Life is short, the art long, opportunity fleeting, experience treacherous, judgment is difficult. It is not enough for the physician to do what is necessary … the circumstances must be favorable.
Although the resident work hours debate has focused appropriately on providing the safest environment for training and medical care, the broader impact of such changes on the development of empathy and the expression of moral character in medicine is unknown. The development of ethical physicians is highly linked to experiences in the training period and therefore deserves careful consideration in the setting of fundamental changes in the structure of residency training and the consequent changes in the patient-physician relationship.
Changes in the traditional model of care and residency training create a tension between the need for self-health and the professional ideals of altruism and self-sacrifice. As a profession, we share the moral imperative that the patient's well-being is our first concern. However, a reduction in work hours raises concerns of the development of a “pass-off” mentality in patient care in which the clock arbitrarily defines the availability of our care and compassion.2–3 This inescapable tension lies at the heart of the ethical conundrum that residency programs face as they attempt to create a delicate balance among conflicting allegiances and unknown consequences.
Obstacles to Professionalization
The organizational context of medicine affects the physician's ethical behavior and professionalization. The informal curriculum, which influences the way trainees perceive standards of comportment and internalizes these observations, is an important component of this organizational culture.4 This socialization is a process of moral enculturation that transmits normative rules regarding behavior, expectations, and professional identity. Unfortunately, several studies report that medical students and physicians in training have witnessed unethical behavior or have done something they believed was unethical.5–7 Trainees who witness an episode of unethical behavior are more likely to act improperly themselves for fear of poor evaluation or to fit in with the team. These same students are more than twice as likely to report erosion of their ethical principles if they had behaved unethically for fear of poor evaluation.5 A pre-Accreditation Council for Graduate Medical Education duty hours restriction survey of 1,181 premedical students, medical students, residents, and clinical faculty found a consistently decreasing empathic score during training, which was highest in premedical students and lowest in medical residents.8
The consequence of long duty hours on the moral development of physicians is less understood. Long hours have been a professional expectation that is considered to be a rite of passage for physicians in training. It has become synonymous with the notion of total dedication to patient care. However, extended work hours have serious unintended consequences. The clinical environment of medical training programs can be so intense as to lead to conditions that may actually deprofessionalize trainees. Residents have been shown to develop a “getting rid of patients” attitude in demanding work environments characterized by heavy workloads, excessive time demands, and insufficient education in the emotional aspects of health care.5–11 The end result is burnout. Burnout, a state highly associated with a loss of empathy and inattention to personal and patient needs, is associated with emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment.12–13 Many studies have documented the association of decreased empathy and mood disturbances such as depression with sleep deprivation.14 Instead of a high quality of care, long hours can lead to suboptimal patient care and diminished job commitment.15–16
Physicians are not solely individual moral agents. They are embedded in a social environment that can either facilitate or hamper their commitment to the professional ideals of medicine. Social psychologists have conducted observational studies and simulations underscoring the importance of both individual and situational characteristics in eliciting helping behavior.17 Time constraints are a ubiquitous feature of medical practice. Studies have shown that perceived time constraints can limit people's willingness to help others. Using a simulated scenario, one study involving students from a seminary demonstrated that even in students training for a helping profession, such as ministry, the degree of time pressure determined the degree of assistance (63% helped if they were early; 45% helped if they were right on time; 10% helped if running late). Being only a few minutes late was enough to dissuade helping behavior. Importantly, a few helped even when under a time crunch.18 Helping behavior is still evident under less than ideal circumstances, but its occurrence is not optimized. Constantly rushed physicians in the clinical encounter may be less likely to go beyond the required technical aspects of medical care. Optimizing empathic connection with patients requires time.19
Professional Ideals and Work Hours Limits
Physician professionalism is rooted in altruism and entails the ideals of selfless commitment, excellence of care, duty, accountability, and compassion in the doctor-patient relationship. These ideals are at the core of the “patient ownership” notion, a notion physicians are expected to embrace. With the introduction of work hours limitations causing a discontinuity of care, there is growing concern with the perceived erosion of these professional ideals.20–21
A competing ethical dilemma is posed by the inevitable loss of autonomy that physicians in training face, in situations in which they would want to stay with their patient to provide care (or perhaps learn more about their social situation) at a time when the duty hours rule has been exceeded. Although this may occur rarely in a system with a low work burden, it will inevitably occur if residents are to be granted any degree of responsibility. In this situation, residents must choose between obeying the rules and attending to a patient—a direct challenge to the ethical principles of altruism and selflessness.
Accountability is another ethical principle that requires redefinition in the setting of shorter shifts and more patient-care handoffs. We hear senior physicians lament the inevitably increasing refrain, “I don't know. I am just covering the patient.” Work hours limits lead to increased turnover of patient-care responsibility with a concomitant increased propensity for medical errors. In addition, residency programs, with accreditation precariously hanging on trainee sign-out time, may focus more attention and punitive consequences of the timing rather than the quality of care.
