Jonathan M. Green, MD
Requests for Single Reprints: Jonathan M. Green, MD, Washington University School of Medicine, 660 South Euclid Avenue, Box 8052, St. Louis, MO 63110; e-mail, email@example.com.
Green J.; The Changed Nature of Scut: An Absence at the Bedside. Ann Intern Med. 2007;147:588. doi: 10.7326/0003-4819-147-8-200710160-00014
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Published: Ann Intern Med. 2007;147(8):588.
It was a late night on call when my pager went off. I called the floor. The nurse informed me that my patient, Mr. McDonough, had a fever. I grumbled and trudged to the ward to do one of the numerous fever work-ups of my internship.
“Hi, Mr. McDonough, I hear you have a bit of a temperature,” I said as I entered the room. He looked at me, tried to smile, and agreed. He was sweating, and his blanket was tossed from his bed. I looked for a vein to draw blood and noted his clammy skin. His pulse was strong but rapid. He was breathing easily. I examined him more carefully and heard the rhonchi in his chest. He coughed some sputum into a cup for me, and I ordered a chest x-ray. I worried as I walked up to the house officers' lab to Gram stain the sputum and look at the urine. He just didn't look that good to me.
Amy E O'Connell
Thomas Jefferson University
October 15, 2007
Reaction of a neophyte physician-in-training
As a third year medical student just beginning the hallowed task of patient care, I am very surprised by the lack of direct patient care that occurs in present day medicine. When I anticipated third year, I often felt a sense of nervousness and intimidation thinking about the level of personal interaction and procedural skill that would be required to take care of sick people: taking histories, doing extensive physicals, drawing blood, putting in IVs, adjusting machinery. Since beginning third year has arrived, I have often felt as though that anxiety was misinformed, that I was naive in my anticipation of what being a doctor actually means. The nurses, therapists, and social workers are the people who are responsible for most of the day-to-day management in inpatient medicine. I have been thinking I must have missed some important manual about what doctors actually do when I was applying to schools, and was ashamed to admit my confusion. In his article Dr. Green has presented an opinion, however, that makes me realize that my initial conceptualization was not completely erroneous, merely lagging behind the times. I am reassured to know that I am not the only one scratching my head. I don't know what the solution to this situation is, as residents seem to have more managerial responsibility placed on them with each day that passes. Thanks to Dr. Green's comments, however, I feel reassured in the knowledge that other people are dissatisfied. Dissatisfaction is the strongest stimulus for change.
Rochester General Hospital
I can certainly understand Dr Green's concern about residents' increasing distance form the bedside. He subtly suggests that some scutwork is good for training the housestaff. However, in the present climate of decreasing work hours and busy inpatient service, the only practical way forward is to delegate these tasks to nurses and technicians. A physician's crucial role is in the decision making and thats what we must stress during the training. This does not mean that bedside teaching must suffer. All attending rounds and clinical case presentations must be done at the bedside to infuse enthusiasm towards bedside learning among the housestaff and the students.
Edward J. Volpintesta
October 18, 2007
Doctors or "medical managers" ?
The medical managerial responsibilities that the young doctor-in- training decries only get worse in real life practice especially, if he goes on to practice general internal medicine, also called primary care.
As a primary care physician he will find that just as in the hospital, his role becomes more that of a medical coordinator and less that of what has traditioally been considered a "doctor".
Like all primary care doctors,he will find that every day will be filled with mulitasking that wears physicians down and actually distracts them from the satisfaction of practice of "real medicine" including: responding to visiting nurse requests to verify orders or answer questions about a patient's condition, pharmaces and HMOs asking for changes from brand name to generic drugs or to change from one drug not on their formulary to one that is, responding providers of oxygen by periodic checking of patients' needs for oxygen, responding to CAT scan findings of "incidentalomas" and ordering further tests to rule out the rare possibiillity of their signifying serious diseases, poring over an endless stream of lab results and consultant reports, writing out excuses for work abscences, hyper-documenting everything they do to have a good defense in case a malpractice suit were to be filed, ordering unnecessary tests and consultations as part of good "defensive medicine" and, trying to stay current by staying informed on every new medication that comes out, many of which offer little improvement over older ones.
The list goes on and on. All physicians have managerial tasks and paperwork of some kind, but for generalists, the situation has gotten out of hand and actually has become a serious detraction that could lead to medical error. Certainly,it is a major cause of physician demoralization.
