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Academic productivity or petulant work aversion?
m u s t initiate a formal study not only to determine w h a t schedule of on-site attending coverage is optimal, but also to establish guidelines for the activities of attending physicians when they are on duty w i t h housestaff. These guidelines should address the questions of how faculty can best provide quality patient care, housestaff supervision, and education in the ED while also considering the resident's need for graded responsibility and independent practice.
Robert K Knopp, MD, FACEP Department of Emergency Medicine Valley Medical Center Fresno, California 1. Asch DA, Parker RM: The Libby Zion case. N Engl J Med 1988; 318:771-775.
A c a d e m i c Productivity or Petulant Work Aversion? In response to the paper by H e n n e m a n et a] in this issue of Annals. we will try to describe our philosophy on 24h o u r a t t e n d i n g coverage. O u r p o s i t i o n has n o t c h a n g e d since our previous articulation, b3 but we will react to the slightly changed focus of the survey presented The former rationale was that noncoverage is good education for residents because it enables t h e m to develop independence. The reason for always choosing the night shift, weekends, and holidays for the development of that independence was always skirted. Now it m a y be inferred that the night shift is not only too slow to be a productive climate for resident education, but that because academic attending physicians have a responsibility to produce academically, this night coverage is an unfair burden. It will prevent t h e m from doing research, writing papers, and pursuing other academic endeavors that will lead to promotion, and in r u m to retention at the particular institutions that mandate p r o m o t i o n for continued employment. Additional findings in the H e n n e m a n paper are that residents would like for attendings to spend less t i m e performing p r i m a r y patient care and more t i m e in direct supervision and teaching of residents. This survey, based on a c o m b i n a t i o n of resident and attending opinion from slightly more than half of the total surveyed, seems to indicate that those programs that require 24-hour attending coverage also require m o r e primary patient care from the attending physicians. The implied converse however, is yet to be demonstrated, namely that those programs requiring neither 24hour coverage nor primary patient care from the attending p h y s i c i a n provide better instruction. T h e study, however, fails to show any statistical difference regarding resident supervisor and education. It would also appear that attendings from programs w i t h less t h a n 24-hour coverage are less present in the emergency department during daytime hours, although this difference, apparent in Table 1, is never analyzed and h o w it m i g h t reflect as percentages is not explained. Moreover, there is an implied attitude that it is somehow inferior or undesirable for attending physicians to provide pnma~y patient care. In fact, it can enhance the resident's experience i f the attending staff is willing to care for patients who have little or no teaching value to the resident. One can only presume that this follows the role model pro18:1 January 1989
vided by some other specialties wherein attending physicians have an active clinical role (while on service) only a very small portion of the year except for some m i n o r clinic responsibilities. The role model provided by surgical specialties is ignored, as is the historic role of bedside teaching articulated by Osler. It would have been helpful to define primary patient care, as this m a y range from directing a major t r a u m a case or performing a procedure {this limiting resident experience) to protecting the residents from cases w i t h poor educational value, such as medication refills. Let us review the purpose of attending physicians because we t h i n k that the role is becoming subverted by the unnecessary focus on resident education. The primary responsibility of an ED, be it academic, public, or private is to care for the clinical problems that are presented. T h e r e is also a frequent responsibility to the c o m m u n i t y in regard to supervision of the prehospital care system relating to that c o m m u n i t y and institution. There are a l s o d i s a s t e r r e s p o n s e a n d f r e q u e n t s o c i a l r e s p o n sibilities as the ED is often the only place that one can enter the medical delivery system, even if the problem is more social than medical. This involves complex transfer relationships, a s well as political, economic, and social conceres that extend far beyond the complex medical concerns of the individual patients. To ignore these responsibilities or to renounce t h e m to partially trained residents is neither wise nor effective. It is enough t o ask the residents to acquire the fluency of emergency medicine as a new language. To e x p e c t t h e m to be responsible for all the senior administrative, political, economic, and social obligations of the department is unfair to the resident and the institution. We believe that the night shift can be viewed as an opportunity for the very kind of teaching that both resident and attending alike state are missing from training programs. A n d if the w o r k l o a d is so slow that there is n o t h i n g to teach from on the night shift, w h y have a resident there at all? We have found in our private hospital rotations that there is n o t enough w o r k to support two physicians 2 4 hours per day in any of the private EDs. We therefore assign the residents only to those shifts that require double coverage. Curiously, our residents have never stated that they would prefer to cover the night shift on which the attending would not have to do so m u c h primary patient care.