Physician career satisfaction faces assault from many directions. Our professional ideals demand from us large amounts of time. However, increased work hours are associated with higher rates of professional dissatisfaction.22 Importantly, high self-reported physician satisfaction is strongly linked to patient satisfaction and greater levels of trust and confidence in their physicians.23–24 In addition, increased resident physician well-being is associated with enhanced empathy and, thus, possibly improving doctor-patient relationships.25
Some of the features most highly associated with career satisfaction among physicians, such as autonomy, relationships with patients and colleagues, are at greatest jeopardy in the era of tightly restricted work hours. In many cases, the institution of work hours rules has resulted in less patient contact and educational programs, with similar amounts of administrative tasks squeezed into the remaining time.26–28 Although other measures to address this, such as stricter caps on the number of admissions and procedures, have been implemented, it has appropriately been done so cautiously so that residency graduates will have attained competency that depends on seeing a large number of patients or performed a large number of procedures. Specialties that require broad expertise, such as general surgery or outpatient medicine, could suffer in comparison with increased subspecialization of a narrow topic, with high potential to further erode the availability of empathic and available primary providers.
The ideals of physician professionalism are difficult to achieve relative to the viewpoint of the “days of the giants” when an individual could, and therefore should, do everything. Our ethical identity is larger than any single physician. A team approach to medical care should not diminish our highest ideals, but such a change will require a new type of education, often delivered by an older generation of physicians grounded in the sentiment of the “personal ownership of the patient.” The new generation “owns” patients only as part of a team.
Work hours restrictions can improve a physician's ability to meet the ideals of excellence in care by increasing physician well-being, decreasing fatigue-related errors, and thus enhancing patient safety.29 If safe patient-care transitions are ensured, then the inevitable increase in handoffs from one physician to another will not increase mortality or utilization.30–31 Hence, attending physicians can begin to worry less about the negative impact of work hours restrictions and begin to build new and enlightened models of medical professionalism.32–33
Moral Traits: From an Individual to a “Systems” Model
Medical professionals are a community of highly educated individuals with a commitment to a core set of ideals and principles. This community provides both technical and ethical socialization. It is commonly held that physicians should embody and consistently demonstrate certain virtues such as compassion, altruism, accountability, and empathy. These virtues are seen as individual characteristics that comprise the internal framework of moral character. But moral traits are also situation-sensitive psychological and behavioral dispositions. We all have them and are the products of our life experiences, sociocultural education, and temperament. Moral traits can work together or separately and are analogous to skills. No one thinks it strange that one person might be good at mathematics but terrible at drawing. Similarly, one could be very dependable and skillful in a trait such as being truthful and yet unpredictable in expressing and practicing empathy. Different skills develop to greater or lesser degrees in an individual. This leads to the phenomenon of discovering, for example, that a “morally outstanding” physician at the hospital is also mired in an embezzlement scandal.
How do we promote the connection between the patient and the doctor and optimize the expression of moral virtue in medicine? The dynamic relationship between individual character traits and the situational dependence of their expression suggests that a systems approach will help promote and nurture moral development. In other words, to optimize the chances for high moral character among training program graduates, educators need to create a system in which the default is to engender ethical behavior.
The shift from an individual model of medical errors to a systems approach provides an important parallel for understanding the nature of clinical empathy. Patient safety is a major pillar of medical practice, but, nonetheless, errors occur. The punitive model of faulting the individual has been shown to be inadequate in preventing further errors. The Perfectibility Model of errors claims that if physicians and nurses could be trained appropriately, there would be no mistakes.34–35 This shift has proven to be beneficial in creating a professional culture that allows for both increased error reporting (both near misses and adverse events) and identification of nonpunitive loci for preventive intervention. Successful error prevention occurs in a system in which it is literally difficult to make an error.34 Similarly, empathy is not only an inter- or intrapersonal characteristic but also a system characteristic that should sustain and nurture physicians. By reducing physical and emotional exhaustion while allowing for the maximal level of empathy, we can help make it easier for physicians to make decisions that strengthen the doctor-patient relationship.
Moral behavior is a community-driven and -supported process. Accountability is an essential component of this endeavor. In response to the horrors of unaccountable research experimentation in the 20th century, institutional review boards were created to ensure compliance with ethical standards.36 They are a structural safeguard for our moral decision making that prevents researchers from being lone moral agents without accountability. Similarly, reducing work hours has been a structural change that will help preserve public safety by preventing physicians from taking the moral “shortcuts” that can occur with increasing work and time pressures. Work hours rules are beneficial but insufficient to optimize an ethical work and training environment.
Expanding the Systems Model Across the Resident Education Continuum
Ethical behavior can be supported by systems that make it more difficult to veer from the ideal. In conjunction with work hours reforms, other system changes must be implemented to address the inescapable tension between self-sacrifice and self-health that exists because of the unpredictable nature of providing medical care. The tension placed on trainees should not be between the patient's well-being and the resident's adherence to work hours rules. Instead, the system needs to allow both needs to be met. This is an opportunity for the medical profession to develop new standards for individual accountability within a team of providers. The rules that govern call systems need to be flexible enough to allow for occasional situations in which a resident physician, for example, who wants to remain at the bedside of a dying patient beyond the daily allotted hours, can do so safely. If the overall sleep debt is reduced and closely monitored, this could be done in a number of ways. The physician could be allowed to stay and then have the next day off or allowed to do so with transportation home and a later subsequent start time. In recognition of the many areas of sleep science that are not well understood, programs should be allowed to experiment with alternative systems that promote patient continuity in settings in which patient safety, resident safety, and work intensity are carefully monitored.
