Stop calling doctors fleas and teaching professionalism

At the recent AAMC meeting on how to integrate quality into teaching hospitals, the question that kept popping up from speaker after speaker was how to address the fact that doctors in teaching hospitals don’t get along.

Unfortunately, all the specialty bashing that takes place prevents the adoption of a team based culture necessary to advance quality and safety.  As one speaker highlighted, how can we really start to address this topic when specialty services are busy blocking the consult or disparaging the internal medicine doctor by calling them a ‘flea.’

I hadn’t heard the term ‘flea’ in awhile but many onlookers were nodding in agreement, possibly thinking about the last time they heard someone disparaging the ER for an incomplete workup or a specialist blocking the consult as ‘inappropriate.’  The discussion about quality and safety morphed into every medical educator’s favorite topic, ‘professionalism.’

Ironically, while medical educators love discussing professionalism, this word has become despised by medical students.  It has been the subject of the last 2 years of senior class shows at Pritzker.  Why?  Because in response to numerous calls by the AAMC and other groups including the public, Pritzker, like many other schools, have launched a professionalism initiative designed to promote professionalism.

As you can guess, any efforts to ‘teach professionalism’ to students seem preachy and insincere.  So, what’s a medical educator to do?

After years of contemplating this problem with colleagues and experts, we concluded that we first need to identify and reward faculty role models and ensure that our faculty and residents emulate the behaviors that we wish to see in our students.  Apparently, we aren’t alone.

The American Board of Internal Medicine Foundation has awarded 6 grants to variety of organizations to promote professionalism among physicians in practice.  We are fortunate to have received funding through this mechanism to actually address the topic at hand — specialty bashing in teaching hospitals — particularly between hospitalists, primary care physicians, and emergency medicine doctors.

Interestingly, this problem is more prevalent in teaching hospitals.  When our residents rotate at a nearby community hospital, they often comment on how nice the doctors are to each other, even thanking them for consultations.  Of course, unlike the attendings in teaching hospitals on fixed salary, physicians in the community hospital actually make more money for each consultation.  So, aligning financial incentives can actually promote professionalism.

I was at this meeting with one of our 2nd year medical students who earned rave reviews for his presentation on student efforts in teaching quality and safety at Pritzker (while I may be biased, you can see his presentation for yourself.) On the way home, we noted that although professionalism is a dirty word among our students, but that medical educators continue to perseverate on it even at a meeting about quality and safety.  We need a better word and a better way to address these issues.  Because most students are professional, it’s the actions of a few that are remembered by faculty and attributed to all students and their generation.

On a side note, Marcus also asked me why medicine doctors are called ‘fleas’ since he had not heard that term…yet.   I did not know the answer but here are some potential origins I found – the most useful of sources being

  • Internists can be spotted with a stethoscope around their neck, or a ‘flea’ collar
  • Internists, like fleas, are the last things to leave a dying body
  • They travel in packs on rounds
  • Doctors were very devoted to their plague patients, similar to fleas that were responsible for spreading the deadly disease.

While I don’t know the exact reason, it’s interesting that while 3 of the reasons are clearly derogatory, one explanation of ‘fleas’ actually highlights ‘professionalism.’ Ironically, maybe all we have to do to get doctors to stop using this term is to say that it’s part of that dirty p word ‘professionalism.’

Vineet Arora is an internal medicine physician who blogs at FutureDocs.

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  • Dr. J

    As a community doctor I occasionally need to phone and send a patient to the ‘Man’s Best Hospital’ and many of these phone calls remind me of this sort of anti-collegial behavior. I work in a medium community hospital where the docs are nice, live normal lives, go home to their families at the end of the day and help each other out.
    I think the doctors at the MBH think anyone in the community is there because they are in exile, because they weren’t bright enough for academia. Really we are just regular nice folk who didn’t like the shenanigans and backstabbing at the MBH.
    Instead of trying to correct this issue, which has been going on for many decades, perhaps we should just consider sending our trainees to the community for a few months so that they know there are other options when they finish training?

  • solo dr

    Many of the academic docs would rather spend time doing research for articles than see patients. In med school and residency, the primary care attendings averaged 2-4 total days/month of outpatient clinic and 1 month each year of inpatient rounding. Most of the time they simply wrote agree with above and cosigned our notes. They were available for teaching and research during their downtime. They also are paid about 30% less than private doctors, who work routinely 60+ hour weeks year round. Academic docs did have the freedom to spend extra time with patients, but the arguments over this journal article states this but then this journal article states something else made rounds endless and often low yield. When I did inpatient rotations, rounds would last 1 hour with the residents/students only and often 2-3 hours to simply discuss 10 patients. In private practice, nothing would get done if we had the pace of academic docs. As a final note, a local university Geriatrics clinic sees four patients twice a week and books 6 months out, telling families they are too busy to see patients.

  • Pete

    That’s funny and so true. Those that hide behind the ivory towers (MBH) really behave that way. However, I think we (community docs) tend to think of them the way they think of us. It’s been my experience that the very best residents ended up in the community and those that couldn’t hack it in residency stayed at MBH. We always said it was a combination of laziness and personality disorder that kept them out of community medicine. Granted, my points and views are probably as valid as theirs are of us.

  • Trader

    Fleas are the last ones to jump off a dying dog…

    Kinda like ‘Blades’ huh?

  • Dr. Mary Johnson

    “Flea” doesn’t bother me so much. Badge of honor and all that.

    But “dime-a-dozen” REALLY pissed me off. Of course, that was not a doctor talking . . . it was a non-profit hospital executive.

  • Doc D

    So, do we want physician “hate speech” codes like some of our universities? Moralizing and preaching usually doesn’t have more than a temporary impact. You need real regulation to get PC behavior.

    Maybe the parisanship (what a word) has increased since my training day. I never saw these terms (“fleas”) as more than locker room give-and-take. But that was then…

  • jsmith

    Get highly competitive people, put them in a high pressure environment and a frequently adversarial relationship and then expect them not to backbite or complain about each other. Good luck with that.

  • Jill

    When I worked at a hospital this was a big problem – not just the not getting along with each other, but the constant competition – and it doesn’t have to be teaching hospitals.

  • rezmed09

    I usually don’t find the disparaging remarks coming from the attendings, but rather the younger docs in training.

    Higher pay for “fleas” would erase this issue, and If the the “fleas” were the docs that everyone wanted to be it wouldn’t matter what nickname the specialty were given.

  • Anon

    The problem is the medicine/ED doctors consults specialists for things they don’t want to do. Patient has a bad headache- consult neurology even before examining the patient- so they (ED/medicine) don’t have to think about it. I think this is inappropriate. If you did your stuff and consulted us only if you still needed help, that is fine.

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