How residents and fellows think

I recently finished reading Jerome Groopman’s outstanding book, How Doctors Think. First and foremost, I’d recommend the book to anyone directly or indirectly involved in patient care. Groopman shares anecdotes from his own personal experience to make some important points about the way that clinicians’ minds work, which is instructive to doctors and patients alike.

In thinking more about the lessons in cognitive psychology and decision-making science contained within the book, however, I realized how particularly applicable Dr. Groopman’s insights are to graduate medical education. And in thinking about the oft-debated ramifications of the “80-hour work week,” (short-hand for the residency work-hour restrictions and discussions of the last several years), I came to understand how critical Groopman’s insights are to the future of health care in the United States. Residency and fellowship programs are unlikely to be a major discussion point in the health care reform debate, but how residents and fellows are trained — and how current changes in the structure of these programs are affecting this training — will have as far-reaching consequences as anything else on the costs and quality of U.S. health care.

Viewed through the lens of Groopman’s book, here are a few potential threats to “how residents think” and “how fellows think” that are likely to become more (not less) formidable in the years ahead:

The “nightfloat”

This position — a resident who starts a shift in the late evening, admits patients, answers emergencies on the hospital wards through the night, and goes home to sleep in the morning — has, for many institutions, helped to ensure that residents get enough sleep in between shifts. Having spent some time as a nightfloat myself, I remember well what it was like to admit five or more patients through the emergency room and “cover” another 60 upstairs, all in the earliest hours of the morning. Though I tried to be as thorough as possible, I had to work quickly. Lots of snap judgments, reliance on the reads of the emergency room radiologists, probably a tendency to over-order and over-treat in the interests of optimizing efficiency — and when morning came, a 15-minute verbal and written hand-off of the entire night’s activities to an incoming intern so I could go home and sleep before another night to come.

William Wood

Having supervised interns on morning rounds fresh from night-float handoffs as a resident and now as a fellow, I know how easy it was for interns not to question the nightfloat’s assumptions and findings, and to assume — again, often in the name of efficiency — that everything had been done correctly in the admitting process and that the task ahead was simply to implement a plan.

In reading Groopman’s book, I can see how many opportunities there are for residents, whether admitting at night or taking over the next day, to fall prey to many different kinds of cognitive errors and to make mistakes in reasoning and judgment. Without the ability to follow patients from presentation to discharge, residents may not see the consequences of these errors and might be more likely to repeat them again.

More things to do, less time to think

In my own hospital and in other hospitals across the country, patient rosters continue to increase as turnover and overall volume increase as well. Residents are under pressure to leave the hospital on time in order to meet work-hour requirements. Patients are sicker and more complicated than ever before, and an array of available diagnostic tests and procedures invites overuse. Each ordered test produces the need to track down and follow up the results.

Residents and interns who come in for a day’s work are increasingly “running the list” and “checking off boxes” from the time of clocking in to the time of clocking out, with little time left over for reflection, reasoning and thinking. The didactic exercises that are meant to foster such reflection — such as morning report in which an expert clinician walks house staff through cases that involve subtleties, twists and turns in clinical reasoning and judgment — are more and more often being skipped by residents and interns who feel under pressure to get the work of the day done.

Efficiency and early discharges

Just as there is pressure to get the work of each day done, hospitals with few available inpatient beds and tight financial constraints exert pressure on residents to discharge patients as quickly (and safely) as possible. We rightly recognize the need to ensure a smoother connection between hospital discharge and outpatient care, and to recognize which issues are “inpatient issues” and which are “outpatient issues.” However, I again worry that there are opportunities lost for critical thinking through difficult problems.

Discharging a patient as soon as he or she is “stable,” so that the baton can be passed to another clinician outside the hospital — opening up an inpatient bed and saving some hospitalization costs — at its worst encourages intellectual laziness and makes inpatient care less about “doctoring” and more about “processing.”

As an outpatient clinician who has received recently discharged patients into my clinic after minimal (or sometimes no) work-up for serious problems, I’m concerned that this is happening more and more. I don’t think that this kind of rapid throughput is always all that safe for patients either, to which Medicare’s recent emphasis on reducing unnecessary re-admissions can attest.

Narratives about diseases, not patients

Though the examples above are especially applicable to residency, there are other trends that influence “how fellows think,” particularly in my own field of oncology, that are of some concern too. The first that comes to mind is the increasing use of “narrative” for diseases and not patients. This goes hand in hand with the increasingly sophisticated algorithms for disease classification and treatment that Groopman appropriately views with some caution and skepticism.

Maybe the best (but not the only) examples of this can be found in typical CME case studies, or sometimes multidisciplinary tumor conferences. In these finely articulated presentations, we hear a sentence or two to identify a patient, followed by a disease identifier (early stage CLL, IPSS Intermediate-2 MDS, oligometastatic breast cancer, etc.) after which comes a smooth summary of disease response or progression to various chemotherapeutic agents over a period of time.

Occasionally, side effects to treatment and their management are woven into the narrative. But we often don’t hear much about who the patient is, the discussions in the exam room with the clinician, the diagnostic reasoning to correctly identify the nature and severity of the disease(s) causing the patient’s symptoms, or the often difficult weighing of risks and benefits of different approaches.

The effect? Neatly packaged or categorized diseases — and nicely predictable and manageable responses to therapy — create the illusion that highly complex illnesses fall into neat little boxes, and that treatment choices are relatively straightforward once one can apply a label to the disease process and stage. I think that through this, abstract disease narratives divorce the listener from the emotional content of patient care, shift the emphasis from the patient to the disease, and endow the clinician with an unwarranted feeling of control over the situation.

To the extent that the emerging use of “disease narratives” affects oncology fellows in training, there are opportunities lost for learning how to think critically, and for learning how to apply the “art” as well as the science of oncology.

The influence of industry

I’ve written about this before, as have countless others. Industry involvement is critical to the research enterprise of academic institutions, but things get a bit cloudier when it comes to industry influence upon patient care. As Groopman points out, the involvement of pharmaceutical companies can cloud how clinicians think, especially for those who have become “believers” in certain products.

Fellows — again, in my situation, oncologists in training — are especially vulnerable to becoming converted believers and to having their thoughts and judgments colored in ways that they may not like to admit. So is it appropriate, then — to use examples I’ve collated from around the country — for: Fellows to be offered industry slide decks for use in their academic presentations? Fellows to be invited to see their own faculty give industry-sponsored talks at expensive restaurants? Fellows to be given money directly from industry for plane flights and lodging at national conferences?

When we think about the ills of health care in America or “what’s wrong with medicine,” especially in the context of proposed solutions and fixes as part of health care reform, maybe it’s instructive to start by thinking about what’s right with medicine.

Health care at its best involves passionate and thoughtful clinicians who have the time and talent to think critically and to put patients first. After reading Groopman’s book, I’ve come to the conclusion that we’ll need to do some more thinking about how to protect and promote the ability of residents and fellows to become those kinds of doctors.

Bill Wood, MD, is a second year Hematology/Oncology Fellow at the University of North Carolina Chapel Hill and is a member of the HemOnc Today Editorial Board.