The process of high-quality handoffs as a component of team care can be taught to residents to minimize fractured care.37–38 It will be necessary to include residents at both ends of the handoffs in teaching conferences and case reviews ensuring that constructive feedback is given. The use of computer systems with handoff templates would also optimize quality. In the right setting, a clinician who is assuming care for a patient is more likely to discover an unrecognized problem than to err because of the “freshness” of the case.39 This requires the teaching of individual empowerment, which is most likely to occur among well-rested trainees.
Team care will need to be defined broadly. The use of multidisciplinary rounds—faculty, residents, nurses, pharmacists, social workers—as a standard component of rounding on patients would reduce the emphasis on only one individual as the main provider for a patient. The concept of night-float coverage should be replaced with “night-time team members” and should include overlapping schedules and team teaching as a mechanism to reinforce learning and personal accountability. The concept of team care should be expanded to include pre- and posthospital care givers and off-hours (emergency) as well as routine interactions.
Team practice must balance the role played by the attending physician in bridging the continuity gap with the need for graduated autonomy by the residents. This critical balance relies on avoiding excessive work loads for trainees and their supervisors through graded caps. Although surely all patients deserve empathy, in high-intensity environments, the creation of nonteaching services with triage of patients with the highest educational value, rather than the ebb and flow of hospital triage needs, to the care of resident physicians will have additional benefits on professional development. The team approach allows physicians in training to surrender some of the noneducational administrative tasks that replace valuable time spent with patients.40 Time in ambulatory clinics should be designed to avoid conflicts with inpatient demands, as is currently the case in the majority of residency programs. To achieve this, accrediting organizations should shift the burden of requirements from the number of clinic sessions to the quality of the continuity experience, from the perspective of both the patients and the trainees. Surveying patients on their satisfaction with care and communication would be an important quality assurance measure. Residents should be actively engaged in defining and measuring the quality of their own experience and then initiating remediation for improvement. To learn the consequences of their clinical decisions, as a baseline, computer systems should allow for residents to routinely follow their patients even after signing out, signing off, or discharge.
Staffing needs to be adequate to relieve interns and residents of the moral dilemma of choosing between providing adequate care and adhering to time rules. Rather than doing everything faster, the time spent in patient care should be devoted to tasks directly relevant to patient care and should be measured in meaningful terms such as time spent with patients, quality of physician-patient communication, patient outcomes, patient satisfaction, resident learning, and professional development. Additional experiences, such as postdischarge home visits, may promote empathy and systems-based care improvements, but they will only be possible by limiting the existing tasks that currently fall on the housestaff. To minimize the moral conflicts faced by young physicians, trainees should have options that are ethical, safe, and easy. At most institutions, this will require significant infrastructure investment that represents an important shift from viewing of residents as labor to apprentices. In addition to the systems changes, the most critical aspect of retooling the educational experience will be to promote the evolution of the faculty who supervise them from thinking in terms of “my day” to “how we can do a better job for the patient.” Residents should also be trained in ethical principles and in how they apply to daily medical care. An effective system of ethical training will recognize the natural limits of humans to attend to each individual's myriad concerns and needs.
The AMA Code of Medical Ethics41 states that the medical profession has an “obligation to ensure that its members are able to provide safe and effective care. This obligation is discharged by promoting health and wellness among physicians.” In light of medicine's commitment to beneficence, this obligation to wellness requires a strong commitment to creating training programs that can create physicians who embody medicine's highest ideals. Rested and emotionally balanced physicians can begin to be more empathically present with their patients, patient's families, and their own colleagues, as long as that obligation remains central.
Habituation to distress cues can lead to the loss of empathy. Training physicians in a stressful environment will lead to ethical erosion, not better physicians. As a professional community, we are obligated both to inculcate a body of knowledge and to model the behaviors of our profession. In times of transition, resistance to change is inevitable. Medical education leaders should appreciate that work hours reform is beneficial but insufficient to address safety and quality in the broadest professional sense. Attention to the effects on the moral behavior of physicians requires a new approach to medical training that will move the profession toward a broader ethical model in which systems are in place to ensure that the safe and ethical choice is the easiest choice. Mindful of our fragile moral lives, we believe that work hours reform has been an important step toward creating an ethically sustainable workplace. Hippocrates1 notes, “It is not enough for the physician to do what is necessary, but the patient and the attendants must do their part as well, and circumstances must be favorable.” As we continue in our forward march to heal the sick, let us put into action what Hippocrates said 2,500 years ago, “to make the circumstances favorable.”
Dr. Lopez acknowledges the support of an Institutional National Research Service Award #5 T32 HP11001-19.
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