User login
Rules for performing research with children
The road to hell is paved with good intentions – especially true in clinical research. A Food and Drug Administration press release notes, “Historically, children were not included in clinical trials because of a misperception that excluding them from research was in fact protecting them. This resulted in many FDA-approved, licensed, cleared, or authorized drugs, biological products, and medical devices lacking pediatric-specific labeling information.” In an effort to improve on this situation, the FDA published in September 2022 a proposed new draft guidance on performing research with children that is open for public comment for 3 months.
There is a long history of government attempts to promote research and development for the benefit of society. Sometimes government succeeds and sometimes not. For instance, when the U.S. federal government funded scientific research in the 1960s, it sought to increase the common good by promulgating those discoveries. The government insisted that all federally funded research be in the public domain. The funding produced a spectacular number of technological advancements that have enriched society. However, a decade later, the government concluded that too many good research ideas were never developed into beneficial products because without the ability to patent the results, the costs and risks of product development were not profitable for industry. By the late 1970s, new laws were enacted to enable universities and their faculty to patent the results of government-funded research and share in any wealth created.
Pharmaceutical research in the 1970s and 1980s was mostly performed on men in order to reduce the risk of giving treatments of unknown safety to pregnant women. The unintended consequence was that the new drugs frequently were less effective for women. This was particularly true for cardiac medications for which lifestyle risk factors differed between the sexes.
Similarly, children were often excluded from research because of the unknown risks of new drugs on growing bodies and brains. Children were also seen as a vulnerable population for whom informed consent was problematic. The result of these well-intentioned restrictions was the creation of new products that did not have pediatric dosing recommendations, pediatric safety assessments, or approval for pediatric indications. To remediate these deficiencies, in 1997 and 2007 the FDA offered a 6-month extension on patent protection as motivation for companies to develop those pediatric recommendations. Alas, those laws were primarily used to extend the profitability of blockbuster products rather than truly benefit children.
Over the past 4 decades, pediatric ethicists proposed and refined rules to govern research on children. The Common Rule used by institutional review boards (IRBs) to protect human research subjects was expanded with guidelines covering children. The new draft guidance is the latest iteration of this effort. Nothing in the 14 pages of draft regulation appears revolutionary to me. The ideas are tweaks, based on theory and experience, of principles agreed upon 30 years ago. Finding the optimal social moral contract involves some empirical assessment of praxis and effectiveness.
I am loathe to summarize this new document, which itself is a summary of a vast body of literature, that supports the Code of Federal Regulations Title 21 Part 50 and 45 CFR Part 46. The draft document is well organized and I recommend it as an excellent primer for the area of pediatric research ethics if the subject is new to you. I also recommend it as required reading for anyone serving on an IRB.
IRBs usually review and approve any research on people. Generally, the selection of people for research should be done equitably. However, children should not be enrolled unless it is necessary to answer an important question relevant to children. For the past 2 decades, there has been an emphasis on obtaining the assent of the child as well as informed consent by the parents.
An important determination is whether the research is likely to help that particular child or whether it is aimed at advancing general knowledge. If there is no prospect of direct benefit, research is still permissible but more restricted for safety and comfort reasons. Next is determining whether the research carries only minimal risk or a minor increase over minimal risk. The draft defines and provides anchor examples of these situations. For instance, oral placebos and single blood draws are typically minimal risk. Multiple injections and blood draws over a year fall into the second category. One MRI is minimal risk but a minor increase in risk if it involves sedation or contrast.
I strongly support the ideals expressed in these guidelines. They represent the best blend of intentions and practical experience. They will become the law of the land. In ethics, there is merit in striving to do things properly, orderly, and enforceably.
The cynic in me sees two weaknesses in the stated approach. First, the volume of harm to children occurring during organized clinical research is extremely small. The greater harms come from off-label use, nonsystematic research, and the ignorance resulting from a lack of research. Second, my observation in all endeavors of morality is, “Raise the bar high enough and people walk under it.”
Dr. Powell is a retired pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.
The road to hell is paved with good intentions – especially true in clinical research. A Food and Drug Administration press release notes, “Historically, children were not included in clinical trials because of a misperception that excluding them from research was in fact protecting them. This resulted in many FDA-approved, licensed, cleared, or authorized drugs, biological products, and medical devices lacking pediatric-specific labeling information.” In an effort to improve on this situation, the FDA published in September 2022 a proposed new draft guidance on performing research with children that is open for public comment for 3 months.
There is a long history of government attempts to promote research and development for the benefit of society. Sometimes government succeeds and sometimes not. For instance, when the U.S. federal government funded scientific research in the 1960s, it sought to increase the common good by promulgating those discoveries. The government insisted that all federally funded research be in the public domain. The funding produced a spectacular number of technological advancements that have enriched society. However, a decade later, the government concluded that too many good research ideas were never developed into beneficial products because without the ability to patent the results, the costs and risks of product development were not profitable for industry. By the late 1970s, new laws were enacted to enable universities and their faculty to patent the results of government-funded research and share in any wealth created.
Pharmaceutical research in the 1970s and 1980s was mostly performed on men in order to reduce the risk of giving treatments of unknown safety to pregnant women. The unintended consequence was that the new drugs frequently were less effective for women. This was particularly true for cardiac medications for which lifestyle risk factors differed between the sexes.
Similarly, children were often excluded from research because of the unknown risks of new drugs on growing bodies and brains. Children were also seen as a vulnerable population for whom informed consent was problematic. The result of these well-intentioned restrictions was the creation of new products that did not have pediatric dosing recommendations, pediatric safety assessments, or approval for pediatric indications. To remediate these deficiencies, in 1997 and 2007 the FDA offered a 6-month extension on patent protection as motivation for companies to develop those pediatric recommendations. Alas, those laws were primarily used to extend the profitability of blockbuster products rather than truly benefit children.
Over the past 4 decades, pediatric ethicists proposed and refined rules to govern research on children. The Common Rule used by institutional review boards (IRBs) to protect human research subjects was expanded with guidelines covering children. The new draft guidance is the latest iteration of this effort. Nothing in the 14 pages of draft regulation appears revolutionary to me. The ideas are tweaks, based on theory and experience, of principles agreed upon 30 years ago. Finding the optimal social moral contract involves some empirical assessment of praxis and effectiveness.
I am loathe to summarize this new document, which itself is a summary of a vast body of literature, that supports the Code of Federal Regulations Title 21 Part 50 and 45 CFR Part 46. The draft document is well organized and I recommend it as an excellent primer for the area of pediatric research ethics if the subject is new to you. I also recommend it as required reading for anyone serving on an IRB.
IRBs usually review and approve any research on people. Generally, the selection of people for research should be done equitably. However, children should not be enrolled unless it is necessary to answer an important question relevant to children. For the past 2 decades, there has been an emphasis on obtaining the assent of the child as well as informed consent by the parents.
An important determination is whether the research is likely to help that particular child or whether it is aimed at advancing general knowledge. If there is no prospect of direct benefit, research is still permissible but more restricted for safety and comfort reasons. Next is determining whether the research carries only minimal risk or a minor increase over minimal risk. The draft defines and provides anchor examples of these situations. For instance, oral placebos and single blood draws are typically minimal risk. Multiple injections and blood draws over a year fall into the second category. One MRI is minimal risk but a minor increase in risk if it involves sedation or contrast.
I strongly support the ideals expressed in these guidelines. They represent the best blend of intentions and practical experience. They will become the law of the land. In ethics, there is merit in striving to do things properly, orderly, and enforceably.
The cynic in me sees two weaknesses in the stated approach. First, the volume of harm to children occurring during organized clinical research is extremely small. The greater harms come from off-label use, nonsystematic research, and the ignorance resulting from a lack of research. Second, my observation in all endeavors of morality is, “Raise the bar high enough and people walk under it.”
Dr. Powell is a retired pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.
The road to hell is paved with good intentions – especially true in clinical research. A Food and Drug Administration press release notes, “Historically, children were not included in clinical trials because of a misperception that excluding them from research was in fact protecting them. This resulted in many FDA-approved, licensed, cleared, or authorized drugs, biological products, and medical devices lacking pediatric-specific labeling information.” In an effort to improve on this situation, the FDA published in September 2022 a proposed new draft guidance on performing research with children that is open for public comment for 3 months.
There is a long history of government attempts to promote research and development for the benefit of society. Sometimes government succeeds and sometimes not. For instance, when the U.S. federal government funded scientific research in the 1960s, it sought to increase the common good by promulgating those discoveries. The government insisted that all federally funded research be in the public domain. The funding produced a spectacular number of technological advancements that have enriched society. However, a decade later, the government concluded that too many good research ideas were never developed into beneficial products because without the ability to patent the results, the costs and risks of product development were not profitable for industry. By the late 1970s, new laws were enacted to enable universities and their faculty to patent the results of government-funded research and share in any wealth created.
Pharmaceutical research in the 1970s and 1980s was mostly performed on men in order to reduce the risk of giving treatments of unknown safety to pregnant women. The unintended consequence was that the new drugs frequently were less effective for women. This was particularly true for cardiac medications for which lifestyle risk factors differed between the sexes.
Similarly, children were often excluded from research because of the unknown risks of new drugs on growing bodies and brains. Children were also seen as a vulnerable population for whom informed consent was problematic. The result of these well-intentioned restrictions was the creation of new products that did not have pediatric dosing recommendations, pediatric safety assessments, or approval for pediatric indications. To remediate these deficiencies, in 1997 and 2007 the FDA offered a 6-month extension on patent protection as motivation for companies to develop those pediatric recommendations. Alas, those laws were primarily used to extend the profitability of blockbuster products rather than truly benefit children.
Over the past 4 decades, pediatric ethicists proposed and refined rules to govern research on children. The Common Rule used by institutional review boards (IRBs) to protect human research subjects was expanded with guidelines covering children. The new draft guidance is the latest iteration of this effort. Nothing in the 14 pages of draft regulation appears revolutionary to me. The ideas are tweaks, based on theory and experience, of principles agreed upon 30 years ago. Finding the optimal social moral contract involves some empirical assessment of praxis and effectiveness.
I am loathe to summarize this new document, which itself is a summary of a vast body of literature, that supports the Code of Federal Regulations Title 21 Part 50 and 45 CFR Part 46. The draft document is well organized and I recommend it as an excellent primer for the area of pediatric research ethics if the subject is new to you. I also recommend it as required reading for anyone serving on an IRB.
IRBs usually review and approve any research on people. Generally, the selection of people for research should be done equitably. However, children should not be enrolled unless it is necessary to answer an important question relevant to children. For the past 2 decades, there has been an emphasis on obtaining the assent of the child as well as informed consent by the parents.
An important determination is whether the research is likely to help that particular child or whether it is aimed at advancing general knowledge. If there is no prospect of direct benefit, research is still permissible but more restricted for safety and comfort reasons. Next is determining whether the research carries only minimal risk or a minor increase over minimal risk. The draft defines and provides anchor examples of these situations. For instance, oral placebos and single blood draws are typically minimal risk. Multiple injections and blood draws over a year fall into the second category. One MRI is minimal risk but a minor increase in risk if it involves sedation or contrast.
I strongly support the ideals expressed in these guidelines. They represent the best blend of intentions and practical experience. They will become the law of the land. In ethics, there is merit in striving to do things properly, orderly, and enforceably.
The cynic in me sees two weaknesses in the stated approach. First, the volume of harm to children occurring during organized clinical research is extremely small. The greater harms come from off-label use, nonsystematic research, and the ignorance resulting from a lack of research. Second, my observation in all endeavors of morality is, “Raise the bar high enough and people walk under it.”
Dr. Powell is a retired pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.
The future of pediatrics
Things will change. That is a constant. The practice of pediatrics will be different in the future. The pandemic has changed some things; mostly it has accelerated changes, advancements, improvements, and losses that were already occurring. Telemedicine will play a more prominent role in the future. The finances of solo and small-group practice have become more difficult.
As I wrote my prior column on the character traits/virtues of an admirable physician, I also began brainstorming this column on the traits of an admirable profession. Then the American Academy of Pediatrics’ virtual National Conference & Exhibition had many presentations encouraging pediatricians to adopt a conglomeration of activities in their offices. I became skeptical. Which should be selected? To make a wise choice, I review the major goals of medicine, which I have evolved to embrace as the quadruple aims.
First and hopefully always foremost, the health professions are dedicated to the health of their patients and, hopefully, the population at large. This trait dates to the Hippocratic Oath.
Second, physicians have a stewardship over a vast collection of knowledge, skills, resources, and funds. When I started my career, U.S. health care had increased from 6% of the gross domestic product to 9%, nearly twice that of other developed nations, and was expanding rapidly, contributing to widespread economic problems including the national debt. The health economists of the 1980’s made dire predictions that the nation was headed up to 12% of the GDP, which would cause the sky to start falling. Last I checked U.S. health care is approaching 18% of the GDP. The sky seems intact, although the oceans are rising and the hillsides are burning.
