Shelter. We’re giving too much. I’m all for, and completely support a patient centred curriculum. Patient needs have to come first, second, third…last. Everything is secondary to it. Frankly, if the patient is well cared for, and absolutely no learning occurs (although that I simply cannot imagine), then that’s ok.
But we’re doing it too much. GIving way too much. Shelter. Our house staff, (sorry, house staff), has it too easy, and they’re just way over-protected. New contracts with PAIRO, or I guess PARO as it’s now called, (and I guess it’s not a “new contract” because this happened years ago), limit call markedly. And patient experience. Apart from this, academic institutions themselves have brought on changes in policy that severely curtail a learner’s experience.
My first housecall in training was in my second year of medicine, with a supervisor. I did house calls throughout my clerkship year, with supervisors. Then, on my own. As an intern. These were my first real taste of independence, although I really wasn’t. I didn’t really make any decisions of import during these visits. But I was on my own. They were my knuckles that rapped on the door. My young eyes that took in lifestyles and living arrangements with which I was completely unfamiliar. My bottom that chose to sit on the arm of a couch, unsure if a hypodermic was jammed between ketchup stained (and that was, even then, realized to be wishful thinking) cushions. I was the visiting health care professional. ME.
Do you remember your first kiss? Your first time on a bicycle, your father hollering encouragement behind you? Your first day of kindergarten? These first house calls are engraved in my memory. Looking back, I knew nothing. Absolutely nothing. But more than those people. Clearly. My mere presence in those living spaces meant something, to them. Did something, for them. I remember how these people started coming back to clinic, and asking for me. Me. Because I showed I cared. Maybe because I had the guts to be there in the first place. In their home. On the other side of the tracks.
It was the first time I ever really made a difference, and it wasn’t really because of any real expertise, or medical knowledge. If I can name an experience, that moved me from learner, to physician, it was those house calls, done on my own, at my own risk (and, now I can state, from a more mature, experienced viewpoint, also at that of my supervisor, and that of my learning institution), that did it.
House staff never now have that opportunity. Independent house calls for house staff are now deemed too risky. Insurers are blamed. Maybe that’s the case. I’m not privy to those emails, those decisions. If it’s even the case. Or maybe… it’s just an excuse, part of the folklore now. You see, it’s a “fact” I know, despite the fact I’ve never seen the decision written down, the insurer position, the policy number 342, appendix “f”.
Risky, maybe. Anxiety provoking? Yes. Learning, self defining, maturing? What do you think?
Is maturation possible without risk? Of course. But those early housecall experiences made me a physician before I had the knowledge base. They made me a better clerk, intern, resident, physician, person. They helped define me as a PERSON.
And now they can’t happen. The reason given me is insurance.
Inappropriately severe call demands and adverse patient outcomes led to contracts limiting amount of time on call and frequency of call. Gone are the on for 36, off for 12, on for 36 regimens. They were exhausting. Inhumane. Or were they? Were they imposed to train us to think while exhausted? While under duress? Were those rotations the fire for the steel? A recent Swiss study looking at attainment of educational goals with current clinical and call experience suggested that many were now unattainable Buddeberg-Fischer B., & Stamm M.(2010).
I have never had a house staff person participate in a surgical assist after hours. These on call surgical assists are often stat, and house staff live out of the community. By the time they made it in, the thing would be over. Part of the call experience is to try to live the life, to try on the overcoat for size. This, they’ll never feel until it happens to them, in practice. A big deal? Probably not. They’ll have to taste the next full day in office after a sleep disruption on their own. Probably not a big deal… They’ve all done it. Not trained for it, but done it. I’ve only rarely had house staff with me during early hospital rounds. They do their rounds after I’ve already been at the clinic. Their days are relatively protected from scut, which is on my desk. They’re usually gone an hour before me…
Should part of the training of a young physician be to think while exhausted? It used to be. Does it still happen? They profess fatigue, as all workers do, despite the markedly curtailed call and clinic experience.
Better learning probably occurs now. I remember sitting in front of a staff person who was trying to teach me something, and falling asleep. I had made the error of taking my shoes off. His feedback was that I should keep my shoes on…It was harder to fall asleep that way!
But is there adequate patient contact? And there is something to learning to think, under duress…
Buddeberg-Fischer B., & Stamm M.(2010).The medical profession and young physicians’ lifestyles in flux: challenges for specialty training and health care delivery systems. Swiss Med Wkly.140, pp. 131-134. doi: 10.4414/smw.2010.13134.