Priorities

I've worked with kids a lot, particularly before medical school. One kid, I'll never forget, had parents who were very interested in where he went to school, fighting rather hard to get him enrolled and transported to a particular school that they believed would give him the best education. They were adamant and dedicated to this goal.

And they were under investigation by child protective services, with the very real possibility of having their children taken away. Wait, what? Despite these parents' strong desire to have their child at what they believed to be a good school, these parents were neglectful, failing to provide adequate nutrition, as well as poor social, emotional, and structural support for their children. The kid I worked with spent so much time looking after their siblings, they never got a chance to be a kid. These parents weren't opposed to feeding their children, or providing the other necessities of life, but their priorities were completely out of whack. They'd fight for their children to go to a desirable school, which is an admirable thing for parents to do, but it's far less important than putting food on the table. The parents weren't overtly abusive, and had some good intentions, but they were nevertheless neglectful, and that had a huge negative impact on their children.

I bring up this story because I've been struggling a lot with priorities. Clerkship has made it absolutely clear that there are some deep problems in the way we treat patients, and in the way we educate physicians. Yet I've rarely seen too many clear instances of wrong-doing. I've heard stories of physicians who were dismissive or disdainful of patients. Others, who were verbally or physically abusive of students or residents. I've seen or experienced only minor instances of these abuses. Most physicians want the best for their patients and want students to have a good experience, as do most of the other staff responsible for patient care and student education.

However, I've still felt as though the healthcare system has been frequently failing to care for patients, and the education system has frequently failed to properly support students. Given the positive intentions and actions of the majority of the individual actors involved in these systems, I chock these failings up to neglect. And, just as the parents in my story were neglectful because their priorities were in the wrong places, so too does the healthcare system engage in routine neglect of patients due to misplaced priorities. Likewise, the education system frequently neglects the needs of students due to its priorities.

Let me give an example for each. In many departments in the hospital, the main interaction physician teams have with their patients is during morning rounds. Rounds are often fast - 15 minutes per patient - and may not include the whole team. The team itself can change frequently. It's not uncommon for a single patient to see multiple different physicians, residents, or students in the course of their care. Afterwards, the team of physicians may never see the patient again that day, hearing of new concerns or changes in their status only through nurses' reports. Yet, this team will be the ones making decisions on the patient's care, going beyond those 15 minutes of interaction per day only as necessary. Each provider is often courteous and caring during those 15 minutes, but for a sick patient, 15 minutes a day interacting with the people who are most responsible for their care isn't really enough to feel cared for or heard. This is particularly true when these physicians/residents/students are in a rush to finish, as they often are - other patients, mandatory teaching, meetings, and supplementary tasks all take priority to spending extra time with each patient. As much as physicians and trainees want to be present and provide full care for their patients, it is so low on the priority list that it is often neglected.

Same goes for medical education with respect to students. Physician educators care about the well-being of their students. However, when put up against training and testing, it falls in priority. This is how we get incredibly long work weeks for students (and burned out, exhausted students). While medical educators would rather have rested learners, when put up against getting extra hours of hospital time, it simply isn't a priority.

In each case, it's not as though the current priorities are inappropriate goals. In an ideal world, physicians would care for large numbers of patients, while participating in continuing education, meetings, etc. Students having a wealth of experience an admirable goal. Yet, is physician efficiency more important than those physicians spending sufficient time with each patient? Is another 10 hours a week in the hospital more important than learners having time to explore their own interests, spend time with the world outside of medicine, or simply to sleep? I would argue no.

Changing priorities comes with trade-offs, of that I am fully aware. Physicians spending more time with patients may mean more physicians overall and less pay for each. Less time per week in hospital for students may mean a reduction in knowledge at graduation (though studies on that subject are lacking/equivocal). Yet, if we want physicians to put the priority on the care of their patients, or schools on the overall well-being and success of their students, it's going to take embracing or adapting to these trade-offs. The mission statements of hospitals and medical schools often feature these priorities prominently - it's time for them to walk the walk, rather than simply talk the talk.

Physician Names

I find it kind of interesting what physicians are called in the hospital, especially at various stages of training.

Residents are always called by their first names. Always. They've got the title "Dr." at this point, but using it except in official documents almost never gets used. The odd time I'll see a resident introduce themselves with the "Dr." title to patients, mostly to emphasize that despite looking young, they are in fact a doctor who will be responsible for their care, but it's not all that common. The trend I'm noticing is that particularly young-looking physicians, especially shorter women, do this more often, I assume to ward off the unfortunate assumption many patients will make that this person is their nurse or a medical student, not their doctor.

Fully-trained physicians almost always introduce themselves by their title and last name. Residents generally address them by their title, though there are certainly exceptions, especially in small programs. Nurses tend to move from title and last name to first name as they get older, which I think is a decent way to subtly convey seniority and keep physicians from getting too big of a head. After what is often 20 years of working, these nurses have more than earned the right to address their physician colleagues the same way those physicians address them (though it should arguably be equal from the start).

What I find especially interesting is how fully-trained physicians are referred to among residents and non-physicians. The first name seems to be used for physicians who are particularly liked, once again conveying a degree of familiarity. But the first name is also often used for physicians who are particularly disliked, almost as a way to knock them down a peg. Physicians who are neither loved nor hated get their title and last name used.

Fellows are another interesting case. In most cases, they're fully-qualified physicians, even though they're still in training. They've passed their certification tests, they can practice independently. Yet they're pretty much always referred to by their first names.

Anyway, nothing overly meaningful, just an interesting sociological pattern in the complex culture of medicine!