Managed care of the 1990s became focused on the consumer experience. Evaluations of physicians and nurses became dependent on consumer surveys. I recall one survey about the care I personally had received as day surgery. It was mostly about scheduling, being greeted on arrival, the waiting room, and other fluff. Only 1 of the over 20 questions had any bearing on whether I thought the diagnosis was correct, the treatment was effective, or my physician was competent. As a cancer patient, my priorities were not aligned with that survey’s concept of quality.
From 2008, I recall the Triple Aim: “Improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care.”
Over the ensuing decade, physician wellness has been added to make a quadruple aim. If the system isn’t professionally rewarding, burnout occurs. Skills and experience are lost. The best and brightest are not attracted to the specialty. Quality goes down. So physicians must factor this into decisions about the future of pediatrics.
There are many social determinants of health that have large impacts on the population health of children, and it does not necessarily follow that I should spend my patient care time on those determinants. As a professional, I have a responsibility to ensure that I am treating important problems that match my extensive (and expensive) training, knowledge, skills, and experience.
I recently read a persuasive argument that caring for ADHD is an important and doable part of modern general pediatrics. I agree, but I agreed with the proponent’s idea 25 years ago when I joined a large group and saw my own ADHD patients. Change can be slow.
Pharmacology options for anxiety have become safer, more effective, and better understood in children. General pediatricians may now be able to provide important, earlier, and accessible intervention for pediatric anxiety and other mental health issues.
Food insecurity is a worsening issue during the pandemic, but not one which I have specialized abilities to address. A brochure listing available local resources could be posted in waiting rooms and exam rooms. Is spending time asking about it during a visit the best use of a pediatrician’s time? That is a choice a professional needs to make. It may depend on your patient panel and community resources. In the past, I was more inclined to focus on medical care and donate the extra income to my church’s food bank. But the world has changed. Perhaps the pediatrician’s office of the 2020s is a department store, with social workers, psychologists, and therapists located under the same roof. It reminds me of the Mayo model. Wealthy people would travel to Rochester for an executive physical. That physical would frequently recommend seeing a couple specialists before leaving town. It is an effective model but also luxurious.
Racism causes major harms, both to physical health and mental health. Is asking about it a wise use of limited time for well-child visits? What resources will you offer?
Climate change, hurricanes, and wildfires are harming children. Is debating the issue with your patient’s parents productive? I am zealous about the topic. I spend considerable time and money promoting the credibility of science within various religious organizations, but I try to avoid bringing politics into my interactions with patients.
As a professional, your choices may be different. Many people are telling you what you should care about. The executive well-child visit would be beneficial, but it would also take 2 hours. Don’t be misled into spending too much effort on issues not in your expertise. Choose wisely.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at pdnews@mdedge.com.
Things will change. That is a constant. The practice of pediatrics will be different in the future. The pandemic has changed some things; mostly it has accelerated changes, advancements, improvements, and losses that were already occurring. Telemedicine will play a more prominent role in the future. The finances of solo and small-group practice have become more difficult.
As I wrote my prior column on the character traits/virtues of an admirable physician, I also began brainstorming this column on the traits of an admirable profession. Then the American Academy of Pediatrics’ virtual National Conference & Exhibition had many presentations encouraging pediatricians to adopt a conglomeration of activities in their offices. I became skeptical. Which should be selected? To make a wise choice, I review the major goals of medicine, which I have evolved to embrace as the quadruple aims.
First and hopefully always foremost, the health professions are dedicated to the health of their patients and, hopefully, the population at large. This trait dates to the Hippocratic Oath.
Second, physicians have a stewardship over a vast collection of knowledge, skills, resources, and funds. When I started my career, U.S. health care had increased from 6% of the gross domestic product to 9%, nearly twice that of other developed nations, and was expanding rapidly, contributing to widespread economic problems including the national debt. The health economists of the 1980’s made dire predictions that the nation was headed up to 12% of the GDP, which would cause the sky to start falling. Last I checked U.S. health care is approaching 18% of the GDP. The sky seems intact, although the oceans are rising and the hillsides are burning.
Managed care of the 1990s became focused on the consumer experience. Evaluations of physicians and nurses became dependent on consumer surveys. I recall one survey about the care I personally had received as day surgery. It was mostly about scheduling, being greeted on arrival, the waiting room, and other fluff. Only 1 of the over 20 questions had any bearing on whether I thought the diagnosis was correct, the treatment was effective, or my physician was competent. As a cancer patient, my priorities were not aligned with that survey’s concept of quality.
From 2008, I recall the Triple Aim: “Improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care.”
Over the ensuing decade, physician wellness has been added to make a quadruple aim. If the system isn’t professionally rewarding, burnout occurs. Skills and experience are lost. The best and brightest are not attracted to the specialty. Quality goes down. So physicians must factor this into decisions about the future of pediatrics.
There are many social determinants of health that have large impacts on the population health of children, and it does not necessarily follow that I should spend my patient care time on those determinants. As a professional, I have a responsibility to ensure that I am treating important problems that match my extensive (and expensive) training, knowledge, skills, and experience.
I recently read a persuasive argument that caring for ADHD is an important and doable part of modern general pediatrics. I agree, but I agreed with the proponent’s idea 25 years ago when I joined a large group and saw my own ADHD patients. Change can be slow.
Pharmacology options for anxiety have become safer, more effective, and better understood in children. General pediatricians may now be able to provide important, earlier, and accessible intervention for pediatric anxiety and other mental health issues.
Food insecurity is a worsening issue during the pandemic, but not one which I have specialized abilities to address. A brochure listing available local resources could be posted in waiting rooms and exam rooms. Is spending time asking about it during a visit the best use of a pediatrician’s time? That is a choice a professional needs to make. It may depend on your patient panel and community resources. In the past, I was more inclined to focus on medical care and donate the extra income to my church’s food bank. But the world has changed. Perhaps the pediatrician’s office of the 2020s is a department store, with social workers, psychologists, and therapists located under the same roof. It reminds me of the Mayo model. Wealthy people would travel to Rochester for an executive physical. That physical would frequently recommend seeing a couple specialists before leaving town. It is an effective model but also luxurious.
Racism causes major harms, both to physical health and mental health. Is asking about it a wise use of limited time for well-child visits? What resources will you offer?
Climate change, hurricanes, and wildfires are harming children. Is debating the issue with your patient’s parents productive? I am zealous about the topic. I spend considerable time and money promoting the credibility of science within various religious organizations, but I try to avoid bringing politics into my interactions with patients.
As a professional, your choices may be different. Many people are telling you what you should care about. The executive well-child visit would be beneficial, but it would also take 2 hours. Don’t be misled into spending too much effort on issues not in your expertise. Choose wisely.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at pdnews@mdedge.com.
Things will change. That is a constant. The practice of pediatrics will be different in the future. The pandemic has changed some things; mostly it has accelerated changes, advancements, improvements, and losses that were already occurring. Telemedicine will play a more prominent role in the future. The finances of solo and small-group practice have become more difficult.
As I wrote my prior column on the character traits/virtues of an admirable physician, I also began brainstorming this column on the traits of an admirable profession. Then the American Academy of Pediatrics’ virtual National Conference & Exhibition had many presentations encouraging pediatricians to adopt a conglomeration of activities in their offices. I became skeptical. Which should be selected? To make a wise choice, I review the major goals of medicine, which I have evolved to embrace as the quadruple aims.
First and hopefully always foremost, the health professions are dedicated to the health of their patients and, hopefully, the population at large. This trait dates to the Hippocratic Oath.
Second, physicians have a stewardship over a vast collection of knowledge, skills, resources, and funds. When I started my career, U.S. health care had increased from 6% of the gross domestic product to 9%, nearly twice that of other developed nations, and was expanding rapidly, contributing to widespread economic problems including the national debt. The health economists of the 1980’s made dire predictions that the nation was headed up to 12% of the GDP, which would cause the sky to start falling. Last I checked U.S. health care is approaching 18% of the GDP. The sky seems intact, although the oceans are rising and the hillsides are burning.
Managed care of the 1990s became focused on the consumer experience. Evaluations of physicians and nurses became dependent on consumer surveys. I recall one survey about the care I personally had received as day surgery. It was mostly about scheduling, being greeted on arrival, the waiting room, and other fluff. Only 1 of the over 20 questions had any bearing on whether I thought the diagnosis was correct, the treatment was effective, or my physician was competent. As a cancer patient, my priorities were not aligned with that survey’s concept of quality.
From 2008, I recall the Triple Aim: “Improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care.”
Over the ensuing decade, physician wellness has been added to make a quadruple aim. If the system isn’t professionally rewarding, burnout occurs. Skills and experience are lost. The best and brightest are not attracted to the specialty. Quality goes down. So physicians must factor this into decisions about the future of pediatrics.
There are many social determinants of health that have large impacts on the population health of children, and it does not necessarily follow that I should spend my patient care time on those determinants. As a professional, I have a responsibility to ensure that I am treating important problems that match my extensive (and expensive) training, knowledge, skills, and experience.
I recently read a persuasive argument that caring for ADHD is an important and doable part of modern general pediatrics. I agree, but I agreed with the proponent’s idea 25 years ago when I joined a large group and saw my own ADHD patients. Change can be slow.
Pharmacology options for anxiety have become safer, more effective, and better understood in children. General pediatricians may now be able to provide important, earlier, and accessible intervention for pediatric anxiety and other mental health issues.
Food insecurity is a worsening issue during the pandemic, but not one which I have specialized abilities to address. A brochure listing available local resources could be posted in waiting rooms and exam rooms. Is spending time asking about it during a visit the best use of a pediatrician’s time? That is a choice a professional needs to make. It may depend on your patient panel and community resources. In the past, I was more inclined to focus on medical care and donate the extra income to my church’s food bank. But the world has changed. Perhaps the pediatrician’s office of the 2020s is a department store, with social workers, psychologists, and therapists located under the same roof. It reminds me of the Mayo model. Wealthy people would travel to Rochester for an executive physical. That physical would frequently recommend seeing a couple specialists before leaving town. It is an effective model but also luxurious.
Racism causes major harms, both to physical health and mental health. Is asking about it a wise use of limited time for well-child visits? What resources will you offer?
Climate change, hurricanes, and wildfires are harming children. Is debating the issue with your patient’s parents productive? I am zealous about the topic. I spend considerable time and money promoting the credibility of science within various religious organizations, but I try to avoid bringing politics into my interactions with patients.
As a professional, your choices may be different. Many people are telling you what you should care about. The executive well-child visit would be beneficial, but it would also take 2 hours. Don’t be misled into spending too much effort on issues not in your expertise. Choose wisely.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He has no relevant financial disclosures. Email him at pdnews@mdedge.com.
Making and using guidelines
Modern medicine increasingly relies on the adoption and use of guidelines.
Forty years ago, medicine was like free-form, rhythmic gymnastics in which physicians would develop an artisanal treatment plan for each patient. Now, medicine frequently involves recognizing when we need to do a triple-twisting, double-back somersault (the Biles II) and then performing it. The belief is that better outcomes flow from reduced variability in diagnostic and treatment plans, based on guidelines developed from evidence-based medicine from large meta-analyses. This dogma, still unproven in real life, probably works best for 95% of patients. The physician must not omit a step of deciding whether their particular patient is one of the 5% of patients to whom the guideline does not apply.
To be useful, the guidelines must be based on accurate science, produce a significantly positive cost-benefit-risk analysis, be wisely constructed, and be clearly written.
Alas, many guidelines fall far short of this ideal, and when they fail, they impugn all of medical care, they lower the credibility of the organizations that issue them, and they lower the public’s trust in medicine, which thereby impedes improving the public health. Don’t sweat the small stuff for public health guidelines.
The science matters. Nutritional guidelines have been particularly rickety, as John P.A. Ioannidis, MD, wrote in a JAMA op-ed 1 year ago.1 For instance, previous dietary recommendations to reduce cholesterol by avoiding eggs have since been shown to be wrong. The recommendation for reducing salt intake has been heavily criticized. Now the decades-long condemnation of red meat has been challenged. New “guidelines,” suggested by one group (let’s view it as a minority report that contradicts many official guidelines) in the October 1, 2019, issue of Annals of Internal Medicine, say that red meat and processed meats aren’t the boogeyman.2 The authors of the accompanying editorial are from the Center for Pediatric and Adolescent Comparative Effectiveness Research at Indiana University, Indianapolis.3 The editorial supports the new study, criticizing past recommendations because “the field of nutritional epidemiology is plagued by observational studies that have conducted inappropriate analyses, accompanied by likely erroneous conclusions.”