Annals of Emergency Medicine
106/167
EDITORIALS
The academic role of the emergency physician has been studied by Sanders et al. 4 They compared clinical, administrative, and research t i m e for e m e r g e n c y medicine, cardiology, and orthopedics. To our surprise, emergency medicine had the fewest clinical hours. N o t to our surprise, emergency medicine had the fewest research hours. It appears that the bulk of the academic emergency physician t i m e is spent in administration. It is our opinion that this is by choice and represents a misperception of w h a t is necessary to obtain p r o m o t i o n , as well as a m i s p e r c e p t i o n of w h a t academics are all about.5, 6 We do not understand where the idea comes from that academic emergency physicians have few clinical responsibilities because they train residents. We do not understand where the idea comes from that academic emergency physicians do not have to work very hard to succeed. We do not understand where the idea comes from that academic emergency p h y s i c i a n s s h o u l d n o t have to w o r k u n p l e a s a n t shifts.h8 The actuality is that it requires great motivation and dedication to be an academic emergency physician. There are obligations to clinical, administrative, and teaching needs. But if one is to be an effective role model, one cannot shirk any of these areas. This means for a longer average work week than a private practice counterpart, and it also usually means a lower salary. To m a n y academic physicians, this is a reason not to work very hard, and to avoid the clinical duties because there is no direct or indirect compensation for those hours and because these clinical duties are perceived as interfering w i t h research and other academic productivity. But we m u s t r e m e m b e r that our specialty arose because of the need to deliver effective clinical care for the variety of problems that present to an ED. 9 We should keep that firmly as our standard because w i t h o u t it there is no need for the specialty of emergency medicine. A n o t h e r argument that we find particularly specious and perhaps illogical is that there is no evidence that attending supervision m a k e s a difference to patient outcome. That ignores the large experience of institutions that have had to endure the tragedies caused by the inappropriate or maladroit decision m a k i n g of the unsupervised, untrained, and w e l l - m e a n i n g but errant h o u s e officer. To argue t h a t one needs a prospective, controlled study of this m a k e s as m u c h sense as to argue that appendectomy is unproven, and that until there is a prospective, controlled study of appendicitis w i t h and w i t h o u t appendectomy, it is mere opinion to conclude that appendectomy is life-saving. If there is no need for attending supervision, then w h y have attendings at all? This in fact was the style of resident training for m a n y years in m a n y specialties. N o one who survived the experience can fail to r e m e m b e r cases that had awful and tragic outcomes that could have been prevented by someone w i t h experience having been there. The H e n n e m a n article suffers from serious methodologic flaws as well because the a m o u n t of t i m e spent in various endeavors is all estimated; there is no gradation of either
I68/107
resident or attending quality; and there is no estimate of academic productivity from the programs that require 24hour attending coverage versus those that do not. We do not believe that anyone would be able to document, even in numbers alone never m i n d in quality, that there are more papers, books, research projects, and journals produced by those academic departments that provide no or only partial night coverage. There are m a n y o p p o r t u n i t i e s in academic e m e r g e n c y medicine that will produce m u c h fulfillment, but to succeed in being a leader in one's field requires great commitment, self-discipline, and m a n y hours of work. There are no shortcuts. We believe t h a t the m o s t effective d e p a r t m e n t will provide 24-hour attending presence. If other programs do not, let t h e m deal w i t h their own internal administrative problems, and let the resident applicants m a k e the choice of how they wish to be supervised. In the end, this argum e n t will become academic because third-party payers and state legislatures, as well as others, will mandate 24-hour attending coverage. To s u m m a r i z e our position: emergency medicine is not an easy specialty. It requires great energy,, imagination, comm i t m e n t , and experience. We believe that the best patient care, the best administrative structure, and the best resident education is provided by the 24-hour supervision of highquality and experienced attending physicians. Let's stop whining about how hard our lives are in academic medicine and get on w i t h the business of training future leaders in our field. Peter Rosen, M D Emergency Medical Services Vincent Markovchick, M D Emergency Medicine Residency Program Denver General Hospital Denver, Colorado Richard Wolfe, M D D e p a r t m e n t of Emergency Medicine University of Colorado Health Sciences Center Denver
REFERENCES
1. Rosen P, Markovchick VS: Attending coverage. Ann Emerg Med 1985;14:897-899. 2. Rosen P, Markovchick VS: Attending coverage (letter). Ann Emerg Med 1986;15:765. 3. Rosen P, Markovchick VS: Twenty-fourhour coverage: Economics, academics, or comforts? [editorial).] Emerg Med 1985;3:489: 4. Sanders AB, Spaite DB, Smith R, et ah Allocation of time in three academic specialties. J Emerg Med 1988;6:435-537. 5. Rosen P, Harwood-Nuss A: The academics of emergency medicine. J Emerg Med 1988;6:425-426. 6. Krome RL: Up the academic ladder. J Emerg Med 1985;3:59-64. 7. Olson CM: Shift work. I Emerg Med 1984;2:37-45. 8. Rosen P: Night shift and the emergency physician. [ Emerg Med 1984;2:29-31. 9. Rosen P: The biology of emergency medicine. JACEP 1979;8:280-283.
