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Posted on August 19, 2016 at 3:15 PM

by Jon C. Tilburt, MD & Richard R. Sharp, PhD

Discontinuity, handoffs, and shiftwork have infiltrated the fabric of healthcare. These changes, made in the name of patient safety, may have the unintended effect of reducing residency training to little more than a terrible shift job, disconnected from the professional ethos so critical to the practice of medicine.

In their piece in AJOB this month Dubov and colleagues highlight several problems with resident duty hour restrictions. They postulate that cultivating a vocabulary of personal and professional “ownership” could counteract the detrimental effects of those restrictions. Their facility with the duty-hours literature is impressive and they rightly note how duty hour restrictions may have especially deleterious effects on surgical training. They also appeal to behavioral economics, arguing that short-term work distorts the kind of global and longitudinal reasoning that medical training should foster, writing: “Lack of decision ownership is similar to fighting one battle at a time without a guiding strategy.”

But in many ways, the need to fight one battle at a time is what much of modern medicine has been reduced to—trying to address complex and multilayered health problems with discrete procedural and pharmaceutical solutions delivered intermittently, often by strangers. In that sense, inpatient admissions are a microcosm of modern medicine’s limitations. In this brave new world, the rhetoric of patient “ownership” will most likely be drowned out by a constant need to “get ‘em out” before the shift ends and a new team of strangers takes the helm. It is perhaps only in some nostalgic past that we can imagine a resident being as deeply invested in her patients as Dubov and colleagues propose, free of systemic pressures to meet patient volume goals and motivated solely by an authentic desire to do what is best for each individual patient.

The vocabulary of ownership introduced by Dubov and colleagues should remind us that the raw and challenging conversations that animated early duty hour conversations are still possible. Those who would ask whether medical professionalism is under siege may find in this rhetoric a new way to raise questions about nobility, professional grit, and authentic patient advocacy. Since the first duty hours were imposed in 2003, conversations about medical professionalism seem to have drifted, drifted toward a vocabulary of competence, behavioral conformity, and even wellness. In contrast, the concepts of professionalism that resonated with earlier trainees were laden with heavy notes of paternalism, self-sacrifice, and personal investment in ways that now strike many physicians as much too intimate and outdated.

There is surely something about the rightness and wrongness of going to bat for a patient that is worth talking about, even when that effort may be at odds with the rules that govern resident work. If nothing more, the linguistic maneuver that Dubov and colleagues suggest, punctuated with an appeal to organizational psychology and behavioral economics, feels more palatable and fresh than hauling out Pellegrino’s list of virtues for the health professions (as relevant as they may still be). In that spirit, we greatly appreciate how the articles in this issue of the journal challenge the presumed benefits of duty-hour restrictions, making those rules feel strange enough to question once again–not because we should go back to that prior state, but because we need a better way forward.

Dubov and colleagues postulate that the temporal association of duty hours with care fragmentation is more than just an association but reflects causation, proximally mediated by a decline in “ownership.” It could also be that duty hour restrictions and handoffs were both the result of a broader deprofessionalization already afoot, a movement that advocates of personal “wellness” and “lifestyle professionalism” were eager to promote in the guise of their respective brands. The practice of medicine may be changing, but not merely as a consequence of duty hours. Rather, these changes may more closely mirror the circumstances in which US physicians practice, with considerably more “shift work” and the requisite need to manage patient handoffs and promote continuity of care across healthcare providers, as opposed to individual physicians “owning patients” throughout their hospital admissions or early clinical management. We may lament these bygone days, but they are gone.

There’s an important methodological point here as well. Even if we could show that loss of professional “ownership” contributed to a decline in outcome-relevant continuity, it does not follow that doing a “brief ownership intervention” during the period of residency training will fix the problem. Whether we want to try to recover the paternalistic ownership mentality of an earlier generation is an important question these authors have raised but have not resolved. Discontinuity, handoffs, and shiftwork appear to be with us for the foreseeable future and we should work to mitigate their detrimental effects. It is equally clear that it would troublesome to return to “the good ol’ days” of burned out, unhealthy, work-obsessed, predominantly male residents who lived at the hospital and who may have endangered some patients as a result of their chronic fatigue. What we should care about is preserving the safety and humanity of duty hours, while re-imagining what it means to promote professionalism within the complexity of modern healthcare systems. This is long-term, slow work that will not be achieved by merely shifting the rhetoric of the debate.

What we need is not just a discrete fix to duty hours but a more global, holistic remedy to the many threats to medical professionalism, along with a re-envisioning of what it would take to cultivate a robust culture of caring. For a fresh take on some enduring problems in the structure and ethos of the professional formation of physicians we are profoundly grateful to Dubov and colleagues. We are less clear about whether that wake-up call will translate into the adoption of a new ethical dialect for medical trainees, one that includes concepts of “ownership.” Despite some skepticism, we hope this new frame of reference will lead to greater soul-searching and innovation in defining and delimiting points of reference in promoting authenticity in care. Whatever words we choose, they need to make sense of both the enduring features of human connection inherent in a healing relationship and the shifting responsibilities of the next generation of physicians, who will accept a professional identity that transcends any particular job that they may hold.

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