1) After the resident work-hour restrictions were implemented in 2002, there has been more supervision during night float.
My take: Good for patient safety, bad for training. Being independent on the overnight cross-coverage team provided one of the best learning opportunities during residency.
2) The Cleveland Clinic’s medical school is going tuition free.
My take: Brilliant. These students will have substantially less debt burden than the average medical student. Hopefully their choice of specialty will have less of a financial motive, increasingly the likelihood they would choose a generalist field.
If this trend spreads, top-tier students will find medical school attractive again.
3) A reader writes: “I was reading the WSJ saw a full page color ad showing a father and his 3-year-old daughter, saying something like ‘when my daughter had a fever of 103 last night, I’m glad I got to speak to nurse instead of an answering machine’ . . .
. . . These kinds of programs, along with ‘disease management’ programs for e.g. asthma and diabetes, are bunch of crap. If anything, they only serve to further fracture care . . .
. . . I think these programs are really designed to avoid trips to the ER, and ultimately save insurers money.”
My take: Couple of points here.
Not all physician offices use answering machines off-hours. Patients in my practice can reach a doctor 24 hours a day.
I agree that one goal of telephone triage is to reduce ED visits, and thus costs. Liability however, becomes an obstacle, as it is impossible to diagnose accurately over the phone. Can you be 100% sure that the child with the 103 degree fever didn’t have meningitis? If the health insurer is willing to accept all malpractice liability for their off-hours telephone triage service, I have no problems with it.
Disease management programs certainly have their place. Working in conjunction with a primary care physician, they can be helpful adjuncts to ensure that patients are up to date with lab tests and are taking their medications.
Problems arise when they intervene with therapeutic decisions independent of the physician. Having a clear, centralized decision maker is a necessity when multiple providers and nurses are caring for the patient.
Related posts:
- Night float
- Would you accept a lower salary if you could graduate from medical school debt free?
- Free medical school
- Diagnosis to chronic disease management
- Surviving night float
- Momma in triage
- Making night float easier
{ 9 comments }
We’ve got 24hour call and all of my phone advice ends with “I can’t definatively diagnose this over the phone so if anything changes or gets worse call me back”
I have that kind of coverage and I like it.
Sometimes if your child is sick all sensibility goes out the door. Maybe tylenol would help!
It’s nice to have someone to call. The do tend to run you through what seems like a computer generated series of questions, and overall I think they drag you in more often than is strictly necessary.
If I thought I was going to be waking the Doctor up I wouldn’t call at all. With this I know somebody is there, on the the payroll and I’m not waking them up or interrupting something else that’s more important.
The main thing I remember about nights in the hospital after my surgery was repeatedly hearing the line “the covering resident really doesn’t like to change anything at night.” This applied both to changing an IV rate (because they were pumping fluid into me so fast I had to go to the bathroom every 2 hours, something I could not do without assistance), and ordering more pain medication when I didn’t have enough (CT came for you in the middle of the night- ouch). Good for training, bad for patients. I was utterly terrified of nighttime in that place. More supervision doesn’t seem like such a bad thing.
I wonder if the Clinic’s move will reduce the number of med school graduates who work in underserved areas in hopes of having their loans repayed.
I think the future is that medical schools will have to pay students to attend. Keep in mind that many health care entities are structured as nonprofit organizations for tax purposes. Granting full-tuition scholarships to each medical student may go a long way towards offsetting behaviors jeopardizing that status and is cheaper than charity care. The answer is not cheaper or no medical school tuition, it is not loan repayment or forgiveness. It is market return on investment via fees collected and tax credits for charitable care.
Cleveland Clinic is geared toward producing physician scientists. Most (all?) students take a year for research. I doubt many of them become generalists.
Sorry kevin I disagree (and I graduated long before you). There SHOULD be night float and more attending backup. Frankly, before the hour rule, working residents to death was nothing more than an excuse for academic attending laziness. You tell me kevin, if there are strict hour limits on pilots and truck drivers, why shouldn’t there be at least some half-hearted (remember the limit is ONLY 80 hours per week) to allow doctors in training adequate time for sleep. Or another way kevin, would you want your wife, or child taken care of by some R1 or R2 after there 36th-40th hour of work? I wouldn’t and I’ve done it (in training and the real world).
Anon 2:24- I am of your generation (MD 1981) and trained in the old school. Yes I was tired, and occasionally made mistakes that were caught and corrected by my senior resident because they were held responsible (by the attending MDs) for the errors of their underlings (I still remember one of them telling me every night I worked under his supervision “call me for everything“). That is the best training and the safest for patients also. What I don’t want is my wife or child taken care of by a theoretically fully trained doc who was trained under a system where she learned that her responsibility to her patient ends by the clock, not by when the patient is no longer sick.
jb:
If you are truly old school then you know the academic attendings were never around after hours when the $hit hit the fan. Yes some senior residents are good, some sucked, frankly a year or two of additional residency under your belt is not the same thing as being in practice say 10-20 years. Look, I am not saying that attendings should be holding the residents hands. I am saying they should be involved in tough confusing decisions and management issues that may be out of the realm of knowledge of residents. Isn’t that what good patient care is about? As far as the hour limits, I can’t tell you how many hundreds of hours I waited around post call for a gift of God academic attending to finish his research or whatever meetings before rounding. The amount of time simply wasted in residency is enormous. If there is one good thing to this hour process (besides minimizing sleep deprivation), residencies are actually looking at minimizing wasted time. Frankly after 30 hours stright (the current hourly limit), I know I am not at my best. Maybe you are a superman, but recent studies have shown the increased error rate in sleep-deprived medical residents. Every other profession requires some type of humanistic treatment of it’s employees/trainees, why should medicine be different? No study I have seen yet shows a detriment to resident education no matter what us “old timers” may think. I guess time will tell.
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