Annals of Emergency Medicine
18:1 January 1989
Robert K Knopp, MD, FACEP Department of Emergency Medicine Valley Medical Center Fresno, California 1. Asch DA, Parker RM: The Libby Zion case. N Engl J Med 1988; 318:771-775.
A c a d e m i c Productivity or Petulant Work Aversion? In response to the paper by H e n n e m a n et a] in this issue of Annals. we will try to describe our philosophy on 24h o u r a t t e n d i n g coverage. O u r p o s i t i o n has n o t c h a n g e d since our previous articulation, b3 but we will react to the slightly changed focus of the survey presented The former rationale was that noncoverage is good education for residents because it enables t h e m to develop independence. The reason for always choosing the night shift, weekends, and holidays for the development of that independence was always skirted. Now it m a y be inferred that the night shift is not only too slow to be a productive climate for resident education, but that because academic attending physicians have a responsibility to produce academically, this night coverage is an unfair burden. It will prevent t h e m from doing research, writing papers, and pursuing other academic endeavors that will lead to promotion, and in r u m to retention at the particular institutions that mandate p r o m o t i o n for continued employment. Additional findings in the H e n n e m a n paper are that residents would like for attendings to spend less t i m e performing p r i m a r y patient care and more t i m e in direct supervision and teaching of residents. This survey, based on a c o m b i n a t i o n of resident and attending opinion from slightly more than half of the total surveyed, seems to indicate that those programs that require 24-hour attending coverage also require m o r e primary patient care from the attending physicians. The implied converse however, is yet to be demonstrated, namely that those programs requiring neither 24hour coverage nor primary patient care from the attending p h y s i c i a n provide better instruction. T h e study, however, fails to show any statistical difference regarding resident supervisor and education. It would also appear that attendings from programs w i t h less t h a n 24-hour coverage are less present in the emergency department during daytime hours, although this difference, apparent in Table 1, is never analyzed and h o w it m i g h t reflect as percentages is not explained. Moreover, there is an implied attitude that it is somehow inferior or undesirable for attending physicians to provide pnma~y patient care. In fact, it can enhance the resident's experience i f the attending staff is willing to care for patients who have little or no teaching value to the resident. One can only presume that this follows the role model pro18:1 January 1989
vided by some other specialties wherein attending physicians have an active clinical role (while on service) only a very small portion of the year except for some m i n o r clinic responsibilities. The role model provided by surgical specialties is ignored, as is the historic role of bedside teaching articulated by Osler. It would have been helpful to define primary patient care, as this m a y range from directing a major t r a u m a case or performing a procedure {this limiting resident experience) to protecting the residents from cases w i t h poor educational value, such as medication refills. Let us review the purpose of attending physicians because we t h i n k that the role is becoming subverted by the unnecessary focus on resident education. The primary responsibility of an ED, be it academic, public, or private is to care for the clinical problems that are presented. T h e r e is also a frequent responsibility to the c o m m u n i t y in regard to supervision of the prehospital care system relating to that c o m m u n i t y and institution. There are a l s o d i s a s t e r r e s p o n s e a n d f r e q u e n t s o c i a l r e s p o n sibilities as the ED is often the only place that one can enter the medical delivery system, even if the problem is more social than medical. This involves complex transfer relationships, a s well as political, economic, and social conceres that extend far beyond the complex medical concerns of the individual patients. To ignore these responsibilities or to renounce t h e m to partially trained residents is neither wise nor effective. It is enough t o ask the residents to acquire the fluency of emergency medicine as a new language. To e x p e c t t h e m to be responsible for all the senior administrative, political, economic, and social obligations of the department is unfair to the resident and the institution. We believe that the night shift can be viewed as an opportunity for the very kind of teaching that both resident and attending alike state are missing from training programs. A n d if the w o r k l o a d is so slow that there is n o t h i n g to teach from on the night shift, w h y have a resident there at all? We have found in our private hospital rotations that there is n o t enough w o r k to support two physicians 2 4 hours per day in any of the private EDs. We therefore assign the residents only to those shifts that require double coverage. Curiously, our residents have never stated that they would prefer to cover the night shift on which the attending would not have to do so m u c h primary patient care.