Clarity also matters. One factor in the current opiate epidemic was guidance in the mid-1990s making pain the “fifth vital sign.” This certainly was not the only factor nor was it necessarily the primary one. Most disasters, like most codes on the ward, proceed from multiple smaller failures and missteps. An emphasis on assessing pain in hospitalized patients did not intend to be interpreted as requiring that all pain be eliminated with strong medication, but that was the practical consequence. In response to the epidemic of overdose deaths, guidelines were promulgated in 2016 recommending reducing doses used for chronic opiate regimens. Some patients with chronic pain feared, and soon experienced, the consequences of those changes. In October 2019, those guidelines were revised telling physicians to go slower.4 In explaining the revision, one government official is quoted as saying: “Clearly we believe that there has been misinterpretation of the guidelines, which were very clear.”5 F. Scott Fitzgerald once wrote that “the test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function.” I reread that governmental doublespeak three times and my brain broke.
Clinical practice guidelines are an important part of modern medicine. But we need to be wiser about their creation. The science needs to be rigorous. The committees need to contain skeptics rather than just research scientists and clinicians with a vested interest in the field. The purported benefits of the guideline must be weighed against costs, risks, and unintended consequences. Humility is important. All physicians are taught the principle: “First, do no harm.” In explaining medical ethics to students, I rephrase that principle as: “Be cautious and humble. You are not as smart as you think you are.” Consider this food for thought the next time you read or create a guideline.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.
References
1. JAMA. 2018;320(10):969-70.
2. Ann Intern Med. 2019 Oct 1. doi: 10.7326/M19-1621.
3. Ann Intern Med. 2019 Oct 1. doi: 10.7326/M19-2620.
4. U.S. Department of Health & Human Services. HHS guide for clinicians on the appropriate dosage reduction or discontinuation of opioid analgesics. https://www.hhs.gov/opioids/sites/default/files/2019-10/Dosage_Reduction_Discontinuation.pdf.
5. “New guidelines on opioid tapering tell doctors to go slow.” Washington Post. 2019 Oct 10.
Modern medicine increasingly relies on the adoption and use of guidelines.
Forty years ago, medicine was like free-form, rhythmic gymnastics in which physicians would develop an artisanal treatment plan for each patient. Now, medicine frequently involves recognizing when we need to do a triple-twisting, double-back somersault (the Biles II) and then performing it. The belief is that better outcomes flow from reduced variability in diagnostic and treatment plans, based on guidelines developed from evidence-based medicine from large meta-analyses. This dogma, still unproven in real life, probably works best for 95% of patients. The physician must not omit a step of deciding whether their particular patient is one of the 5% of patients to whom the guideline does not apply.
To be useful, the guidelines must be based on accurate science, produce a significantly positive cost-benefit-risk analysis, be wisely constructed, and be clearly written.
Alas, many guidelines fall far short of this ideal, and when they fail, they impugn all of medical care, they lower the credibility of the organizations that issue them, and they lower the public’s trust in medicine, which thereby impedes improving the public health. Don’t sweat the small stuff for public health guidelines.
The science matters. Nutritional guidelines have been particularly rickety, as John P.A. Ioannidis, MD, wrote in a JAMA op-ed 1 year ago.1 For instance, previous dietary recommendations to reduce cholesterol by avoiding eggs have since been shown to be wrong. The recommendation for reducing salt intake has been heavily criticized. Now the decades-long condemnation of red meat has been challenged. New “guidelines,” suggested by one group (let’s view it as a minority report that contradicts many official guidelines) in the October 1, 2019, issue of Annals of Internal Medicine, say that red meat and processed meats aren’t the boogeyman.2 The authors of the accompanying editorial are from the Center for Pediatric and Adolescent Comparative Effectiveness Research at Indiana University, Indianapolis.3 The editorial supports the new study, criticizing past recommendations because “the field of nutritional epidemiology is plagued by observational studies that have conducted inappropriate analyses, accompanied by likely erroneous conclusions.”
Clarity also matters. One factor in the current opiate epidemic was guidance in the mid-1990s making pain the “fifth vital sign.” This certainly was not the only factor nor was it necessarily the primary one. Most disasters, like most codes on the ward, proceed from multiple smaller failures and missteps. An emphasis on assessing pain in hospitalized patients did not intend to be interpreted as requiring that all pain be eliminated with strong medication, but that was the practical consequence. In response to the epidemic of overdose deaths, guidelines were promulgated in 2016 recommending reducing doses used for chronic opiate regimens. Some patients with chronic pain feared, and soon experienced, the consequences of those changes. In October 2019, those guidelines were revised telling physicians to go slower.4 In explaining the revision, one government official is quoted as saying: “Clearly we believe that there has been misinterpretation of the guidelines, which were very clear.”5 F. Scott Fitzgerald once wrote that “the test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function.” I reread that governmental doublespeak three times and my brain broke.
Clinical practice guidelines are an important part of modern medicine. But we need to be wiser about their creation. The science needs to be rigorous. The committees need to contain skeptics rather than just research scientists and clinicians with a vested interest in the field. The purported benefits of the guideline must be weighed against costs, risks, and unintended consequences. Humility is important. All physicians are taught the principle: “First, do no harm.” In explaining medical ethics to students, I rephrase that principle as: “Be cautious and humble. You are not as smart as you think you are.” Consider this food for thought the next time you read or create a guideline.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.
References
1. JAMA. 2018;320(10):969-70.
2. Ann Intern Med. 2019 Oct 1. doi: 10.7326/M19-1621.
3. Ann Intern Med. 2019 Oct 1. doi: 10.7326/M19-2620.
4. U.S. Department of Health & Human Services. HHS guide for clinicians on the appropriate dosage reduction or discontinuation of opioid analgesics. https://www.hhs.gov/opioids/sites/default/files/2019-10/Dosage_Reduction_Discontinuation.pdf.
5. “New guidelines on opioid tapering tell doctors to go slow.” Washington Post. 2019 Oct 10.
Modern medicine increasingly relies on the adoption and use of guidelines.
Forty years ago, medicine was like free-form, rhythmic gymnastics in which physicians would develop an artisanal treatment plan for each patient. Now, medicine frequently involves recognizing when we need to do a triple-twisting, double-back somersault (the Biles II) and then performing it. The belief is that better outcomes flow from reduced variability in diagnostic and treatment plans, based on guidelines developed from evidence-based medicine from large meta-analyses. This dogma, still unproven in real life, probably works best for 95% of patients. The physician must not omit a step of deciding whether their particular patient is one of the 5% of patients to whom the guideline does not apply.
To be useful, the guidelines must be based on accurate science, produce a significantly positive cost-benefit-risk analysis, be wisely constructed, and be clearly written.
Alas, many guidelines fall far short of this ideal, and when they fail, they impugn all of medical care, they lower the credibility of the organizations that issue them, and they lower the public’s trust in medicine, which thereby impedes improving the public health. Don’t sweat the small stuff for public health guidelines.
The science matters. Nutritional guidelines have been particularly rickety, as John P.A. Ioannidis, MD, wrote in a JAMA op-ed 1 year ago.1 For instance, previous dietary recommendations to reduce cholesterol by avoiding eggs have since been shown to be wrong. The recommendation for reducing salt intake has been heavily criticized. Now the decades-long condemnation of red meat has been challenged. New “guidelines,” suggested by one group (let’s view it as a minority report that contradicts many official guidelines) in the October 1, 2019, issue of Annals of Internal Medicine, say that red meat and processed meats aren’t the boogeyman.2 The authors of the accompanying editorial are from the Center for Pediatric and Adolescent Comparative Effectiveness Research at Indiana University, Indianapolis.3 The editorial supports the new study, criticizing past recommendations because “the field of nutritional epidemiology is plagued by observational studies that have conducted inappropriate analyses, accompanied by likely erroneous conclusions.”
Clarity also matters. One factor in the current opiate epidemic was guidance in the mid-1990s making pain the “fifth vital sign.” This certainly was not the only factor nor was it necessarily the primary one. Most disasters, like most codes on the ward, proceed from multiple smaller failures and missteps. An emphasis on assessing pain in hospitalized patients did not intend to be interpreted as requiring that all pain be eliminated with strong medication, but that was the practical consequence. In response to the epidemic of overdose deaths, guidelines were promulgated in 2016 recommending reducing doses used for chronic opiate regimens. Some patients with chronic pain feared, and soon experienced, the consequences of those changes. In October 2019, those guidelines were revised telling physicians to go slower.4 In explaining the revision, one government official is quoted as saying: “Clearly we believe that there has been misinterpretation of the guidelines, which were very clear.”5 F. Scott Fitzgerald once wrote that “the test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function.” I reread that governmental doublespeak three times and my brain broke.
Clinical practice guidelines are an important part of modern medicine. But we need to be wiser about their creation. The science needs to be rigorous. The committees need to contain skeptics rather than just research scientists and clinicians with a vested interest in the field. The purported benefits of the guideline must be weighed against costs, risks, and unintended consequences. Humility is important. All physicians are taught the principle: “First, do no harm.” In explaining medical ethics to students, I rephrase that principle as: “Be cautious and humble. You are not as smart as you think you are.” Consider this food for thought the next time you read or create a guideline.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. Email him at pdnews@mdedge.com.
References
1. JAMA. 2018;320(10):969-70.
2. Ann Intern Med. 2019 Oct 1. doi: 10.7326/M19-1621.
3. Ann Intern Med. 2019 Oct 1. doi: 10.7326/M19-2620.
4. U.S. Department of Health & Human Services. HHS guide for clinicians on the appropriate dosage reduction or discontinuation of opioid analgesics. https://www.hhs.gov/opioids/sites/default/files/2019-10/Dosage_Reduction_Discontinuation.pdf.
5. “New guidelines on opioid tapering tell doctors to go slow.” Washington Post. 2019 Oct 10.
Privacy, propaganda, and polarization
Because I rarely perform surgery, my primary product is providing relevant information delivered with competence, compassion, and commitment. I must make the correct diagnosis and prescribe the correct treatment. I deliver that information with compassion to meet the emotional and spiritual needs of my patients and their parents. Parents can trust that I am committed to providing the best possible care for their child, rather than primarily seeking to enrich myself. After all, I chose pediatrics.
Three years ago I wrote a column about the use of Google as an alternative to physicians. The public can access a massive amount of medical information through the Internet. That information has been growing exponentially. But let’s look at what else has happened in the past 3 years that reflects the difference between my professionalism and the merchandising of the Internet.
I am a medical professional committed to my patients. The purveyors of information via the Internet are primarily dedicated to increased advertising revenue through click baiting and profiling. Apple’s CEO Tim Cook put it this way: “A few years ago, users of Internet services began to realize that when an online service is free, you’re not the customer. You’re the product.”
Facebook and Google learn from the content of people’s messages and search terms to build a personal profile that is valuable to advertisers. Soon that profile could include health information. Recently, 300,000 users were tempted to download a survey app via Facebook. The app developer used Facebook tools to scrape profile information not just on those 300,000 users, but on 87,000,000 contacts who did not give explicit consent. This massive leak of privacy was used to target people’s votes. Similar profiles could be used in focused advertising of health care products and services.
I have a professional and legal responsibility to provide accurate information to my patients. Years ago, Internet service providers lobbied for and obtained legal protections saying that they were not responsible for content transmitted over their networks. That idea made some sense when Facebook was primarily sharing information within families and friends. But then Facebook began a news feed without reporters vetting information and without the ethics of journalism and the fourth estate. A generation ago, three television broadcasting companies competed to provide daily evening news programs consisting of four to six stories carefully chosen to be important and relevant. Now a myriad of polarized blogs on unaccountable social media are designed to solicit clicks, spread advertising, and influence shoppers. The result has been a massive, toxic spill of false information into the noosphere. Given the already poor state of health literacy, this fake news contributes to ongoing problems with vaccine hesitancy, worthless cures, and distrust of the medical profession.
It makes the BP/Deep Horizon oil spill into the Gulf look small by comparison. The cleanup of this social media mess is going to be costly and require new technology. Chemical companies used to dump vast quantities of toxic waste and byproducts into rivers and landfills. Superfund sites involve billion dollar cleanups. Efforts are made to trace where the chemicals came from and to bill the original companies. Under a “cradle to grave” concept, a chemical company cannot avoid liability by giving toxic waste to a fly-by-night waste disposal company. Two years ago, Volkswagen stock lost $15 billion overnight when fraud was exposed in diesel emissions testing. Fines and compensation exceeded $25 billion. It has gained it all back. Facebook stock is worth five times more that Volkswagen. So even billion dollar fines would be a small cost of doing business within social media.
