assessment of readmission risks and strategies to minimize. One of our local hospitals has a “post discharge rotation”-I think I need to learn more about that

    -as an administrator I always criticize our end of life care, and the number of patients who wind up with a “full court press”. It ain’t that easy

    -I’m a better CMO for having been on service, and will go on service quarterly

  8. Wagamama February 20, 2012 at 3:45 pm #

    Bob says:

    ” And perhaps the hour-long chalk talk is no longer the optimal teaching forum for the Twitter generation; today’s trainees may need to learn through multiple small feedings rather than 500cc boluses.”

    How convenient. Since most hospitalists I have worked with would struggle to fill 5 minutes with their entire fund of medical knowledge, let alone a full hour, this is a win-win-win all round.

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