Taking the E-ROAD

In my emergency medicine residency, we all share the jeopardy pager. Like a hot potato, it is passed among house staff who take turns hoping they won’t be called in to replace a sick resident.

My colleagues know that I loathe the idea of doctors working while ill. In my world IVs are commonplace, but I think anybody sick enough to need one shouldn’t come to work. I urge interns, who are uncertain of what may be forgiven, to call in sick if they must.

So my convictions were tested on a sunny fall Sunday when the jeopardy pager went off. One of the interns, a former orthopaedics resident who had switched to emergency medicine, called in sick with vomiting and diarrhea. As that day’s “jeopardy” resident, I would have to work her shift in the pediatric ER. There went hiking, doing laundry and movie night. I drove to the hospital, reminding myself that she was just doing what I’d recommended.

When the shift ended, I called to see how she was. She apologized for her absence, but I had to tell her she’d done the right thing. What good is it to come to work, only to spread your germs around or run to the bathroom every few minutes? As a purely practical matter, how can you safely resuscitate a critically ill person while you are wracked by nausea and lightheadedness?

“I still feel this surgeon’s guilt for not coming in,” she confessed. “I worked through kidney stones when I was in orthopaedics.”

I found that hard to believe.

“The attending told me he couldn’t spare me. I took Motrin. I cried during the whole surgery. Then I went home and passed out on Percocet.”

My colleague left her surgical residency to join ours in emergency medicine, along with five other former surgery and family practice residents who have begun a new residency in our group of 48. She is part of a trend that has been noticed primarily among medical students: in growing numbers, they are choosing “lifestyle” specialties.

“E-ROAD” stands for emergency medicine, radiology, ophthalmology, anesthesiology and dermatology. These are part of a group of medical specialties that offer a “controllable lifestyle” by allowing physicians greater ability to control the amount of time spent on clinical duties. A dermatologist may be able to arrange a weekday 9-to-5 schedule (or something close to it), since there aren’t many nighttime derm emergencies. Emergency medicine is shift work, and though frequent moves between nights and days play havoc with one’s sleep schedule, the field does allow docs to work only as many shifts as they feel they can manage. Compare that with family practice, obstetrics or general surgery, all of which may require the practitioner to come to work unexpectedly and to toil exceptionally long hours to maintain a viable practice.

The trouble with the E-ROAD is that the areas of medicine that most need new physicians are not in the “lifestyle” group. Medical leaders have long recognized a shortage of primary care physicians, or those trained in general internal medicine, family practice and pediatrics. As early as the 1980s, articles were appearing in the medical and surgical literature calling physicians’ attention to this disturbing trend. More recently, in 2006, the American College of Physicians called for “a national health care work force policy … to reverse the impending collapse of primary care medicine.” At the Yale School of Medicine, the number of graduates choosing E-ROAD specialties rose from 17 in 1997 to 34 this year. During that same time period, the number of graduates specializing in internal medicine, pediatrics and family medicine dropped from 36 to 22.

These numbers mirror a national trend. A 2003 study in JAMA: The Journal of the American Medical Association revealed that the percentage of medical students entering primary care declined from 49.2 percent in 1987 to 44.2 percent in 2002. Of that group, many who train in internal medicine do so with the intent to specialize, not to open an office-based general practice. These numbers are bad news. The Council on Graduate Medical Education estimates a deficit of tens of thousands and as many as 197,000 generalists by 2020, out of a total projected number of roughly a million full-time equivalent docs (there were 781,200 full-time equivalent docs in the United States in 2000). There have been efforts to encourage students to choose primary care careers, with strategies ranging from debt forgiveness to improving academic generalists’ schedules. But the dissatisfaction of primary care doctors is growing, and this is not lost on students. The trend has progressed so far that it is unclear who will be providing basic care for coming generations of children, adults and especially the elderly. Aging baby boomers will require generalists who are well-versed in the long-term care of multiple diseases, but it is beginning to look as if specialists will be managing them by organ system, with no one physician coordinating overall care.

“People are using the word ‘crisis’ to describe what’s happening in primary care medicine,” says Greg A. Sachs, M.D. ’85, chief of geriatrics at the University of Chicago until August, when he became chief of general internal medicine and geriatrics at Indiana University. “We’re very worried about where our trainees are coming from.”

Asghar Rastegar, M.D., professor of medicine (nephrology) and associate chair of the Department of Internal Medicine at Yale, points out that medicine is defined as a profession because it has made a social contract with the public. “If our profession does not honor that contract, the public will rewrite the contract,” he warns.

But laments and lambasting alone will not reverse the trends of the last few decades. Doctors have traditionally been willing to work long hours at the cost of personal and family time, perhaps because there are ethical rewards and societal respect that come with doctoring. The postwar “golden age” of medicine, when health care expenditures grew faster than the number of doctors did and doctors enjoyed a great deal of decision-making autonomy, has faded, for better or worse, in the face of a changing health care system.