One information technology that has resisted pollution is Wikipedia. Google has been featuring Wikipedia websites in its search engine results for many years. Now even Facebook is contemplating using Wikipedia to combat fake news. I would not treat a patient solely based on information I found on Wikipedia. But I do find it convenient to remind me of information I had learned in the past and to reassure me that my memory is neither faulty nor outdated.
One senator said Facebook had problems with privacy and propaganda.He missed a third issue – polarization. Internet apps are designed to affirm people’s biases.By targeting Facebook users with news feeds and advertisements tailored to their prior search terms, likes, sites visited, and friends, Facebook provides news feeds that support people’s current beliefs. My own use of Google to search for health information is similarly tainted. Social media also has contaminated the ability of government to solicit public comments on legislative proposals.Similar issues make product reviews unreliable.
Overall, it is clear that the public’s ability to use the Internet to improve their health has been markedly compromised over the past 3 years. Professionalism is important. Three years ago I asked who you were going to believe – me or billionaire Elizabeth Holmes, CEO of Theranos? Since then, one of us has not signed an agreement with the Securities and Exchange Commission involving massive fraud.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He said he had no relevant financial disclosures. Email him at pdnews@mdedge.com.
Because I rarely perform surgery, my primary product is providing relevant information delivered with competence, compassion, and commitment. I must make the correct diagnosis and prescribe the correct treatment. I deliver that information with compassion to meet the emotional and spiritual needs of my patients and their parents. Parents can trust that I am committed to providing the best possible care for their child, rather than primarily seeking to enrich myself. After all, I chose pediatrics.
Three years ago I wrote a column about the use of Google as an alternative to physicians. The public can access a massive amount of medical information through the Internet. That information has been growing exponentially. But let’s look at what else has happened in the past 3 years that reflects the difference between my professionalism and the merchandising of the Internet.
I am a medical professional committed to my patients. The purveyors of information via the Internet are primarily dedicated to increased advertising revenue through click baiting and profiling. Apple’s CEO Tim Cook put it this way: “A few years ago, users of Internet services began to realize that when an online service is free, you’re not the customer. You’re the product.”
Facebook and Google learn from the content of people’s messages and search terms to build a personal profile that is valuable to advertisers. Soon that profile could include health information. Recently, 300,000 users were tempted to download a survey app via Facebook. The app developer used Facebook tools to scrape profile information not just on those 300,000 users, but on 87,000,000 contacts who did not give explicit consent. This massive leak of privacy was used to target people’s votes. Similar profiles could be used in focused advertising of health care products and services.
I have a professional and legal responsibility to provide accurate information to my patients. Years ago, Internet service providers lobbied for and obtained legal protections saying that they were not responsible for content transmitted over their networks. That idea made some sense when Facebook was primarily sharing information within families and friends. But then Facebook began a news feed without reporters vetting information and without the ethics of journalism and the fourth estate. A generation ago, three television broadcasting companies competed to provide daily evening news programs consisting of four to six stories carefully chosen to be important and relevant. Now a myriad of polarized blogs on unaccountable social media are designed to solicit clicks, spread advertising, and influence shoppers. The result has been a massive, toxic spill of false information into the noosphere. Given the already poor state of health literacy, this fake news contributes to ongoing problems with vaccine hesitancy, worthless cures, and distrust of the medical profession.
It makes the BP/Deep Horizon oil spill into the Gulf look small by comparison. The cleanup of this social media mess is going to be costly and require new technology. Chemical companies used to dump vast quantities of toxic waste and byproducts into rivers and landfills. Superfund sites involve billion dollar cleanups. Efforts are made to trace where the chemicals came from and to bill the original companies. Under a “cradle to grave” concept, a chemical company cannot avoid liability by giving toxic waste to a fly-by-night waste disposal company. Two years ago, Volkswagen stock lost $15 billion overnight when fraud was exposed in diesel emissions testing. Fines and compensation exceeded $25 billion. It has gained it all back. Facebook stock is worth five times more that Volkswagen. So even billion dollar fines would be a small cost of doing business within social media.
One information technology that has resisted pollution is Wikipedia. Google has been featuring Wikipedia websites in its search engine results for many years. Now even Facebook is contemplating using Wikipedia to combat fake news. I would not treat a patient solely based on information I found on Wikipedia. But I do find it convenient to remind me of information I had learned in the past and to reassure me that my memory is neither faulty nor outdated.
One senator said Facebook had problems with privacy and propaganda.He missed a third issue – polarization. Internet apps are designed to affirm people’s biases.By targeting Facebook users with news feeds and advertisements tailored to their prior search terms, likes, sites visited, and friends, Facebook provides news feeds that support people’s current beliefs. My own use of Google to search for health information is similarly tainted. Social media also has contaminated the ability of government to solicit public comments on legislative proposals.Similar issues make product reviews unreliable.
Overall, it is clear that the public’s ability to use the Internet to improve their health has been markedly compromised over the past 3 years. Professionalism is important. Three years ago I asked who you were going to believe – me or billionaire Elizabeth Holmes, CEO of Theranos? Since then, one of us has not signed an agreement with the Securities and Exchange Commission involving massive fraud.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He said he had no relevant financial disclosures. Email him at pdnews@mdedge.com.
Because I rarely perform surgery, my primary product is providing relevant information delivered with competence, compassion, and commitment. I must make the correct diagnosis and prescribe the correct treatment. I deliver that information with compassion to meet the emotional and spiritual needs of my patients and their parents. Parents can trust that I am committed to providing the best possible care for their child, rather than primarily seeking to enrich myself. After all, I chose pediatrics.
Three years ago I wrote a column about the use of Google as an alternative to physicians. The public can access a massive amount of medical information through the Internet. That information has been growing exponentially. But let’s look at what else has happened in the past 3 years that reflects the difference between my professionalism and the merchandising of the Internet.
I am a medical professional committed to my patients. The purveyors of information via the Internet are primarily dedicated to increased advertising revenue through click baiting and profiling. Apple’s CEO Tim Cook put it this way: “A few years ago, users of Internet services began to realize that when an online service is free, you’re not the customer. You’re the product.”
Facebook and Google learn from the content of people’s messages and search terms to build a personal profile that is valuable to advertisers. Soon that profile could include health information. Recently, 300,000 users were tempted to download a survey app via Facebook. The app developer used Facebook tools to scrape profile information not just on those 300,000 users, but on 87,000,000 contacts who did not give explicit consent. This massive leak of privacy was used to target people’s votes. Similar profiles could be used in focused advertising of health care products and services.
I have a professional and legal responsibility to provide accurate information to my patients. Years ago, Internet service providers lobbied for and obtained legal protections saying that they were not responsible for content transmitted over their networks. That idea made some sense when Facebook was primarily sharing information within families and friends. But then Facebook began a news feed without reporters vetting information and without the ethics of journalism and the fourth estate. A generation ago, three television broadcasting companies competed to provide daily evening news programs consisting of four to six stories carefully chosen to be important and relevant. Now a myriad of polarized blogs on unaccountable social media are designed to solicit clicks, spread advertising, and influence shoppers. The result has been a massive, toxic spill of false information into the noosphere. Given the already poor state of health literacy, this fake news contributes to ongoing problems with vaccine hesitancy, worthless cures, and distrust of the medical profession.
It makes the BP/Deep Horizon oil spill into the Gulf look small by comparison. The cleanup of this social media mess is going to be costly and require new technology. Chemical companies used to dump vast quantities of toxic waste and byproducts into rivers and landfills. Superfund sites involve billion dollar cleanups. Efforts are made to trace where the chemicals came from and to bill the original companies. Under a “cradle to grave” concept, a chemical company cannot avoid liability by giving toxic waste to a fly-by-night waste disposal company. Two years ago, Volkswagen stock lost $15 billion overnight when fraud was exposed in diesel emissions testing. Fines and compensation exceeded $25 billion. It has gained it all back. Facebook stock is worth five times more that Volkswagen. So even billion dollar fines would be a small cost of doing business within social media.
One information technology that has resisted pollution is Wikipedia. Google has been featuring Wikipedia websites in its search engine results for many years. Now even Facebook is contemplating using Wikipedia to combat fake news. I would not treat a patient solely based on information I found on Wikipedia. But I do find it convenient to remind me of information I had learned in the past and to reassure me that my memory is neither faulty nor outdated.
One senator said Facebook had problems with privacy and propaganda.He missed a third issue – polarization. Internet apps are designed to affirm people’s biases.By targeting Facebook users with news feeds and advertisements tailored to their prior search terms, likes, sites visited, and friends, Facebook provides news feeds that support people’s current beliefs. My own use of Google to search for health information is similarly tainted. Social media also has contaminated the ability of government to solicit public comments on legislative proposals.Similar issues make product reviews unreliable.
Overall, it is clear that the public’s ability to use the Internet to improve their health has been markedly compromised over the past 3 years. Professionalism is important. Three years ago I asked who you were going to believe – me or billionaire Elizabeth Holmes, CEO of Theranos? Since then, one of us has not signed an agreement with the Securities and Exchange Commission involving massive fraud.
Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis. He said he had no relevant financial disclosures. Email him at pdnews@mdedge.com.
Fair is fair
All physicians have a problem with people who don’t pay their bills. My previous multispecialty clinic would ultimately fire patients who made no effort to work out a payment plan. The internal medicine physicians advocated that policy. But the physician across the table from me at lunch one day was a pediatric subspecialist, the only one of her kind within a 3-hour drive. Her concern was for the medical care of the child. She didn’t want harm to come to the child because the parents were deadbeats. Some of her patients had complex problems that would not be within the capability of local general pediatricians. If fired from our clinic, the parents might not make the trip to the academic centers 3 hours away to obtain needed subspecialty service. Reporting that behavior as medical neglect was ineffective given the dire financial condition of the state’s child-protective services. What was the moral thing to do?
Ethics consults come in a variety of forms. Most are questions involving a particular patient, but many involve policy. As a clinical ethicist, my repertoire for addressing these issues run the gamut from conversations with CEOs, to ethics committee meetings, to bedside consults with families, to discussions in the hospital physicians’ lounge. While the media are enamored with flashy medical ethics problems such as abortion, stem cells, and lung transplants, the majority of my work has been more mundane, centered on financial issues, and informal consults, such as the discussion I had over lunch.
Ultimately, the discussion came down to deciding what is fair and just, tempered by compassion and advocacy for the child. In times gone by (a.k.a the 1950’s and 1960’s), physicians would provide services and then reach into the insurance company treasury and take whatever sum they considered appropriate. As long as it was usual, customary, and reasonable, the insurance company was happy to pay it, add a surcharge, and pass the costs on to the patient’s employer or the government. The out of control inflation of health care costs in the 1970s and 1980s changed the game. Managed care organizations were at financial risk for increasing costs. They began setting and enforcing the doctor’s reimbursement rates. Dentists avoided this problem by maintaining balance billing. Most physician contracts banned that option.
As health care costs kept increasing (they exceed 17% of the GDP according to the latest data), there has inevitably been increased scrutiny of the fairness of the system and the size of the piece of the pie each physician receives. Relative value units (RVUs) were introduced to provide a comparison for the work provided by different specialties. For more than 40 years, John E. Wennberg has been studying how costs vary between counties and other small geographic areas. Atul Gawande called the public’s attention to the problem of utilization variation in a New Yorker article of 2009 entitled, "The Cost Conundrum." He noted that a town in Texas was spending more than twice as much per capita on Medicare as El Paso, Tex. Many people have used these data to suggest that the United States has a major problem with overutilization. Some advocates of Obamacare anticipate it can achieve substantial cost savings by reducing variation toward a norm.
However, in May 2013 an article by James D. Reschovsky and his associates was published suggesting that 75%-85% of the variation might actually be explained by differences in health status of the local population (Med. Care Res. Rev. 2013 [doi:20131077558713487771]). If this is true, the potential for cost savings is substantially reduced. Critics claim it is possible that physicians in poor health status areas are just better and more aggressive at coding comorbid conditions. The research hasn’t been able to distinguish these behaviors. But these are important issues in establishing fair reimbursement.
In the long run, having a fair system is important. We cannot depend upon charity care by individual physicians to make up for disparities. For instance, each summer when I have worked in an urban location, some local group has created an outlet for providing low-cost school physicals and asked physicians to donate time to the project. From a medical standpoint, I have argued that without growth charts and without prior records to identify chronic medical conditions and disabilities, these doc-in-the-box school physicals, while cheap, are a waste of money and my time. My ethical concern is whether, by participating in that charade, I am actually delaying the development and implementation of an appropriate health care system. I expect that ethical conundrum also has significant regional variation.
Dr. Powell is an associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He said he had no relevant financial conflicts. Readers can e-mail Dr. Powell at pdnews@frontlinemedcom.com.
