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Curbside Consult with Dr. Jayne 8/22/11

As most of us know, it doesn’t matter how much time you spend doing e-mail. It’s impossible to stay ahead. Sometimes I e-mail myself articles that I would like to mention. Before I have a chance to get my thoughts on paper, they scroll up, up, and away as the inbox gets larger and larger.

(Speaking of, have you ever tried to change the way you work your e-mail, say from top to bottom when you’re used to working bottom to top? I recently had this experience, and for whatever reason, it was extremely difficult. Talk about assaults on muscle memory! It’s finally back the way I like it, but it was a painful experiment that although designed to yield efficiency, just made me crazy.)

As I did some e-mail cleanup during a bit of unexpected free time (thank you, cancelled conference call!) I found an e-mail that reminded me to look at a journal article: Longer Lengths of Stay and Higher Risk of Mortality among Inpatients of Physicians with More Years in Practice.  The study looks at patients hospitalized during a two year period (2002-2004, coinciding with the residency training calendar on a July-June basis) on the teaching service.

For those of you not in hospitals that have residency programs, the teaching service is staffed by interns and residents under the supervision of an attending physician. Depending on the structure of the teams, supervision of the trainees varies, but ultimately it’s the attending physician who’s on the line should something go wrong.

There is speculation that patients who are hospitalized in July do worse because of transitions in the trainee pool (I talked about this “July Effect” last month), so I was glad to see this study controlled for the variable of having residents and students involved in care. All of the patients were treated at Montefiore Medical Center in the Bronx. They also controlled for any chance that having a more lengthy physician-patient relationship would influence the outcome by restricting patients to those who had never received care from the attending physician.

The authors looked at four groups of attending physicians: those in practice 1-5, 6-10, 11-20, and >20 years. Although the number of physicians was only 59, they looked at over 6,000 patient admissions. Patient groups were similar in demographics and clinical characteristics.

The study found that physicians in practice more than 20 years had greater mean length of stay numbers and greater mortality rates (both in-hospital and 30-day) than physicians with less than five years in practice. This impacted the sickest patients greater than those with less-complex conditions.

They also found that when the teaching service was less busy, patients stayed the same amount of time regardless of physician age. However when there were more patients to care for, length of stay increased in the longer-practicing group.

The authors conclude, “Inpatient care by physicians with more years in practice is associated with higher risk of mortality. Quality-of-care interventions should be developed to maintain inpatient skills for physicians.”

Well, isn’t that special! Talk about a solution that doesn’t necessarily address root cause.

Quite a few organizations commented on the study, with some citing earlier data showing that more seasoned physicians are less likely to adhere to published guidelines. This strengthens the argument that physicians should have to recertify periodically to prove that they are staying abreast of current standards of care. 

I agree with that. My specialty requires everyone to recertify, but other specialties have allowed older physicians to be “grandfathered” into perpetual certification.

Certification aside, though, I’d like to propose two other areas that need analysis. The first is the fact that the more seasoned physicians have gone through a tremendous amount of change in medicine over the last two decades. There have been drastic changes in the non-clinical work physicians are responsible for (insurance issues, E&M coding, pay for performance, loss of autonomy, economic pressures, etc.) and one of the natural responses to change is to entrench in the past.

The second involves looking at the systems that have proliferated based on the changes above, both operational and technical. There has been a proliferation of operational platforms impacting how clinicians are forced to navigate – everything from the Disney Institute to Six Sigma. Simultaneously, there’s been tremendous pressure to move to electronic systems that range widely in their ease of use, stability, and quality.

I’d like to see similar data where they survey the physicians about their comfort level with not only hospital policies and procedures (including proliferation of care coordinators, discharge specialists, length of stay coordinators, coding coaches, etc.) impacting their care, but also on their comfort level with the systems they use and how well they use them.

Because of the presence of interns and residents, I have a sneaking suspicion that some of the more experienced attendings may not have leveraged technology and the team approach (sometimes perceived as interference) as much as they could have. Old work habits are hard to break, and when you’re used to the lower-ranking physicians doing everything and just co-signing at the end, it’s easy to miss things.

Coupled with a mistrust for technology, it’s even more complex. I suspect newer attendings for whom these systems have always been present would be more likely to be hands-on with the technology rather than passive.

Regardless of the reasons, it’s something that deserves a second look.

E-mail Dr. Jayne.