Douglas R. Bacon, M.D., Editor

What Are We Teaching?

A response was needed.

A recent letter to the editor that commented on an October 2003 NEWSLETTER article¹ needed an editorial remark, yet the usual two or three lines I could write just did not seem sufficient. At issue was the tension that has appeared more and more frequently between the generations of physicians concerning dedication, self-sacrifice and in some measure the very definition of professionalism in medicine.² In a fascinating article published in the Annals of Internal Medicine titled “Medical Professionalism in the New Millennium: A Physician Charter,” the authors describe the elements of professionalism in terms of the societal expectation of both patients and physicians. At issue here was a “fundamental principle” called the “principle of primacy of patient welfare.” This physician charter claims that “market forces, societal pressures and administrative exigencies must not compromise this principle.”³ The term “residency” was created because the physician in training never left the hospital; he or she was in residence to handle any and all patient care issues. The Accreditation Council for Graduate Medical Education (ACGME) has imposed a modern redefinition of residency for all specialties with limited work hours and specific time off.⁴ The exchange between ASA NEWSLETTER authors clearly demonstrates the paradigm shift in training, which some claim strikes at the very definition of professionalism that this administrative exigency is creating.

The article that sparked the letter to the editor was written by resident member Jill E. Beland, M.D. In her essay, Dr. Beland reminded the ASA NEWSLETTER readership of the financial and emotional realities that medical education and residency impose upon those training in the early 21st century. Debt piles up to the point where it may be mid-career before the educational loans are satisfied. I sympathize with her concerns about the economics of fellowship training, and for that very reason, I did not pursue further subspecialty training. There has never been a good time to start a family during medical school or residency for either women or men.

There are tremendous financial and emotional burdens associated with residency training, but there always have been. The Anesthesia Foundation, created in the early 1950s, has long recognized the financial concerns of residency training, magnified now by the increasing costs of medical education, and has tried to ease financial problems with loans that are to be repaid after training. As a credit to our colleagues, the repayment rate exceeds 90 percent.

Responding to Dr. Beland’s article in the February 2004 NEWSLETTER, Wendy J. Watson, M.D.,⁵ compared current American residents to those in training with whom she worked in Moshi, Tanzania, at the Kilimanjaro Christian Medical College (KCMC). Simply put, the letter seemed to be saying to our most junior colleagues, “Stop whining, you don’t know how good you have it.” Dr. Watson details the life of the residents at KCMC. An explanation is needed, however. Is the resident living six and a half hours from his or her family because there is no housing for families at KCMC, or is this the resident’s own choice for personal reasons? Also while $2,000 seems to be a very meager yearly salary, what is its relative worth in Tanzania?

As a lifelong academic anesthesiologist who trained just before the Bell Commission recommendations became law in the state of New York in 1989, I have been tempted to tell my current students about the “good old days” when there were no restrictions on working hours. I have worked more than 80 hours a week for more than four weeks straight and never felt that patient care was enhanced by long work hours. There remains the concern, however, that by limiting resident work hours, young physicians would see themselves as hourly workers, and this would “… sever the bond between doctor and patient — a bond that has been the bedrock of our conception of a physician.”⁶ In an interesting irony, if this argument is followed to its logical conclusion, the “principle of the primacy of patient welfare” is endangered by the very institution, ACGME, charged with teaching professionalism!

The opinions of both Dr. Beland and Dr. Watson strike at the heart of the debate about professionalism. Why spend all those hours in the hospital working? Neither author speaks about the rewards of training, of being an anesthesiologist or of being a practicing physician. Outside of pain medicine practice, anesthesiologists rarely have long-term relationships with patients. Our physician-patient relationship is of short but intense duration, and we often learn more about the patient beyond the written history and physical by their reaction to our anesthetics. We must gain the trust of our patients, for we are about to accompany them on a journey between life and death, and they must trust us with their most treasured possession, their life. Oftentimes we have less than five minutes to establish this complex relationship.

While we can focus on the sacrifices we all have made and continue to make, anesthesiology, medicine and our patients are all the poorer. As professionals we need to continue the attitude, somewhat endangered by counting hours, that the patient comes first.

The very best example of this patient-first philosophy may be found in a very short essay published in the Journal of the American Medical Association in 1997. “He Lifted His Eyes”⁷ tells the story of an anonymous resident on his pediatric rotation. The resident is described as tall and red haired, tired with bags under his eyes. Yet during his history, despite his fatigue and the fact that the Mediport removal is a “minor” case, the resident notes the fear in the small child for whom he must care. Speaking with the child and mother, he decides not to access the port and perform an intravenous induction, the one thing the child fears, but to use volatile agents and let the child become anesthetized in the manner in which she desired. The resident told the little girl her favorite bedtime story as he quietly induced the anesthetic.

The last sentence of “He Lifted His Eyes” never fails to elicit a strong emotional response. “[The resident] had noticed a little girl’s unstated fears and transformed the last, dreaded procedure into a gentle triumph.” This is the intense physician-patient relationship anesthesiologists forge every day in the operating room. In our haste to examine all that is wrong with our lives and our profession, we fail to notice the things we do right. Knowing that one has made a difference by working each day to uphold the “principle of primacy of patient welfare” is what it means to be a professional. Recently rereading the classic American novel about training, The House of God,⁸ convinced me that it was not the patients who were to blame, as the author suggests, but the attending staff for the unprofessional tone of the book. By not supporting the emotional needs of the residents, the attending staff created a hostile reaction in the residents toward their most vulnerable patients. Acknowledging that our junior colleagues have emotional needs and pointing out where and how they make a difference in the care of a patient is as important as critiquing their anesthetic management.

Professionalism is what we must teach our medical students and residents and what we should show our colleagues each day by the manner in which we practice. I went into medicine to care for my fellow human beings; it is why I stay active and why I hope to continue doing so for the next 20 years or more. The “principle of the primacy of patient welfare” makes medicine in general and anesthesiology specifically the most noble of professions, privileged beyond the counting of hours, sacrifices or cost.

– D.R.B.

References:

1. Beland JE. The cost of being a resident. ASA Newsl. 2003; 67(10):32.

2. Adams D. Generation gripe: Young doctors less dedicated, hardworking? American Medical News Online. Feb. 2, 2004. <www.ama-assn.org/amednews/2004/02/02/prl20202.htm>. Accessed on February 9, 2004.

3. ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: A physician charter. Ann Intern Med. 2002; 136:243-246.

4. Resident Duty Hours Language: Final Requirements. <www.acgme.org>. Accessed on February 9, 2004.

5. Watson WJ. The relative cost of being a resident. ASA Newsl. 2004; 68(2):38.

6. Holzman IR, Barnett SH. The Bell Commission: Ethical implications for the training of physicians. Mt Sinai J Med. 2000; 67:136-139.

7. Keene N. A piece of my mind. He lifted his eyes. JAMA. 1997; 277(19):1502.

8. Shem S. The House of God. New York: Dell; 1995.

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