All physicians have a problem with people who don’t pay their bills. My previous multispecialty clinic would ultimately fire patients who made no effort to work out a payment plan. The internal medicine physicians advocated that policy. But the physician across the table from me at lunch one day was a pediatric subspecialist, the only one of her kind within a 3-hour drive. Her concern was for the medical care of the child. She didn’t want harm to come to the child because the parents were deadbeats. Some of her patients had complex problems that would not be within the capability of local general pediatricians. If fired from our clinic, the parents might not make the trip to the academic centers 3 hours away to obtain needed subspecialty service. Reporting that behavior as medical neglect was ineffective given the dire financial condition of the state’s child-protective services. What was the moral thing to do?
Ethics consults come in a variety of forms. Most are questions involving a particular patient, but many involve policy. As a clinical ethicist, my repertoire for addressing these issues run the gamut from conversations with CEOs, to ethics committee meetings, to bedside consults with families, to discussions in the hospital physicians’ lounge. While the media are enamored with flashy medical ethics problems such as abortion, stem cells, and lung transplants, the majority of my work has been more mundane, centered on financial issues, and informal consults, such as the discussion I had over lunch.
Ultimately, the discussion came down to deciding what is fair and just, tempered by compassion and advocacy for the child. In times gone by (a.k.a the 1950’s and 1960’s), physicians would provide services and then reach into the insurance company treasury and take whatever sum they considered appropriate. As long as it was usual, customary, and reasonable, the insurance company was happy to pay it, add a surcharge, and pass the costs on to the patient’s employer or the government. The out of control inflation of health care costs in the 1970s and 1980s changed the game. Managed care organizations were at financial risk for increasing costs. They began setting and enforcing the doctor’s reimbursement rates. Dentists avoided this problem by maintaining balance billing. Most physician contracts banned that option.
As health care costs kept increasing (they exceed 17% of the GDP according to the latest data), there has inevitably been increased scrutiny of the fairness of the system and the size of the piece of the pie each physician receives. Relative value units (RVUs) were introduced to provide a comparison for the work provided by different specialties. For more than 40 years, John E. Wennberg has been studying how costs vary between counties and other small geographic areas. Atul Gawande called the public’s attention to the problem of utilization variation in a New Yorker article of 2009 entitled, "The Cost Conundrum." He noted that a town in Texas was spending more than twice as much per capita on Medicare as El Paso, Tex. Many people have used these data to suggest that the United States has a major problem with overutilization. Some advocates of Obamacare anticipate it can achieve substantial cost savings by reducing variation toward a norm.
However, in May 2013 an article by James D. Reschovsky and his associates was published suggesting that 75%-85% of the variation might actually be explained by differences in health status of the local population (Med. Care Res. Rev. 2013 [doi:20131077558713487771]). If this is true, the potential for cost savings is substantially reduced. Critics claim it is possible that physicians in poor health status areas are just better and more aggressive at coding comorbid conditions. The research hasn’t been able to distinguish these behaviors. But these are important issues in establishing fair reimbursement.
In the long run, having a fair system is important. We cannot depend upon charity care by individual physicians to make up for disparities. For instance, each summer when I have worked in an urban location, some local group has created an outlet for providing low-cost school physicals and asked physicians to donate time to the project. From a medical standpoint, I have argued that without growth charts and without prior records to identify chronic medical conditions and disabilities, these doc-in-the-box school physicals, while cheap, are a waste of money and my time. My ethical concern is whether, by participating in that charade, I am actually delaying the development and implementation of an appropriate health care system. I expect that ethical conundrum also has significant regional variation.
Dr. Powell is an associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He said he had no relevant financial conflicts. Readers can e-mail Dr. Powell at pdnews@frontlinemedcom.com.
All physicians have a problem with people who don’t pay their bills. My previous multispecialty clinic would ultimately fire patients who made no effort to work out a payment plan. The internal medicine physicians advocated that policy. But the physician across the table from me at lunch one day was a pediatric subspecialist, the only one of her kind within a 3-hour drive. Her concern was for the medical care of the child. She didn’t want harm to come to the child because the parents were deadbeats. Some of her patients had complex problems that would not be within the capability of local general pediatricians. If fired from our clinic, the parents might not make the trip to the academic centers 3 hours away to obtain needed subspecialty service. Reporting that behavior as medical neglect was ineffective given the dire financial condition of the state’s child-protective services. What was the moral thing to do?
Ethics consults come in a variety of forms. Most are questions involving a particular patient, but many involve policy. As a clinical ethicist, my repertoire for addressing these issues run the gamut from conversations with CEOs, to ethics committee meetings, to bedside consults with families, to discussions in the hospital physicians’ lounge. While the media are enamored with flashy medical ethics problems such as abortion, stem cells, and lung transplants, the majority of my work has been more mundane, centered on financial issues, and informal consults, such as the discussion I had over lunch.
Ultimately, the discussion came down to deciding what is fair and just, tempered by compassion and advocacy for the child. In times gone by (a.k.a the 1950’s and 1960’s), physicians would provide services and then reach into the insurance company treasury and take whatever sum they considered appropriate. As long as it was usual, customary, and reasonable, the insurance company was happy to pay it, add a surcharge, and pass the costs on to the patient’s employer or the government. The out of control inflation of health care costs in the 1970s and 1980s changed the game. Managed care organizations were at financial risk for increasing costs. They began setting and enforcing the doctor’s reimbursement rates. Dentists avoided this problem by maintaining balance billing. Most physician contracts banned that option.
As health care costs kept increasing (they exceed 17% of the GDP according to the latest data), there has inevitably been increased scrutiny of the fairness of the system and the size of the piece of the pie each physician receives. Relative value units (RVUs) were introduced to provide a comparison for the work provided by different specialties. For more than 40 years, John E. Wennberg has been studying how costs vary between counties and other small geographic areas. Atul Gawande called the public’s attention to the problem of utilization variation in a New Yorker article of 2009 entitled, "The Cost Conundrum." He noted that a town in Texas was spending more than twice as much per capita on Medicare as El Paso, Tex. Many people have used these data to suggest that the United States has a major problem with overutilization. Some advocates of Obamacare anticipate it can achieve substantial cost savings by reducing variation toward a norm.
However, in May 2013 an article by James D. Reschovsky and his associates was published suggesting that 75%-85% of the variation might actually be explained by differences in health status of the local population (Med. Care Res. Rev. 2013 [doi:20131077558713487771]). If this is true, the potential for cost savings is substantially reduced. Critics claim it is possible that physicians in poor health status areas are just better and more aggressive at coding comorbid conditions. The research hasn’t been able to distinguish these behaviors. But these are important issues in establishing fair reimbursement.
In the long run, having a fair system is important. We cannot depend upon charity care by individual physicians to make up for disparities. For instance, each summer when I have worked in an urban location, some local group has created an outlet for providing low-cost school physicals and asked physicians to donate time to the project. From a medical standpoint, I have argued that without growth charts and without prior records to identify chronic medical conditions and disabilities, these doc-in-the-box school physicals, while cheap, are a waste of money and my time. My ethical concern is whether, by participating in that charade, I am actually delaying the development and implementation of an appropriate health care system. I expect that ethical conundrum also has significant regional variation.
Dr. Powell is an associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He said he had no relevant financial conflicts. Readers can e-mail Dr. Powell at pdnews@frontlinemedcom.com.
At What Price Stewardship?
It is the frequent juxtaposition of very disparate items that makes medical ethics both outrageously frustrating and ironically amusing. Does one hand of the health care system really have a clue about what the other hand is doing?
Take, for instance, three articles in the March 17, 2011 issue of the New England Journal of Medicine. An op-ed piece by Dr. Sean Palfrey bemoans how, because of a variety of incentives, the practice of modern American medicine has become a high-tech, unaffordable endeavor. Clinicians have abandoned judgment in favor of testing and treating everything imaginable. I agree with his clarion call for practice guidelines that would reduce excessive testing and comparative effectiveness research to eliminate extravagant therapies. But, I also agreed with those very same ideas when they were being advanced by public health policy analysts 25 years ago. The wasteful clinical decision making Dr. Palfrey describes has only gotten worse (N. Engl. J. Med. 2011;364:e21).
The cost of health care in the United States is rising uncontrollably. Medical technology progresses, but is it really advancing? On the whole, does new technology do more, or cost less? In the past 25 years, computer technology has advanced so that today for $100 I can buy a device that will backup 1,000,000 times more data than the $100 device I used back then, and it will do it faster. In contrast, medical progress generally tends to increase the cost of diagnosis and treatment.
For instance, in the same edition of the New England Journal, there is an article by Dr. William W. Busse and his associates about the use of a monoclonal antibody to treat asthma for an inner-city pediatric population (N. Engl. J. Med. 2011;364:1005-15).
The novel therapy does produce slightly better results, but little mention is made in the article about the cost of this medication, which would be about 10 times more expensive per year than current controller therapy is and, in absolute terms, cost more than the median household income of the patient population included in the study. Dr. Palfrey pleads that "we need to incorporate more realistic clinical, scientific, and financial information into practice." But the asthma article, while full of informative scientific graphs, doesn’t provide any of the financial information needed to address Dr. Palfrey’s ambition.
In the 15 years after Medicare was established, health care costs doubled from 5% of the Gross Domestic Product (GDP) to 10% in the 1980s. The pundits of a quarter century ago projected dire economic consequences as those costs, already considered detrimental to the economy, would rise past 12%, then 15% of the GDP. By 2010, U.S. health care costs exceeded 17% of the GDP and the upward trend continues. Other countries have achieved equal or better health outcomes for a lot less money.
The past 25 years have seen various attempts by economists to elicit physician participation in restraining this rise in health care costs. The New Jersey experiment with Diagnosis Related Groups (DRGs) in 1980 gave way to proliferation of Health Maintenance Organizations (HMOs), then Preferred Provider Organizations (PPOs) with physicians as gatekeepers, then the never-implemented 1994 Clinton plan for Regional Health Alliances, followed by expansion of Managed Care Organizations (MCOs) and now, the yet to be defined Accountable Care Organizations (ACOs). Despite three decades of alphabet soup, costs continue to rise.
For the past year, each edition of the New England Journal has had about as many feature articles on health care finance as it has had on new medical science. This mix of articles is quite appropriate given the challenges facing U.S. health care. The March 17th article by Jeroen N. Struijs, Ph.D., and Caroline A. Baan, Ph.D.,looks at bundled cost reimbursement, a concept very similar to the old New Jersey DRGs. The article seeks to glean lessons from the Netherlands’ efforts to affect clinical decision making by aligning financial incentives to reward cost efficiency (N. Engl. J. Med. 2011;364:990-1).
Wise use of resources requires integrating ethical, scientific, and financial perspectives. The New England Journal managed to get three articles, each emphasizing one of these three facets, into the same magazine. Alas, each article stayed in its own silo, quite oblivious to the ideas a few pages away. The task before modern medicine is blending these three facets together. Can we get clinical decision makers, medical researchers, and economists into dialogue?
I strongly believe that physicians must view controlling health care expenditures as a professional duty. Either we embrace that stewardship or we will continue to find that cost control measures will be thrust upon us. Currently, that control occurs in the form of a clerk with a large book telling us whether or not a surgical procedure is preapproved or whether that hospital admission was, in retrospect, covered by insurance. Surely, highly educated professionals can do better than this.
Learning to be good stewards will take education, new tools, and practice. I suggest starting with low-hanging fruit. The Food and Drug Administration and Medicare have recently decided to approve a novel, individually tailored immunotherapy for prostate cancer that adds, on average, 4 months of life to an elderly patient at the price of $93,000. Perhaps it is an example of Lewis Thomas’s halfway technology. But as low-hanging fruit goes, that looks like a watermelon.
Dr. Kevin Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis.
It is the frequent juxtaposition of very disparate items that makes medical ethics both outrageously frustrating and ironically amusing. Does one hand of the health care system really have a clue about what the other hand is doing?
Take, for instance, three articles in the March 17, 2011 issue of the New England Journal of Medicine. An op-ed piece by Dr. Sean Palfrey bemoans how, because of a variety of incentives, the practice of modern American medicine has become a high-tech, unaffordable endeavor. Clinicians have abandoned judgment in favor of testing and treating everything imaginable. I agree with his clarion call for practice guidelines that would reduce excessive testing and comparative effectiveness research to eliminate extravagant therapies. But, I also agreed with those very same ideas when they were being advanced by public health policy analysts 25 years ago. The wasteful clinical decision making Dr. Palfrey describes has only gotten worse (N. Engl. J. Med. 2011;364:e21).
