Tuesday, September 18, 2012

The evolution of the inpatient attending physician: JAMA Viewpoint

I enjoyed this recent perspective article in JAMA by Dr. Bob Wachter of UCSF and Dr. Abraham Verghese of Stanford about the role of the inpatient ward attending in the "modern era" of hospital medicine, with the rise of the hospitalist movement and housestaff duty hours restrictions. Full text is available here. Again, I am sorry this is only available to JAMA subscribers or institutional members. However, you can listen to a very nice audio summary interview by JAMA editor Howard Bauchner and the two authors free of charge (scroll down to the 9/11/12 podcast).

When I was an internal medicine intern and resident at UCSF in the late 1980's - and coincidentally Bob Wachter was one of my chief residents at the time - the ward attending was a senior physician who was supposed to be in charge of our team of residents (usually 2-3 interns and 1 second-year resident) and would "supervise" us. But the reality was that we had tremendous autonomy in those days, and it seemed as if most if not all of the medical decisions on the patients on our service were made by us, the housestaff, all of whom had been out of medical school 2-3 years at the most, and not by the senior guy. His/her job was to spend a little time teaching, often about topics related to his/her subspecialty, whether relevant to the patients at hand or not, to write the daily attending progress note, and then to get out of the way and go back to the lab or office. The non-physicians reading this will no doubt find that level of (non)-supervision deplorable, and now with the perspective of almost 30 years behind me, I would have to agree with you. We did have too much autonomy, and it was not an ideal situation from a patient safety or quality of care standpoint. I'm glad it is so different now. However, lest you think it was unconscionably reckless and bordering on malpractice, we usually did a very good job taking care of our patients, and we learned to be responsible, obsessively detail-oriented, and independent in our medical reasoning and decision-making. And there was no doubt that the patients viewed us as their real doctors during that hospital stay, not the semi-anonymous old guy in the long white coat that came in 5 times a week parading in the room with a huge team of unknown people wearing scrubs and short white coats, all the while not saying much and deferring to the sleep-deprived young 'uns with the clipboards and pockets jammed with papers.

I like this perspective article because it was balanced and was not one of those "days of the giants" pieces romanticizing the old way of practicing medicine. In the modern era, attendings are usually young physicians themselves, often hospitalists physicians, who are not that many years out of training, but are typically much more involved in the day-to-day activities than 1980's attending. They are personally responsible for every major medical decision, as it should be. The hospital team structure these days is much more matrixed and redundant, and in my opinion much better for patient safety and continuity. Still, in the olden days before EHR's and discharge planners, the bedside teaching we received from the senior physicians, with a greater emphasis on interacting with the patient, listening to the patient story, and doing the physical exam, had plenty of merit, even in its brevity. Hope you enjoy the piece.

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