Annals of Emergency Medicine
106/167
EDITORIALS
The academic role of the emergency physician has been studied by Sanders et al. 4 They compared clinical, administrative, and research t i m e for e m e r g e n c y medicine, cardiology, and orthopedics. To our surprise, emergency medicine had the fewest clinical hours. N o t to our surprise, emergency medicine had the fewest research hours. It appears that the bulk of the academic emergency physician t i m e is spent in administration. It is our opinion that this is by choice and represents a misperception of w h a t is necessary to obtain p r o m o t i o n , as well as a m i s p e r c e p t i o n of w h a t academics are all about.5, 6 We do not understand where the idea comes from that academic emergency physicians have few clinical responsibilities because they train residents. We do not understand where the idea comes from that academic emergency physicians do not have to work very hard to succeed. We do not understand where the idea comes from that academic emergency p h y s i c i a n s s h o u l d n o t have to w o r k u n p l e a s a n t shifts.h8 The actuality is that it requires great motivation and dedication to be an academic emergency physician. There are obligations to clinical, administrative, and teaching needs. But if one is to be an effective role model, one cannot shirk any of these areas. This means for a longer average work week than a private practice counterpart, and it also usually means a lower salary. To m a n y academic physicians, this is a reason not to work very hard, and to avoid the clinical duties because there is no direct or indirect compensation for those hours and because these clinical duties are perceived as interfering w i t h research and other academic productivity. But we m u s t r e m e m b e r that our specialty arose because of the need to deliver effective clinical care for the variety of problems that present to an ED. 9 We should keep that firmly as our standard because w i t h o u t it there is no need for the specialty of emergency medicine. A n o t h e r argument that we find particularly specious and perhaps illogical is that there is no evidence that attending supervision m a k e s a difference to patient outcome. That ignores the large experience of institutions that have had to endure the tragedies caused by the inappropriate or maladroit decision m a k i n g of the unsupervised, untrained, and w e l l - m e a n i n g but errant h o u s e officer. To argue t h a t one needs a prospective, controlled study of this m a k e s as m u c h sense as to argue that appendectomy is unproven, and that until there is a prospective, controlled study of appendicitis w i t h and w i t h o u t appendectomy, it is mere opinion to conclude that appendectomy is life-saving. If there is no need for attending supervision, then w h y have attendings at all? This in fact was the style of resident training for m a n y years in m a n y specialties. N o one who survived the experience can fail to r e m e m b e r cases that had awful and tragic outcomes that could have been prevented by someone w i t h experience having been there. The H e n n e m a n article suffers from serious methodologic flaws as well because the a m o u n t of t i m e spent in various endeavors is all estimated; there is no gradation of either
I68/107
resident or attending quality; and there is no estimate of academic productivity from the programs that require 24hour attending coverage versus those that do not. We do not believe that anyone would be able to document, even in numbers alone never m i n d in quality, that there are more papers, books, research projects, and journals produced by those academic departments that provide no or only partial night coverage. There are m a n y o p p o r t u n i t i e s in academic e m e r g e n c y medicine that will produce m u c h fulfillment, but to succeed in being a leader in one's field requires great commitment, self-discipline, and m a n y hours of work. There are no shortcuts. We believe t h a t the m o s t effective d e p a r t m e n t will provide 24-hour attending presence. If other programs do not, let t h e m deal w i t h their own internal administrative problems, and let the resident applicants m a k e the choice of how they wish to be supervised. In the end, this argum e n t will become academic because third-party payers and state legislatures, as well as others, will mandate 24-hour attending coverage. To s u m m a r i z e our position: emergency medicine is not an easy specialty. It requires great energy,, imagination, comm i t m e n t , and experience. We believe that the best patient care, the best administrative structure, and the best resident education is provided by the 24-hour supervision of highquality and experienced attending physicians. Let's stop whining about how hard our lives are in academic medicine and get on w i t h the business of training future leaders in our field. Peter Rosen, M D Emergency Medical Services Vincent Markovchick, M D Emergency Medicine Residency Program Denver General Hospital Denver, Colorado Richard Wolfe, M D D e p a r t m e n t of Emergency Medicine University of Colorado Health Sciences Center Denver
REFERENCES
1. Rosen P, Markovchick VS: Attending coverage. Ann Emerg Med 1985;14:897-899. 2. Rosen P, Markovchick VS: Attending coverage (letter). Ann Emerg Med 1986;15:765. 3. Rosen P, Markovchick VS: Twenty-fourhour coverage: Economics, academics, or comforts? [editorial).] Emerg Med 1985;3:489: 4. Sanders AB, Spaite DB, Smith R, et ah Allocation of time in three academic specialties. J Emerg Med 1988;6:435-537. 5. Rosen P, Harwood-Nuss A: The academics of emergency medicine. J Emerg Med 1988;6:425-426. 6. Krome RL: Up the academic ladder. J Emerg Med 1985;3:59-64. 7. Olson CM: Shift work. I Emerg Med 1984;2:37-45. 8. Rosen P: Night shift and the emergency physician. [ Emerg Med 1984;2:29-31. 9. Rosen P: The biology of emergency medicine. JACEP 1979;8:280-283.
Annals of Emergency Medicine
18:1 January 1989