The cost of health care in the United States is rising uncontrollably. Medical technology progresses, but is it really advancing? On the whole, does new technology do more, or cost less? In the past 25 years, computer technology has advanced so that today for $100 I can buy a device that will backup 1,000,000 times more data than the $100 device I used back then, and it will do it faster. In contrast, medical progress generally tends to increase the cost of diagnosis and treatment.
For instance, in the same edition of the New England Journal, there is an article by Dr. William W. Busse and his associates about the use of a monoclonal antibody to treat asthma for an inner-city pediatric population (N. Engl. J. Med. 2011;364:1005-15).
The novel therapy does produce slightly better results, but little mention is made in the article about the cost of this medication, which would be about 10 times more expensive per year than current controller therapy is and, in absolute terms, cost more than the median household income of the patient population included in the study. Dr. Palfrey pleads that "we need to incorporate more realistic clinical, scientific, and financial information into practice." But the asthma article, while full of informative scientific graphs, doesn’t provide any of the financial information needed to address Dr. Palfrey’s ambition.
In the 15 years after Medicare was established, health care costs doubled from 5% of the Gross Domestic Product (GDP) to 10% in the 1980s. The pundits of a quarter century ago projected dire economic consequences as those costs, already considered detrimental to the economy, would rise past 12%, then 15% of the GDP. By 2010, U.S. health care costs exceeded 17% of the GDP and the upward trend continues. Other countries have achieved equal or better health outcomes for a lot less money.
The past 25 years have seen various attempts by economists to elicit physician participation in restraining this rise in health care costs. The New Jersey experiment with Diagnosis Related Groups (DRGs) in 1980 gave way to proliferation of Health Maintenance Organizations (HMOs), then Preferred Provider Organizations (PPOs) with physicians as gatekeepers, then the never-implemented 1994 Clinton plan for Regional Health Alliances, followed by expansion of Managed Care Organizations (MCOs) and now, the yet to be defined Accountable Care Organizations (ACOs). Despite three decades of alphabet soup, costs continue to rise.
For the past year, each edition of the New England Journal has had about as many feature articles on health care finance as it has had on new medical science. This mix of articles is quite appropriate given the challenges facing U.S. health care. The March 17th article by Jeroen N. Struijs, Ph.D., and Caroline A. Baan, Ph.D.,looks at bundled cost reimbursement, a concept very similar to the old New Jersey DRGs. The article seeks to glean lessons from the Netherlands’ efforts to affect clinical decision making by aligning financial incentives to reward cost efficiency (N. Engl. J. Med. 2011;364:990-1).
Wise use of resources requires integrating ethical, scientific, and financial perspectives. The New England Journal managed to get three articles, each emphasizing one of these three facets, into the same magazine. Alas, each article stayed in its own silo, quite oblivious to the ideas a few pages away. The task before modern medicine is blending these three facets together. Can we get clinical decision makers, medical researchers, and economists into dialogue?
I strongly believe that physicians must view controlling health care expenditures as a professional duty. Either we embrace that stewardship or we will continue to find that cost control measures will be thrust upon us. Currently, that control occurs in the form of a clerk with a large book telling us whether or not a surgical procedure is preapproved or whether that hospital admission was, in retrospect, covered by insurance. Surely, highly educated professionals can do better than this.
Learning to be good stewards will take education, new tools, and practice. I suggest starting with low-hanging fruit. The Food and Drug Administration and Medicare have recently decided to approve a novel, individually tailored immunotherapy for prostate cancer that adds, on average, 4 months of life to an elderly patient at the price of $93,000. Perhaps it is an example of Lewis Thomas’s halfway technology. But as low-hanging fruit goes, that looks like a watermelon.
Dr. Kevin Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis.
It is the frequent juxtaposition of very disparate items that makes medical ethics both outrageously frustrating and ironically amusing. Does one hand of the health care system really have a clue about what the other hand is doing?
Take, for instance, three articles in the March 17, 2011 issue of the New England Journal of Medicine. An op-ed piece by Dr. Sean Palfrey bemoans how, because of a variety of incentives, the practice of modern American medicine has become a high-tech, unaffordable endeavor. Clinicians have abandoned judgment in favor of testing and treating everything imaginable. I agree with his clarion call for practice guidelines that would reduce excessive testing and comparative effectiveness research to eliminate extravagant therapies. But, I also agreed with those very same ideas when they were being advanced by public health policy analysts 25 years ago. The wasteful clinical decision making Dr. Palfrey describes has only gotten worse (N. Engl. J. Med. 2011;364:e21).
The cost of health care in the United States is rising uncontrollably. Medical technology progresses, but is it really advancing? On the whole, does new technology do more, or cost less? In the past 25 years, computer technology has advanced so that today for $100 I can buy a device that will backup 1,000,000 times more data than the $100 device I used back then, and it will do it faster. In contrast, medical progress generally tends to increase the cost of diagnosis and treatment.
For instance, in the same edition of the New England Journal, there is an article by Dr. William W. Busse and his associates about the use of a monoclonal antibody to treat asthma for an inner-city pediatric population (N. Engl. J. Med. 2011;364:1005-15).
The novel therapy does produce slightly better results, but little mention is made in the article about the cost of this medication, which would be about 10 times more expensive per year than current controller therapy is and, in absolute terms, cost more than the median household income of the patient population included in the study. Dr. Palfrey pleads that "we need to incorporate more realistic clinical, scientific, and financial information into practice." But the asthma article, while full of informative scientific graphs, doesn’t provide any of the financial information needed to address Dr. Palfrey’s ambition.
In the 15 years after Medicare was established, health care costs doubled from 5% of the Gross Domestic Product (GDP) to 10% in the 1980s. The pundits of a quarter century ago projected dire economic consequences as those costs, already considered detrimental to the economy, would rise past 12%, then 15% of the GDP. By 2010, U.S. health care costs exceeded 17% of the GDP and the upward trend continues. Other countries have achieved equal or better health outcomes for a lot less money.
The past 25 years have seen various attempts by economists to elicit physician participation in restraining this rise in health care costs. The New Jersey experiment with Diagnosis Related Groups (DRGs) in 1980 gave way to proliferation of Health Maintenance Organizations (HMOs), then Preferred Provider Organizations (PPOs) with physicians as gatekeepers, then the never-implemented 1994 Clinton plan for Regional Health Alliances, followed by expansion of Managed Care Organizations (MCOs) and now, the yet to be defined Accountable Care Organizations (ACOs). Despite three decades of alphabet soup, costs continue to rise.
For the past year, each edition of the New England Journal has had about as many feature articles on health care finance as it has had on new medical science. This mix of articles is quite appropriate given the challenges facing U.S. health care. The March 17th article by Jeroen N. Struijs, Ph.D., and Caroline A. Baan, Ph.D.,looks at bundled cost reimbursement, a concept very similar to the old New Jersey DRGs. The article seeks to glean lessons from the Netherlands’ efforts to affect clinical decision making by aligning financial incentives to reward cost efficiency (N. Engl. J. Med. 2011;364:990-1).
Wise use of resources requires integrating ethical, scientific, and financial perspectives. The New England Journal managed to get three articles, each emphasizing one of these three facets, into the same magazine. Alas, each article stayed in its own silo, quite oblivious to the ideas a few pages away. The task before modern medicine is blending these three facets together. Can we get clinical decision makers, medical researchers, and economists into dialogue?
I strongly believe that physicians must view controlling health care expenditures as a professional duty. Either we embrace that stewardship or we will continue to find that cost control measures will be thrust upon us. Currently, that control occurs in the form of a clerk with a large book telling us whether or not a surgical procedure is preapproved or whether that hospital admission was, in retrospect, covered by insurance. Surely, highly educated professionals can do better than this.
Learning to be good stewards will take education, new tools, and practice. I suggest starting with low-hanging fruit. The Food and Drug Administration and Medicare have recently decided to approve a novel, individually tailored immunotherapy for prostate cancer that adds, on average, 4 months of life to an elderly patient at the price of $93,000. Perhaps it is an example of Lewis Thomas’s halfway technology. But as low-hanging fruit goes, that looks like a watermelon.
Dr. Kevin Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis.
A Question of Commitment
It is such a common scenario. It might be 4:45 p.m. in a rural, two-doctor office, or 9:30 a.m. Saturday during rounds in the nursery, or 11:55 a.m. in a teaching hospital. You are waiting on just one more lab result before you can finish that last patient encounter of the day, but you are also running late for your daughter’s soccer game. Do you stay and finish up, or sign the problem out to your partner who is on call?
I was taught there are three "coms" that characterize ideal physicians: They are competent, compassionate, and committed to their patients above all else. Those three characteristics are reflected in the mirror each morning. Your reputation is built on them. Your patient trusts you because of them. But you don’t want to disappoint your daughter, either. "So," says the little voice in my head, "just how committed are you?"
Dr. James Gordon reflects on this in the American Medical Association Virtual Mentor column "Sharing the Pain" (Virtual Mentor 2007;9:508-10).
"In the old days, anyone who wanted to go into medicine had to be prepared for a life of exhaustion. Before laws and regulations prohibited one-in-two call, we were rapidly conditioned to accept the idea that the life of a doctor was not only one of service, but a kind of servitude. ... In the first year of residency, the fledgling doctor learns never to leave work for anyone else at the end of the day."
Dr. Michael B. Edmond reflects on how this has changed for today’s newer physicians in "Taylorized Medicine" (Ann. Intern. Med. 2010;153:845-6).
"The marked changes in the way we conduct our business in teaching hospitals have been driven by advances in technology that have improved the process of care. ... But the biggest changes have been driven by the rules of the ACGME on resident work hours and their rigid enforcement.
"Every resident now has an invisible but heavy stopwatch sitting on their shoulder, ticking loudly, constantly reminding them that their task list still has many unchecked items as time slips away."
Dr. Edmond claims that in the past, "part of the maturation process for young physicians was coming to terms with the daily unpredictability and lack of control associated with caring for acutely ill inpatients."
Dr. Gordon claims that in his era, "regardless whether you had been up all night, you did not leave loose ends for your colleagues." He goes on to claim that, "in the end, most of us embraced the pain, which made us a fraternity."
But what I see is that Generation X and Y physicians have developed a different solution with a different work-life balance. These newer doctors don’t and won’t work the long and particularly the unpredictable hours that the prior generation did. They don’t have a spouse who runs the household. They have kids at daycare who need to be picked up on time. Many prefer working 0.8 full-time equivalent (FTE). So they have adopted a different work ethic. They recognize that unpredictable events sometimes – even routinely – make it necessary to sign out work to the on-call colleague. The new fraternity is committed to relieving last night’s on-call person, and expecting the same when it is their turn. Work flow is organized to hand off tasks to ensure that the patients’ needs are always paramount. The technological tools for carrying out these handoffs aren’t working smoothly – yet.
There are advantages to this new paradigm. It reduces the House of God attitudes I saw in medical school, and that will benefit patients. It will also benefit physicians as we balance our professional and personal lives.
Personally, I’m comfortable being cared for by a doctor from the older generation, whose commitment was evident in his long hours. Of course, that assumes that those excessive hours haven’t spawned burnout, substance abuse, or divorce – all of which would negatively impact my care. I have the expertise and wealth to afford such a doctor, if I could find one who isn’t too busy. But Henry Ford reminds me that the horse and buggy aren’t the way of the future.
This column, "Beyond the White Coat," regularly appears in Pediatric News, an Elsevier publication. Dr. Kevin Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He said that he has no conflicts of interest to disclose.
It is such a common scenario. It might be 4:45 p.m. in a rural, two-doctor office, or 9:30 a.m. Saturday during rounds in the nursery, or 11:55 a.m. in a teaching hospital. You are waiting on just one more lab result before you can finish that last patient encounter of the day, but you are also running late for your daughter’s soccer game. Do you stay and finish up, or sign the problem out to your partner who is on call?
I was taught there are three "coms" that characterize ideal physicians: They are competent, compassionate, and committed to their patients above all else. Those three characteristics are reflected in the mirror each morning. Your reputation is built on them. Your patient trusts you because of them. But you don’t want to disappoint your daughter, either. "So," says the little voice in my head, "just how committed are you?"
Dr. James Gordon reflects on this in the American Medical Association Virtual Mentor column "Sharing the Pain" (Virtual Mentor 2007;9:508-10).
"In the old days, anyone who wanted to go into medicine had to be prepared for a life of exhaustion. Before laws and regulations prohibited one-in-two call, we were rapidly conditioned to accept the idea that the life of a doctor was not only one of service, but a kind of servitude. ... In the first year of residency, the fledgling doctor learns never to leave work for anyone else at the end of the day."
Dr. Michael B. Edmond reflects on how this has changed for today’s newer physicians in "Taylorized Medicine" (Ann. Intern. Med. 2010;153:845-6).
