Saturday, January 12, 2013

Letter to the Editor: Nostalgic Professionalism- Professionalism in the era of duty hours: time for a shift change?

Marcus Welby, MD: Nostalgic Professionalism
Drs. Edmond, Wenzel and I wrote a letter to the editor of JAMA last month in response to this article on professionalism in the era of duty hour restrictions.

The letter was not published. This is neither the first nor the last time that one of our submissions has been rejected. No worries. The letter is published below.

To the Editor:
As clinicians trained before the ACGME duty hour restrictions, we have strong concerns about the viewpoint published by Arora et al (1).These authors would argue that we cling to the now antiquated notion of 'nostalgic professionalism,' defined as consistently placing the patient's or the profession's needs above one'sown personal needs (2). 

Nostalgic professional values conflict with the current model of training and Arora and colleagues’newly proposed model of professionalism, which emphasizes the importance of physicians' health and work-life balance. They argue for residency training that fully adopts a team-based model of patient care, one in which patient ownership is not delegated to a single resident physician, but shared among a group of team members. The authors have no data that such a shift in practice will be acceptable to patients or make the quality of care better. Our experience suggests the opposite is likely: patients want more not less time with their physicians, and we think that an in-depth history and physical examination and ongoing follow-up bring a physician and patient close together.This cannot be achieved with shift-work teams. Moreover, the rigor and quality of medical education may be affected as there is no substitute for direct patient care when learning the practice and art of medicine.

We fail to be convinced that all members of a medical team will fully know the details of the patient’s history and clinical course without experiencing a complete doctor-patient encounter. Through a careful history and physical examination, the doctor-patient relationship is established(3)and further enhanced by daily follow-up. Anything short of this rigor will erode the quality of that relationship, and negatively impact patient ownership and the physician’s individual sense of professional responsibility.As subspecialist consultants in the current era of multiple hand offs of patient care, we routinely experience the downsides of interacting with clinicians who know the patient less well because they have only dealt with a limited segment of the patient’s inpatient course. 

In our view, the patient will always come first. It is a duty that lies at the core of humanism, which opposes any compromise of professionalism.

1.    Arora VM, Farnan JM, Humphrey HJ. Professionalism in the era of duty hours: time for a shift change?JAMA. 2012;308(21):2195-6
2.    Hafferty FW, Levinson D. Moving beyond nostalgia and motives: towards a complexity science view of medical professionalism. PerspectBiol Med. 2008;51(4):599-615
3.    Verghese A, Brady E, Kapur CC, Horwitz RI. The bedside evaluation: ritual and reason. Ann Intern Med2011;155(8):550-3

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