COMMENTARY

Doctoring for Dollars -- When Did We Take That Oath?

Julian L. Seifter, MD

Disclosures

May 21, 2015

Bound by Vows, Tied to Responsibilities

Julian L. Seifter, MD

Doctors are caught between two kinds of commitment: the promise we made on entering the profession to put our patients first, and the demands of a job that sometimes pulls us away from patients, piling on tasks not directly connected to their care or well-being but required by hospitals, insurers, or government agencies. In a way, we are held hostage by the oath we are true to. When I attended my graduation ceremony at Albert Einstein College of Medicine, several decades ago, the class recited the Oath of Maimonides, including the following language:

Inspire me with love for my art and for Thy creatures. Do not allow thirst for profit or ambition for renown and admiration to interfere with my profession, for these are the enemies of truth and of love for mankind, and they can lead astray in the great task of attending to the welfare of Thy creatures.

Whether it's Maimonides or Hippocrates or more modern variations, the vow to put patients first, regardless of all other considerations, remains the same. We can't rise up and say, "Enough! (of code numbers, pharmacy calls, paperwork)." We have to find a way to stay true to our professional responsibilities to our patients while also meeting the demands of our jobs. Clinicians often find themselves in a bind: They can't do it all; they have to do it all.

Clinicians often find themselves in a bind: They can't do it all; they have to do it all.

An example: It's 10:00 PM when I get to the parking garage, and then I can't remember where I left my car. When I arrived, 14 hours ago, I was thinking about the day ahead and didn't notice which floor I was on. Using my remote key, I follow the beeping sound one floor up and find my Volvo, alone except for one other car parked a few spaces away—and there's my friend, just getting into the driver's seat. The parking gods seem to like to put us near each other; we often meet here at this late hour. She is a primary care physician, my age. Turns out her last patient was at 5:00 pm. She fills me in on what she has been doing for the last 5 hours: writing notes, answering calls and email, searching for labs, writing to colleagues about shared patients, meeting with one of her patients who has been admitted to the hospital, leaving a note in the chart—a typical day not unlike mine.

Borrowing From Peter to Pay Paul

Not everyone with professional obligations works 14-hour days. Recently I was on an evening flight out of Cleveland—the last flight to Boston on a Sunday—and my plane, delayed for 2 hours in Virginia, had finally arrived at Hopkins International. Once we had boarded and the plane had taxied onto the runway, I breathed a sigh of relief: I was going to make it home so I could get to work for an early Monday meeting. But after idling on the tarmac for 10 minutes, the plane turned around and taxied back to the gate. The pilot's voice came over the loudspeaker: "We're sorry, but we are 5 minutes over the maximum time allowed for a pilot to work in one day." Needless to say, I missed my Monday morning meeting.

Pilot fatigue is taken seriously. Some 30 years ago, house staff fatigue began to be taken seriously. The Libby Zion case resulted, as everyone knows, in strict regulation of the length of residents' work shifts, reducing trainee errors caused by lack of sleep because (obviously) they are no longer sleep-deprived. The fallout has been complicated, however. Errors arising from faulty "handoffs" also pose a risk because (obviously) now there is a handoff where there wasn't one before; residents, receiving a more piecemeal exposure because of the time restriction, can no longer follow a complex illness for a consecutive 36 hours.

Then there is the kind of phone call I get from the renal fellow at 3:00 AM Should she go into the hospital to see a uremic patient who is in the emergency department? It's not a clinical question but a scheduling one: If she comes in to see the patient in the middle of the night, she can't come to my afternoon clinic the next day because she'll have to leave at noon. At some point in my career, it became harder to keep abreast of these rules than to manage a potassium of 8 mEq/L and a pericardial friction rub.

 
why are hour restrictions applied only to the young, physically fit house staff and not the older physicians?
 

Sometimes I think we have this hours thing all wrong. If sleep deprivation impairs good judgment and worsens patient outcomes, why are hour restrictions applied only to the young, physically fit house staff and not the older physicians? You know—the ones who fall asleep during grand rounds that they are required to attend to get enough credit to stay credentialed. Is sleep important only before you are in practice? I can hear Mark Twain saying that "a good night's sleep is wasted on the young."

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