"The marked changes in the way we conduct our business in teaching hospitals have been driven by advances in technology that have improved the process of care. ... But the biggest changes have been driven by the rules of the ACGME on resident work hours and their rigid enforcement.
"Every resident now has an invisible but heavy stopwatch sitting on their shoulder, ticking loudly, constantly reminding them that their task list still has many unchecked items as time slips away."
Dr. Edmond claims that in the past, "part of the maturation process for young physicians was coming to terms with the daily unpredictability and lack of control associated with caring for acutely ill inpatients."
Dr. Gordon claims that in his era, "regardless whether you had been up all night, you did not leave loose ends for your colleagues." He goes on to claim that, "in the end, most of us embraced the pain, which made us a fraternity."
But what I see is that Generation X and Y physicians have developed a different solution with a different work-life balance. These newer doctors don’t and won’t work the long and particularly the unpredictable hours that the prior generation did. They don’t have a spouse who runs the household. They have kids at daycare who need to be picked up on time. Many prefer working 0.8 full-time equivalent (FTE). So they have adopted a different work ethic. They recognize that unpredictable events sometimes – even routinely – make it necessary to sign out work to the on-call colleague. The new fraternity is committed to relieving last night’s on-call person, and expecting the same when it is their turn. Work flow is organized to hand off tasks to ensure that the patients’ needs are always paramount. The technological tools for carrying out these handoffs aren’t working smoothly – yet.
There are advantages to this new paradigm. It reduces the House of God attitudes I saw in medical school, and that will benefit patients. It will also benefit physicians as we balance our professional and personal lives.
Personally, I’m comfortable being cared for by a doctor from the older generation, whose commitment was evident in his long hours. Of course, that assumes that those excessive hours haven’t spawned burnout, substance abuse, or divorce – all of which would negatively impact my care. I have the expertise and wealth to afford such a doctor, if I could find one who isn’t too busy. But Henry Ford reminds me that the horse and buggy aren’t the way of the future.
This column, "Beyond the White Coat," regularly appears in Pediatric News, an Elsevier publication. Dr. Kevin Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He said that he has no conflicts of interest to disclose.
It is such a common scenario. It might be 4:45 p.m. in a rural, two-doctor office, or 9:30 a.m. Saturday during rounds in the nursery, or 11:55 a.m. in a teaching hospital. You are waiting on just one more lab result before you can finish that last patient encounter of the day, but you are also running late for your daughter’s soccer game. Do you stay and finish up, or sign the problem out to your partner who is on call?
I was taught there are three "coms" that characterize ideal physicians: They are competent, compassionate, and committed to their patients above all else. Those three characteristics are reflected in the mirror each morning. Your reputation is built on them. Your patient trusts you because of them. But you don’t want to disappoint your daughter, either. "So," says the little voice in my head, "just how committed are you?"
Dr. James Gordon reflects on this in the American Medical Association Virtual Mentor column "Sharing the Pain" (Virtual Mentor 2007;9:508-10).
"In the old days, anyone who wanted to go into medicine had to be prepared for a life of exhaustion. Before laws and regulations prohibited one-in-two call, we were rapidly conditioned to accept the idea that the life of a doctor was not only one of service, but a kind of servitude. ... In the first year of residency, the fledgling doctor learns never to leave work for anyone else at the end of the day."
Dr. Michael B. Edmond reflects on how this has changed for today’s newer physicians in "Taylorized Medicine" (Ann. Intern. Med. 2010;153:845-6).
"The marked changes in the way we conduct our business in teaching hospitals have been driven by advances in technology that have improved the process of care. ... But the biggest changes have been driven by the rules of the ACGME on resident work hours and their rigid enforcement.
"Every resident now has an invisible but heavy stopwatch sitting on their shoulder, ticking loudly, constantly reminding them that their task list still has many unchecked items as time slips away."
Dr. Edmond claims that in the past, "part of the maturation process for young physicians was coming to terms with the daily unpredictability and lack of control associated with caring for acutely ill inpatients."
Dr. Gordon claims that in his era, "regardless whether you had been up all night, you did not leave loose ends for your colleagues." He goes on to claim that, "in the end, most of us embraced the pain, which made us a fraternity."
But what I see is that Generation X and Y physicians have developed a different solution with a different work-life balance. These newer doctors don’t and won’t work the long and particularly the unpredictable hours that the prior generation did. They don’t have a spouse who runs the household. They have kids at daycare who need to be picked up on time. Many prefer working 0.8 full-time equivalent (FTE). So they have adopted a different work ethic. They recognize that unpredictable events sometimes – even routinely – make it necessary to sign out work to the on-call colleague. The new fraternity is committed to relieving last night’s on-call person, and expecting the same when it is their turn. Work flow is organized to hand off tasks to ensure that the patients’ needs are always paramount. The technological tools for carrying out these handoffs aren’t working smoothly – yet.
There are advantages to this new paradigm. It reduces the House of God attitudes I saw in medical school, and that will benefit patients. It will also benefit physicians as we balance our professional and personal lives.
Personally, I’m comfortable being cared for by a doctor from the older generation, whose commitment was evident in his long hours. Of course, that assumes that those excessive hours haven’t spawned burnout, substance abuse, or divorce – all of which would negatively impact my care. I have the expertise and wealth to afford such a doctor, if I could find one who isn’t too busy. But Henry Ford reminds me that the horse and buggy aren’t the way of the future.
This column, "Beyond the White Coat," regularly appears in Pediatric News, an Elsevier publication. Dr. Kevin Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He said that he has no conflicts of interest to disclose.
A Question of Commitment
It is such a common scenario. It might be 4:45 p.m. in a rural, two-doctor office, or 9:30 a.m. Saturday during rounds in the nursery, or 11:55 a.m. in a teaching hospital. You are waiting on just one more lab result before you can finish that last patient encounter of the day, but you are also running late for your daughter’s soccer game. Do you stay and finish up, or sign the problem out to your partner who is on call?
I was taught there are three "coms" that characterize ideal physicians: They are competent, compassionate, and committed to their patients above all else. Those three characteristics are reflected in the mirror each morning. Your reputation is built on them. Your patient trusts you because of them. But you don’t want to disappoint your daughter, either. "So," says the little voice in my head, "just how committed are you?"
Dr. James Gordon reflects on this in the American Medical Association Virtual Mentor column "Sharing the Pain" (Virtual Mentor 2007;9:508-10).
"In the old days, anyone who wanted to go into medicine had to be prepared for a life of exhaustion. Before laws and regulations prohibited one-in-two call, we were rapidly conditioned to accept the idea that the life of a doctor was not only one of service, but a kind of servitude. ... In the first year of residency, the fledgling doctor learns never to leave work for anyone else at the end of the day."
Dr. Michael B. Edmond reflects on how this has changed for today’s newer physicians in "Taylorized Medicine" (Ann. Intern. Med. 2010;153:845-6).
"The marked changes in the way we conduct our business in teaching hospitals have been driven by advances in technology that have improved the process of care. ... But the biggest changes have been driven by the rules of the ACGME on resident work hours and their rigid enforcement.
"Every resident now has an invisible but heavy stopwatch sitting on their shoulder, ticking loudly, constantly reminding them that their task list still has many unchecked items as time slips away."
Dr. Edmond claims that in the past, "part of the maturation process for young physicians was coming to terms with the daily unpredictability and lack of control associated with caring for acutely ill inpatients."
Dr. Gordon claims that in his era, "regardless whether you had been up all night, you did not leave loose ends for your colleagues." He goes on to claim that, "in the end, most of us embraced the pain, which made us a fraternity."
But what I see is that Generation X and Y physicians have developed a different solution with a different work-life balance. These newer doctors don’t and won’t work the long and particularly the unpredictable hours that the prior generation did. They don’t have a spouse who runs the household. They have kids at daycare who need to be picked up on time. Many prefer working 0.8 full-time equivalent (FTE). So they have adopted a different work ethic. They recognize that unpredictable events sometimes – even routinely – make it necessary to sign out work to the on-call colleague. The new fraternity is committed to relieving last night’s on-call person, and expecting the same when it is their turn. Work flow is organized to hand off tasks to ensure that the patients’ needs are always paramount. The technological tools for carrying out these handoffs aren’t working smoothly – yet.
There are advantages to this new paradigm. It reduces the House of God attitudes I saw in medical school, and that will benefit patients. It will also benefit physicians as we balance our professional and personal lives.
Personally, I’m comfortable being cared for by a doctor from the older generation, whose commitment was evident in his long hours. Of course, that assumes that those excessive hours haven’t spawned burnout, substance abuse, or divorce – all of which would negatively impact my care. I have the expertise and wealth to afford such a doctor, if I could find one who isn’t too busy. But Henry Ford reminds me that the horse and buggy aren’t the way of the future.
Dr. Kevin Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He said that he has no conflicts of interest to disclose.
It is such a common scenario. It might be 4:45 p.m. in a rural, two-doctor office, or 9:30 a.m. Saturday during rounds in the nursery, or 11:55 a.m. in a teaching hospital. You are waiting on just one more lab result before you can finish that last patient encounter of the day, but you are also running late for your daughter’s soccer game. Do you stay and finish up, or sign the problem out to your partner who is on call?
I was taught there are three "coms" that characterize ideal physicians: They are competent, compassionate, and committed to their patients above all else. Those three characteristics are reflected in the mirror each morning. Your reputation is built on them. Your patient trusts you because of them. But you don’t want to disappoint your daughter, either. "So," says the little voice in my head, "just how committed are you?"
Dr. James Gordon reflects on this in the American Medical Association Virtual Mentor column "Sharing the Pain" (Virtual Mentor 2007;9:508-10).
"In the old days, anyone who wanted to go into medicine had to be prepared for a life of exhaustion. Before laws and regulations prohibited one-in-two call, we were rapidly conditioned to accept the idea that the life of a doctor was not only one of service, but a kind of servitude. ... In the first year of residency, the fledgling doctor learns never to leave work for anyone else at the end of the day."
Dr. Michael B. Edmond reflects on how this has changed for today’s newer physicians in "Taylorized Medicine" (Ann. Intern. Med. 2010;153:845-6).
"The marked changes in the way we conduct our business in teaching hospitals have been driven by advances in technology that have improved the process of care. ... But the biggest changes have been driven by the rules of the ACGME on resident work hours and their rigid enforcement.
"Every resident now has an invisible but heavy stopwatch sitting on their shoulder, ticking loudly, constantly reminding them that their task list still has many unchecked items as time slips away."
Dr. Edmond claims that in the past, "part of the maturation process for young physicians was coming to terms with the daily unpredictability and lack of control associated with caring for acutely ill inpatients."
Dr. Gordon claims that in his era, "regardless whether you had been up all night, you did not leave loose ends for your colleagues." He goes on to claim that, "in the end, most of us embraced the pain, which made us a fraternity."
But what I see is that Generation X and Y physicians have developed a different solution with a different work-life balance. These newer doctors don’t and won’t work the long and particularly the unpredictable hours that the prior generation did. They don’t have a spouse who runs the household. They have kids at daycare who need to be picked up on time. Many prefer working 0.8 full-time equivalent (FTE). So they have adopted a different work ethic. They recognize that unpredictable events sometimes – even routinely – make it necessary to sign out work to the on-call colleague. The new fraternity is committed to relieving last night’s on-call person, and expecting the same when it is their turn. Work flow is organized to hand off tasks to ensure that the patients’ needs are always paramount. The technological tools for carrying out these handoffs aren’t working smoothly – yet.
There are advantages to this new paradigm. It reduces the House of God attitudes I saw in medical school, and that will benefit patients. It will also benefit physicians as we balance our professional and personal lives.
Personally, I’m comfortable being cared for by a doctor from the older generation, whose commitment was evident in his long hours. Of course, that assumes that those excessive hours haven’t spawned burnout, substance abuse, or divorce – all of which would negatively impact my care. I have the expertise and wealth to afford such a doctor, if I could find one who isn’t too busy. But Henry Ford reminds me that the horse and buggy aren’t the way of the future.
Dr. Kevin Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He said that he has no conflicts of interest to disclose.
It is such a common scenario. It might be 4:45 p.m. in a rural, two-doctor office, or 9:30 a.m. Saturday during rounds in the nursery, or 11:55 a.m. in a teaching hospital. You are waiting on just one more lab result before you can finish that last patient encounter of the day, but you are also running late for your daughter’s soccer game. Do you stay and finish up, or sign the problem out to your partner who is on call?
I was taught there are three "coms" that characterize ideal physicians: They are competent, compassionate, and committed to their patients above all else. Those three characteristics are reflected in the mirror each morning. Your reputation is built on them. Your patient trusts you because of them. But you don’t want to disappoint your daughter, either. "So," says the little voice in my head, "just how committed are you?"