Another article in JAMA in 2003 was one of several that elucidated the principal factors that make doctors miserable: not only long work hours, but also decreasing autonomy, more time pressure and difficulty in maintaining high-quality care. Today’s pressure to see more patients in less time, the diminished freedom of action that has accompanied managed care and reimbursements for thinking that are far less than for doing (an internist who decides upon a treatment strategy earns much less for his trouble than the gastroenterologist who scopes the patient, for example) have begun, perhaps, to alter students’ ambitions. What has always been a difficult job has become increasingly thankless, and students are quietly rebelling.

“About 20 years ago,” says Peter N. Herbert, M.D. ’67, HS ’69, senior vice president and chief of staff at Yale-New Haven Hospital, “I was sitting at the dinner table with my four kids, and I said to them, ‘Who would like to go into medicine?’ And they answered almost as a chorus, ‘Not me!’ I asked them why, and they said, ‘We don’t want to live like you.’ ”

Sachs muses, “I think that unfortunately things like [students’] debt, what they see happening in terms of career options, reimbursement, NIH funding, et cetera—those are things that are shaping people. How much of it’s a generational thing in terms of how much people want out of it, I’m not sure. People want more defined hours. If I was coming out of medical school with $120,000 in debt, I don’t know if I would have made the same choices. … The amount of debt I had is nothing compared to what people have these days.”

Thomas P. Duffy, M.D., professor of medicine (hematology) at Yale, readily acknowledges that heavy debt handicaps today’s graduating medical students. Still, he criticizes their financial aspirations. “Some medical students’ expectations [are] now to achieve upper-class lives shortly after graduation from medical school. The amounts of money that can be made in dermatology and plastic surgery are a temptation that many people cannot resist,” he says. “The need for luxury is more urgent in the current generation than it was in mine.”

A crisis in primary care

Though they may disagree about students’ motivations, nobody questions the fact that the primary care shortage is serious. But how do students’ preferences for “lifestyle” specialties affect the way they care for patients? Overwork and frequent overnight call are often mentioned as repellent factors in primary care medicine. Growing evidence suggests that residents who are forced to neglect personal needs such as adequate rest may be doing patients a grave disservice. A recent Harvard study, published online in December 2006 in the journal PLoS Medicine, found that residents who were more frequently on call reported committing an increased number of medical errors that resulted in harm to a patient. Sleep deprived workers have been likened to drunk drivers with regard to neurobehavioral abilities—according to research published in Nature in 1997, 24 hours of wakefulness causes impairment comparable to a blood alcohol level of 0.10 percent.

Whether impairment by fatigue actually outweighs the benefits of “continuity of care”—being cared for by the same physician hour after hour, thereby avoiding the errors inherent in handoffs to other physicians—has not been formally examined. There is no universal consensus on this topic. “The patients often feel that nobody is conducting the orchestra,” says Herbert. “They see a dizzying array of subspecialists to deal with each of their individual problems, but they often feel that nobody is prioritizing the problems. ... Something major has been lost.” Rastegar agrees. “Continuity of care,” he says, “is probably more important than physicians being ‘well-rested.’ ”

After all, medical students, residents and doctors are used to pushing through fatigue and a lack of enthusiasm. That’s what we do. That’s how we come out at the top of our high school classes, ace chemistry and physics in college and survive the demands of med school. That’s how we drag ourselves away from a half-hour nap in the middle of a 30-hour call to answer a page. We can do it. The question is, should we? Do mental and physical fatigue make us worse doctors? I’m convinced of it. It has long seemed clear to me that sleep deprivation must be as dangerous to doctors as it is to pilots and truck drivers. But not everyone is so sure that work-hour reforms, such as the 80-hour work week introduced in 2003 by the Accreditation Council of Graduate Medical Education, produce better physicians.

“[When] I was a resident,” Sachs recalls, “we were on call every third night. We got one day off every three weeks, always on Sunday. You stayed until your work was done, even post-call. If you had a patient you admitted at 2 a.m. and they crashed 2 p.m. post-call, you admitted them [to the ICU]. I hated that. I thought it was pretty barbaric and inhumane. I think it clearly needed to change. I’m glad that it has. There need to be the sorts of things that allow people to have a life—I certainly didn’t have a life when I was a resident.

“But people’s expectations have also changed. Despite how ‘good’ they have it [compared with] what I went through, people still manage to complain bitterly about how hard they’re working, how many hours they’re working and those sorts of things. I have concerns about how patient-centered and how devoted they are to their patients. [I don’t know] whether it’s changes in training, changes in attitudes or the indebtedness that’s shaping people’s choices. It’s hard to find people who are turned on by the notion that ‘this is my patient, I’m there for them, I put that first, even if that means a lot of inconveniences for me and my family.’ ”

A life in medicine takes its toll

Yale is not particularly noted for turning out primary care doctors, though every year a number of students do choose this path. Three recent classes have produced a total of seven residents bound for family practice, 25 for pediatrics (and six more for medicine/pediatrics) and 19 for internal medicine/primary care. That’s about a fifth of the students who graduated between 2004 and 2006. By comparison, the top primary care med schools, like the University of Washington and the University of North Carolina at Chapel Hill, boast an almost 50 percent primary care graduate rate, according to U.S. News and World Report. (Yalies are no exception to the tendency to seek out E-ROAD specialties: the Class of 2004 had 12 students bound for dermatology, a specialty which offers only about 300 positions each year to the nation’s 15,000-plus medical graduates.)