There is a possibility that someday the real medicine will be done by advanced practice nurses(APRNs) and physician assistants(P.A.s) and doctors will become medical scientists whose role is more coordinating than hands on care.
The retail clinics that are sprouting up nationally and stffed by APRNs is clear evidence that who does "real doctoring" is changing.
The answer? Different training tracks need to be created. Right now medical education is mostly researh-oriented. What is needed is a medical education that early on separates those who will go on to specialization, teaching and research and those who will be dedicated to practical medicine. Right now both groups have to assimilate the same rigorous basic science diet and maintain it for the rest of their careers, even though some, like those in primary care have no need for it. This leads to a disorted view of real life medicine characterized by of over-dependence on science and under-reliance on common sense leading to over use of expensive technlogy and testing.
I would not be surprised if managed care organizations some day started their own medical schools with this type of orientation,turning out physicians that are more practical in outlook. .
Montefiore Medical Center
The Absent Physician: Myth or Fact?
Dr. Green posits that current residency training creates interns who are absent from their patients because of their lack of bedside scut.
I recently completed my residency training. After lengthy admitting history and physical examinations interns spend with patients, subsequent visits are generally short. In some cases, one may see a patient for a mere 10 minutes in a day. If a patient inquired, "What does my doctor do, I never see her?" I would respond, "Advocating for patients."
Behind the scenes, interns check vital signs and lab results, follow up on examination interpretations with appropriate physicians, call consults, write progress notes, answer nurses' pages, fill out insurance forms, adjust dosages for a patient's polypharmacy, etc. In short, interns do scut for the same patients they saw only a few minutes that day. With so much to follow up on, it is a wonder interns have bedside time at all.
Has bedside teaching waned? Perhaps. I believe that most young physicians today would indeed prefer more time learning the vital skills necessary for performing a proper physical examination. However, if self- directed, the skills are still learned. After hearing a heart murmur, one theorizes as to its etiology then looks to echocardiogram results to confirm or negate the hypothesis. When less experienced, the intern may then go back to the patient's bedside to listen more carefully for what was not originally heard. This is the process of learning - trial and error. While physical examination skills are necessary, they are no longer the sole focus of a modern medical practice. Most teaching attendings today will not ask interns details about a heart murmur, but rather about the latest study looking at cardiovascular events with the newest treatment modality. Even if you know perfectly well that the diastolic murmur with an opening snap heard at the heart's apex is caused by mitral stenosis, you will still order the echocardiogram. Furthermore, you should. Why? Because evidence-based medicine will tell you what parameters are necessary for referring your patient to surgery.
Has the nature of scut changed? Yes, one has to know technology to treat patients. Technology per se has not replaced the physician's crucial role at the bedside, but it has become a vital partner in the treatment and management of caring for patients. Therefore, interns must learn both about bedside care and about modern invasive and non-invasive diagnostic and treatment modalities.
Stuart K. Sutton
Eastern Virginia Medical School
Scut work; an opposing view
Dr. Jonathon Green's reminisences of bedside scut work reminded me of some skills which modern students and housestaff might not have the opportunity to develop. Limb lead errors on EKGs would be immediately apparent when you are running it yourself. The difficulty of phlebotomy helps one understand the liklihood of a contaminated blood culture result. Recalling how patients would grimace and writhe in response to my ham- handed IV attempts helps me make real decisions today about whether to request that an IV be started. However, while I truly enjoyed being escorted back 25 years to my days as a lowly medical student and intern being indoctrinated into the profession with scut work, recent thoughts which I'd had about those days have also been brought to mind.
Although my residency was known for producing specialists, I opted for a general internal medicine practice. My students often ask me how and why I made that choice as they contemplate various directions. I have all sorts of answers for them, but part of the reason, as Dr. Green reminded me, was scut work.
Our GI service was absolutely brutal. There was no opportunity to learn anything during my rotation at the university hospital. It often seemed to be a life and death struggle for patients as well as for the housestaff who tried to just keep up with the volume of critically ill patients. We rarely interacted with our attendings and certainly had no time for education. Having been interested in pancreatic diseases since my first year anatomy class and fascinated by inflammatory bowel disease, this could have been the highlight of my training. Instead, after such an experience, I wanted nothing to do with a specialty that might otherwise have been of great interest to me. Obviously there were tasks which were necessary for one of us to perform to care for the patients, but having volumes of mundane drudgery to perform all hours of the day was a waste of time and multiplied my frustrations. An intern who is exhausted from tasks such as re-drawing blood after the last CBC clotted or was dropped by lab personnel is unlikely to learn much from transporting patients to radiology for a chest x-ray.
