A few years ago, I attended a medical staff meeting at the hospital that employed me at the time. These meetings weren’t particularly high on my list of things I loved about the job, and often involved discussions that didn’t really concern me or covered issues over which I had little say and no control. As such, I tended to devote less than my full attention to them. However, I remember this meeting quite well.
Without getting inadvisably detailed, it’s relevant to note that the hospital in question had recruitment difficulties. It wasn’t in a location that was sufficiently desirable to be a draw in itself, and I recall there always being numerous open spots they were trying to fill. They weren’t swimming in applicants clamoring to work there. The reason I mention all of this is that at this meeting several of the more senior members of the medical staff were indulging in a gripe session about the poor priorities of the newer, younger staff members. (Being easily the youngest, newest member of the medical staff present, I kept my fool mouth shut.) These new doctors didn’t want to attend meetings after hours! They were fiercely protective of their private time! They didn’t want to take on extra, non-clinical duties! What was wrong with them? Didn’t they know they were doctors?!
I found it remarkable that members of the medical staff at a hospital with long-term recruiting problems felt like they were in a position to make demands of that nature. How did they expect to meet their staffing needs, if they weren’t willing to accommodate the expectations of the younger generation of physicians? Who did they think they were, to set these standards for doctors worthy enough to join them? I shake my head in wonder at their combination of arrogance and obliviousness to their own situation.
I’ve written about this attitude that pervades my profession before. Husband-of-doctor and LOOG chum Will sees it in how his wife is expected to order her life around her career. “Real” doctors subsume their entire selves into their professional lives. Families, outside interests, their own well-being — these are the considerations of other people. Physicians put their medical practice first at all times, or at least the good ones do. Perhaps it goes without saying that I find this attitude unhealthy, unrealistic and unsustainable. Thankfully, it is now increasingly outmoded. From an article in the New York Times:
For decades, medicine has been dominated by fiercely independent doctors who owned their practices, worked night and day, had comfortable incomes and rarely saw their families.
But with two babies, Dr. Dewar wants a life different from her father’s and grandfather’s. So instead of being an entrepreneur, she will become an employee of a large corporation working 36 hours a week — half the hours her father and grandfather worked.
Her decision is part of a sweeping cultural overhaul of medicine’s traditional ethos that along with wrenching changes in its economics is transforming the profession. Like Dr. Dewar, many other young doctors are taking salaried jobs, working fewer hours, often going part time and even choosing specialties based on family reasons. The beepers and cellphones that once leashed doctors to their patients and practices on nights, weekends and holidays are being abandoned. Metaphorically, medicine has gone from being an individual to a team sport.
For doctors, the changes mean more control of their personal lives but less of their professional ones; for patients, care that is less personal but, as studies have shown, more proficient.
Older doctors view these changes with considerable ambivalence, among them Dr. Dewar’s 90-year-old grandfather and 61-year-old father, although both supported Dr. Kate Dewar’s decisions and were thrilled about the birth of her twins.
The article goes a bit off the mark by focusing so much on the youngest Dr. Dewar, using her as an indicator of broad medical trends. As is clear from the bulk of the story, she found primary care uninteresting, and so it was probably not just the hours that drew her to emergency medicine. Her father and grandfather lament the lack of connection she will feel to her patients as compared to theirs, but this has more to do with her working in an ED than with her choice of circumscribed shifts. What’s true for her is probably not true for new physicians who go into internal medicine, family practice or pediatrics. It’s certainly not true for me.
Now, perhaps my experience isn’t indicative of broader trends either. I do carry a beeper and office cell phone for my on-call duties. My office does have weekend hours, and we do see patients on holidays if needed. Contrary to what is increasingly the norm, we have retained admitting privileges at more than one hospital so we can care for our own inpatients, rather than admitting them to a hospitalist service. We are somewhat unusually accessible to our patients in these regards. But even so, neither I nor my colleagues have been forced to choose between our careers and our families, and I dispute that this must be an either/or proposition, or that protecting our private time means our priorities are out of whack. When I am at work, I am fully at work; the converse is true at home.
There are lots of little fillips throughout the Times article that give a sense of how things were back in the day. This one stood out in my mind:
Dr. William Dewar II opened his practice 67 years ago at his home in Catasauqua, Pa., an Allentown suburb, with his wife, Thelma, as his lone nurse and assistant. He delivered babies and set broken bones. Sick patients showed up on his doorstep at all hours, with some sleeping over. When they needed to be hospitalized, Dr. Dewar oversaw their care. Patients paid cash — $2 for an office visit and $3 for a house call, fees that covered most needed medicines.
Thelma Dewar handled the bills and laboratory tests, often by cooking urine samples on the stove before analysis.
“I loved my practice. Totally loved it,” Dr. Dewar said. “You were in touch with the patients. They were part of your family.”
My first thoughts on reading this were: 1) “gross” and 2) “I suspect you’d need a CLIA waiver for that.” The older Dr. Dewar’s patients doubtless loved that they could stumble to his door at all hours, get affordable care and even a bed for the night (probably also a hot meal). He has my sincere admiration, and it would be idiotic for me to pretend that I have (or want) this kind of connection with my patients. But is it even necessary to enumerate all the ways that contemporary medical practice has changed since his heyday? The world of medicine is so vastly different that it’s ridiculous to expect the way we prioritize our professional lives to be the one constant. One may as well lament the demise of the Studebaker.
If you think that doctors should consider their patients part of their families, then this change is for the worse. But I really don’t think so. I care about my husband and son more than I care about my medical practice, and I always will. That doesn’t mean that I don’t care about my patients, or give them their due. That doesn’t mean I’m not committed to being a compassionate, diligent and competent physician. Quite the contrary — I am far better as a pediatrician because I am also a parent, and know what parenting is like. I am far more attentive during my office hours because I know that I don’t have to rush in order to have time for my family. My patient always have access to me or a colleague, and nobody’s care is made lacking by this arrangement. It may not have been how things used to be, but it strikes me as a perfectly appropriate state of affairs.