Kristen Sueoka, M.D. ’07, is headed for internal medicine/primary care. She chose her field because she wants to focus on patient education and preventive medicine, as well as the management of chronic disease. “I really liked everything I rotated through, and dabbled with the idea of being a surgeon. But it seemed a little too painful a specialty in terms of the training,” she said.

What about being on call?

“I feel like it’s something that I was aware of when I signed up for the job in the first place.”

Yet Sueoka is interested in the psychological toll that a life in medicine can exact. “I think you’re a better doctor if you have a life outside the hospital, if you have outlets for stress, frustration and the emotional issues you encounter at work. One of the best ways to improve medicine, decrease the number of mistakes, decrease the fact that doctors have higher rates of suicide and substance abuse than the general population, is to try to encourage doctors to be well-rounded instead of being married to their career. I think that truly does make for better doctors and better patient care. … The attempt at selflessness really hurts both doctors and patients more.”

Finding a balance

Aisha Sethi, M.D., HS ’06, a University of Chicago dermatologist, went to medical school in Pakistan and chose dermatology after seeing the skin manifestations of leishmaniasis, hemorrhagic fever and other illnesses. “Lifestyle was definitely an important factor in my choice—with having the daily opportunity to perform procedures, but not having to stay in the OR for long hours. I absolutely love it. I could not imagine myself doing anything else. It’s got the lifestyle I expected.”

Her typical day in academic dermatology? “I have clinic all day with one or two residents with me. I get some time off during the week for academic purposes, so I can attend conferences in other departments. I am also the associate residency program director, so I’m working on curriculum development for the residents. On weekends I mostly work on manuscripts I have in progress or go in to the hospital and catch up on biopsy results. When I’m on consults for the month, one to two months a year, then I go in and see consults. With any specialty you can make it as busy or as relaxed as you want. It’s always a balance.”

A Yale-trained geriatrician is finding her own version of that balance. Caroline N. Harada, M.D. ’01, completed a geriatrics fellowship at the University of Chicago, where she is now on the faculty. She says lifestyle did not play a large role in her decision to enter primary care, but she admits that as an academic geriatrician she probably has an easier call schedule and better support than her colleagues in the community.

“There aren’t that many geriatricians out in the community, because in private-practice geriatrics it’s hard to make a living. Medicare reimburses by the number of patients seen, not by time, and interviews [with elderly patients] can take a long time.”

I asked her if she’d noticed a difference in attitudes about medicine between older generations of docs and doctors of her own generation.

“I’m too young to say. Geriatrics is such a young field that there aren’t a lot of old geriatricians,” she said. “I think because geriatricians approach things from a very interdisciplinary background, we understand that the biopsychosocial model of medicine applies to everyone, all of us. You’ve got to put a person in their context. Doctors as much as patients have a context. If that’s not appreciated and recognized, then you aren’t dealing with the full person.”

Are patients better served by physicians who feel this way?

“It’s good for patients, because I don’t think well when I’m tired. I don’t think well when I’m preoccupied with something at home, or need to be in two places at once. When I’m here at work, I try to be 100 percent here. As long as you have an intelligently designed schedule where there’s always somebody on call to address patient concerns and take care of emergencies, patient care doesn’t have to be compromised by allowing doctors to have a decent lifestyle and personal time.”

A lifestyle within a lifestyle

My residency in emergency medicine is over, and I’m working at an academic emergency department in a Chicago hospital. Teaching residents in an urban setting is important to me. But there was another sine qua non in my job search: I must work part-time. After years of topsy-turvy schedules, of rushing home to choose between eating and exercising in the one hour before bed, of wrenching myself from sleep rather than waking naturally and fully rested, of mentally prodding myself through many hungry, discouraging shifts, I was tired. So tired that tendrils of resentment crept into my thoughts about my career in medicine. Fantasies of leaving the field began to take on unsettlingly realistic detail. Yet I think these were the symptoms of fatigue, not of a mistaken choice. I was anxious to prevent these feelings from flourishing into full-blown burnout. One might say I chose a “lifestyle job” within a lifestyle specialty.

I rather thought that those feelings might arise. That is why I chose Yale Med. The Yale system, which treats medical students like graduate students who can be trusted to organize their own learning, allowed me space to ponder, grow up a little and study medicine that interested me in addition to the requirements. Rather than learning to equate medicine with drudgery, I graduated with my passion intact. Residency, though, saw it wane. I can cultivate it again because I’ve chosen a specialty that will let me. My patients, I think, deserve to have a rested, enthusiastic and well-read doctor. Anyone who has had a kidney stone, or has watched someone having one, will perhaps grasp not only the brutal indifference of a culture that does to its members what it did to my colleague, but also the folly of a medical system that tends to ignore the basic needs of physicians. There may not be a simple solution to the crisis in primary care, but it seems likely that students will continue to choose specialties that acknowledge them, not only their patients, as human beings. “Physician, heal thyself.” We will need, I think, to heal one another. YM