Dr. James Gordon reflects on this in the American Medical Association Virtual Mentor column "Sharing the Pain" (Virtual Mentor 2007;9:508-10).
"In the old days, anyone who wanted to go into medicine had to be prepared for a life of exhaustion. Before laws and regulations prohibited one-in-two call, we were rapidly conditioned to accept the idea that the life of a doctor was not only one of service, but a kind of servitude. ... In the first year of residency, the fledgling doctor learns never to leave work for anyone else at the end of the day."
Dr. Michael B. Edmond reflects on how this has changed for today’s newer physicians in "Taylorized Medicine" (Ann. Intern. Med. 2010;153:845-6).
"The marked changes in the way we conduct our business in teaching hospitals have been driven by advances in technology that have improved the process of care. ... But the biggest changes have been driven by the rules of the ACGME on resident work hours and their rigid enforcement.
"Every resident now has an invisible but heavy stopwatch sitting on their shoulder, ticking loudly, constantly reminding them that their task list still has many unchecked items as time slips away."
Dr. Edmond claims that in the past, "part of the maturation process for young physicians was coming to terms with the daily unpredictability and lack of control associated with caring for acutely ill inpatients."
Dr. Gordon claims that in his era, "regardless whether you had been up all night, you did not leave loose ends for your colleagues." He goes on to claim that, "in the end, most of us embraced the pain, which made us a fraternity."
But what I see is that Generation X and Y physicians have developed a different solution with a different work-life balance. These newer doctors don’t and won’t work the long and particularly the unpredictable hours that the prior generation did. They don’t have a spouse who runs the household. They have kids at daycare who need to be picked up on time. Many prefer working 0.8 full-time equivalent (FTE). So they have adopted a different work ethic. They recognize that unpredictable events sometimes – even routinely – make it necessary to sign out work to the on-call colleague. The new fraternity is committed to relieving last night’s on-call person, and expecting the same when it is their turn. Work flow is organized to hand off tasks to ensure that the patients’ needs are always paramount. The technological tools for carrying out these handoffs aren’t working smoothly – yet.
There are advantages to this new paradigm. It reduces the House of God attitudes I saw in medical school, and that will benefit patients. It will also benefit physicians as we balance our professional and personal lives.
Personally, I’m comfortable being cared for by a doctor from the older generation, whose commitment was evident in his long hours. Of course, that assumes that those excessive hours haven’t spawned burnout, substance abuse, or divorce – all of which would negatively impact my care. I have the expertise and wealth to afford such a doctor, if I could find one who isn’t too busy. But Henry Ford reminds me that the horse and buggy aren’t the way of the future.
Dr. Kevin Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He said that he has no conflicts of interest to disclose.
A Question of Commitment
It is such a common scenario. It might be 4:45 p.m. in a rural, two-doctor office, or 9:30 a.m. Saturday during rounds in the nursery, or 11:55 a.m. in a teaching hospital. You are waiting on just one more lab result before you can finish that last patient encounter of the day, but you are also running late for your daughter’s soccer game. Do you stay and finish up, or sign the problem out to your partner who is on call?
I was taught there are three "coms" that characterize ideal physicians: They are competent, compassionate, and committed to their patients above all else. Those three characteristics are reflected in the mirror each morning. Your reputation is built on them. Your patient trusts you because of them. But you don’t want to disappoint your daughter, either. "So," says the little voice in my head, "just how committed are you?"
Dr. James Gordon reflects on this in the American Medical Association Virtual Mentor column "Sharing the Pain" (Virtual Mentor 2007;9:508-10).
"In the old days, anyone who wanted to go into medicine had to be prepared for a life of exhaustion. Before laws and regulations prohibited one-in-two call, we were rapidly conditioned to accept the idea that the life of a doctor was not only one of service, but a kind of servitude. ... In the first year of residency, the fledgling doctor learns never to leave work for anyone else at the end of the day."
Dr. Michael B. Edmond reflects on how this has changed for today’s newer physicians in "Taylorized Medicine" (Ann. Intern. Med. 2010;153:845-6).
"The marked changes in the way we conduct our business in teaching hospitals have been driven by advances in technology that have improved the process of care. ... But the biggest changes have been driven by the rules of the ACGME on resident work hours and their rigid enforcement.
"Every resident now has an invisible but heavy stopwatch sitting on their shoulder, ticking loudly, constantly reminding them that their task list still has many unchecked items as time slips away."
Dr. Edmond claims that in the past, "part of the maturation process for young physicians was coming to terms with the daily unpredictability and lack of control associated with caring for acutely ill inpatients."
Dr. Gordon claims that in his era, "regardless whether you had been up all night, you did not leave loose ends for your colleagues." He goes on to claim that, "in the end, most of us embraced the pain, which made us a fraternity."
But what I see is that Generation X and Y physicians have developed a different solution with a different work-life balance. These newer doctors don’t and won’t work the long and particularly the unpredictable hours that the prior generation did. They don’t have a spouse who runs the household. They have kids at daycare who need to be picked up on time. Many prefer working 0.8 full-time equivalent (FTE). So they have adopted a different work ethic. They recognize that unpredictable events sometimes – even routinely – make it necessary to sign out work to the on-call colleague. The new fraternity is committed to relieving last night’s on-call person, and expecting the same when it is their turn. Work flow is organized to hand off tasks to ensure that the patients’ needs are always paramount. The technological tools for carrying out these handoffs aren’t working smoothly – yet.
There are advantages to this new paradigm. It reduces the House of God attitudes I saw in medical school, and that will benefit patients. It will also benefit physicians as we balance our professional and personal lives.
Personally, I’m comfortable being cared for by a doctor from the older generation, whose commitment was evident in his long hours. Of course, that assumes that those excessive hours haven’t spawned burnout, substance abuse, or divorce – all of which would negatively impact my care. I have the expertise and wealth to afford such a doctor, if I could find one who isn’t too busy. But Henry Ford reminds me that the horse and buggy aren’t the way of the future.
Dr. Kevin Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He said that he has no conflicts of interest to disclose.
It is such a common scenario. It might be 4:45 p.m. in a rural, two-doctor office, or 9:30 a.m. Saturday during rounds in the nursery, or 11:55 a.m. in a teaching hospital. You are waiting on just one more lab result before you can finish that last patient encounter of the day, but you are also running late for your daughter’s soccer game. Do you stay and finish up, or sign the problem out to your partner who is on call?
I was taught there are three "coms" that characterize ideal physicians: They are competent, compassionate, and committed to their patients above all else. Those three characteristics are reflected in the mirror each morning. Your reputation is built on them. Your patient trusts you because of them. But you don’t want to disappoint your daughter, either. "So," says the little voice in my head, "just how committed are you?"
Dr. James Gordon reflects on this in the American Medical Association Virtual Mentor column "Sharing the Pain" (Virtual Mentor 2007;9:508-10).
"In the old days, anyone who wanted to go into medicine had to be prepared for a life of exhaustion. Before laws and regulations prohibited one-in-two call, we were rapidly conditioned to accept the idea that the life of a doctor was not only one of service, but a kind of servitude. ... In the first year of residency, the fledgling doctor learns never to leave work for anyone else at the end of the day."
Dr. Michael B. Edmond reflects on how this has changed for today’s newer physicians in "Taylorized Medicine" (Ann. Intern. Med. 2010;153:845-6).
"The marked changes in the way we conduct our business in teaching hospitals have been driven by advances in technology that have improved the process of care. ... But the biggest changes have been driven by the rules of the ACGME on resident work hours and their rigid enforcement.
"Every resident now has an invisible but heavy stopwatch sitting on their shoulder, ticking loudly, constantly reminding them that their task list still has many unchecked items as time slips away."
Dr. Edmond claims that in the past, "part of the maturation process for young physicians was coming to terms with the daily unpredictability and lack of control associated with caring for acutely ill inpatients."
Dr. Gordon claims that in his era, "regardless whether you had been up all night, you did not leave loose ends for your colleagues." He goes on to claim that, "in the end, most of us embraced the pain, which made us a fraternity."
But what I see is that Generation X and Y physicians have developed a different solution with a different work-life balance. These newer doctors don’t and won’t work the long and particularly the unpredictable hours that the prior generation did. They don’t have a spouse who runs the household. They have kids at daycare who need to be picked up on time. Many prefer working 0.8 full-time equivalent (FTE). So they have adopted a different work ethic. They recognize that unpredictable events sometimes – even routinely – make it necessary to sign out work to the on-call colleague. The new fraternity is committed to relieving last night’s on-call person, and expecting the same when it is their turn. Work flow is organized to hand off tasks to ensure that the patients’ needs are always paramount. The technological tools for carrying out these handoffs aren’t working smoothly – yet.
There are advantages to this new paradigm. It reduces the House of God attitudes I saw in medical school, and that will benefit patients. It will also benefit physicians as we balance our professional and personal lives.
Personally, I’m comfortable being cared for by a doctor from the older generation, whose commitment was evident in his long hours. Of course, that assumes that those excessive hours haven’t spawned burnout, substance abuse, or divorce – all of which would negatively impact my care. I have the expertise and wealth to afford such a doctor, if I could find one who isn’t too busy. But Henry Ford reminds me that the horse and buggy aren’t the way of the future.
Dr. Kevin Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He said that he has no conflicts of interest to disclose.
It is such a common scenario. It might be 4:45 p.m. in a rural, two-doctor office, or 9:30 a.m. Saturday during rounds in the nursery, or 11:55 a.m. in a teaching hospital. You are waiting on just one more lab result before you can finish that last patient encounter of the day, but you are also running late for your daughter’s soccer game. Do you stay and finish up, or sign the problem out to your partner who is on call?
I was taught there are three "coms" that characterize ideal physicians: They are competent, compassionate, and committed to their patients above all else. Those three characteristics are reflected in the mirror each morning. Your reputation is built on them. Your patient trusts you because of them. But you don’t want to disappoint your daughter, either. "So," says the little voice in my head, "just how committed are you?"
Dr. James Gordon reflects on this in the American Medical Association Virtual Mentor column "Sharing the Pain" (Virtual Mentor 2007;9:508-10).
"In the old days, anyone who wanted to go into medicine had to be prepared for a life of exhaustion. Before laws and regulations prohibited one-in-two call, we were rapidly conditioned to accept the idea that the life of a doctor was not only one of service, but a kind of servitude. ... In the first year of residency, the fledgling doctor learns never to leave work for anyone else at the end of the day."
Dr. Michael B. Edmond reflects on how this has changed for today’s newer physicians in "Taylorized Medicine" (Ann. Intern. Med. 2010;153:845-6).
"The marked changes in the way we conduct our business in teaching hospitals have been driven by advances in technology that have improved the process of care. ... But the biggest changes have been driven by the rules of the ACGME on resident work hours and their rigid enforcement.
"Every resident now has an invisible but heavy stopwatch sitting on their shoulder, ticking loudly, constantly reminding them that their task list still has many unchecked items as time slips away."
Dr. Edmond claims that in the past, "part of the maturation process for young physicians was coming to terms with the daily unpredictability and lack of control associated with caring for acutely ill inpatients."
Dr. Gordon claims that in his era, "regardless whether you had been up all night, you did not leave loose ends for your colleagues." He goes on to claim that, "in the end, most of us embraced the pain, which made us a fraternity."
But what I see is that Generation X and Y physicians have developed a different solution with a different work-life balance. These newer doctors don’t and won’t work the long and particularly the unpredictable hours that the prior generation did. They don’t have a spouse who runs the household. They have kids at daycare who need to be picked up on time. Many prefer working 0.8 full-time equivalent (FTE). So they have adopted a different work ethic. They recognize that unpredictable events sometimes – even routinely – make it necessary to sign out work to the on-call colleague. The new fraternity is committed to relieving last night’s on-call person, and expecting the same when it is their turn. Work flow is organized to hand off tasks to ensure that the patients’ needs are always paramount. The technological tools for carrying out these handoffs aren’t working smoothly – yet.
There are advantages to this new paradigm. It reduces the House of God attitudes I saw in medical school, and that will benefit patients. It will also benefit physicians as we balance our professional and personal lives.
Personally, I’m comfortable being cared for by a doctor from the older generation, whose commitment was evident in his long hours. Of course, that assumes that those excessive hours haven’t spawned burnout, substance abuse, or divorce – all of which would negatively impact my care. I have the expertise and wealth to afford such a doctor, if I could find one who isn’t too busy. But Henry Ford reminds me that the horse and buggy aren’t the way of the future.
Dr. Kevin Powell is associate professor of pediatrics at St. Louis University and a pediatric hospitalist at SSM Cardinal Glennon Children’s Medical Center in St. Louis. He said that he has no conflicts of interest to disclose.