Like other older physicians, I sometimes fall prey to a knee-jerk reaction when I hear about restrictions on housestaff work hours (although I admit never having to trudge through snow to draw blood cultures at 2AM). However, recalling how these experiences tainted my outlook helps me see more benefits than negatives to the improved conditions for physicians in training.
Melissa A. Freeman
NYU Medical Center
October 23, 2007
Bedside Medicine Abound
TO THE EDITOR:
On reading Dr. Green's eloquent remarks on the "changed nature of scut," I agree with his intrinsic point regarding the changes that computerized technology and ancillary staff have brought to 21st-century medicine. Still, I am offended at his generalizations. Many residency programs continue to hold the patient and medicine as top priorities and these values are bestowed upon their housestaff. As a second year house officer at a renowned academic program in New York City, I can proudly say that my presence at the bedside can be duly noted.
In my program, the housestaff today, as they did in the past, generate the brick and mortar of the three hospitals through which we rotate day and night. Despite the presence of phlebotomists, transporters, and IV teams, scut, so to speak, is still very much alive. When needed, we draw blood with fine precision, we place intravenous lines in record time, we transport patients, we run urgent labs down to the centrifuge and wait for the results, and we obtain all of our own blood cultures, taking care to avoid contamination for a high yield specimen. When we are paged with fevers, we see, touch, and feel our patient's long before we contemplate dashing to the computer. We have witnessed the early rigors of pneumonia, the initial clamminess of shock, the breathing of impending respiratory failure, and the early headaches of intracranial bleeds. By sheer reflex, vitals are asked for at the mention of a patient's elevated temperature. This is medicine. This is what we have been taught by our senior residents, our attendings, and most importantly, our Hippocratic oaths.
Today's medicine is different; there is more paperwork, more typing, more checking labs on the computer, and technology overrules the physical exam. But I must adamantly disagree with a statement that equates the changed nature of scut to "remoteness" and absence at the bedside. Dr. Green is correct that we, the housestaff, no longer view our specimens under microscopes, diagnosing the microorganisms that live upon them with our own eyes, but that is not to say that the clammy hands of the Mr. McDonough's of the world go unnoticed, at least not where I train.
Melissa A. Freeman, M.D. New York University Medical Center NY, NY 10016
Dr Robert James
Christian Medical College and Hospital, Ldh, Pb, India
October 24, 2007
Re: The Absent Physician: Myth or Fact?
I agree with Dr Green, it is often difficult to imagine how much medical work an intern actually does that goes unnoticed, and as a result of it it is presumed that the junior doctors/interns don't examine the patients often.
The matter of fact being that the off bedside activities of a junior doctor / intern, like collecting lab reports, sorting out pt files, pt progress notes, discussing treatment part with fellow doctors, attending to other patient calls and finally preparing for morning rounds;
these activities happen only if the junior doctor/intern has examined the patient. Only after examining the patient, he can make sense of it all his off bed side activities.
Many a times it is important to leave the patient to rest and not subject him to lengthy exhausting examination drills. Nevertheless it is extremely vital to follow up the patient progess by bed side examination.
Some signs and symptoms cant be 'titrated' in lab tests, they can only be availed of for pt benefit , if the physician is on the bed side. Eg grading encephalopathy can be best done bed side talking to and examining the patient.
I think Sir Hutchisons rightly quoted Michael Swash in his book on Clinical Methods - 'From inability to be left alone; from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, science before art, and cleverness before common sense; from treating patients as cases; and from making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us.; -Michael Swash -The Royal London Hospital.
Another reason of the doctor being absent at pt bedside is the work load. In India especially an intern or a junior doctor has to take care of approximately 20-30 inpatients, whose turn over is very fast. If there were 2 instead of one then it would be fair to say that pt is not being examined by them.
Southern California Kaiser Permanente, Los Angeles Medical Center
October 29, 2007
Scut Gone: is Life Easier or Busier?
In his commentary on the discrepancies between residency training then and now, Dr. Jonathan Green reminds us of the laborious duties of the house officer in the 1980's. He then portrays a typical night call of today's intern and astutely points out how the evolution of modern medicine and its nature has pulled physicians away from the bedside and toward the computer keyboard.
I am that intern of whom Dr. Green speaks. And I am the one who gets called on Mr. McDonough for his fever this evening. Yet almost no part of the equation has remained unchanged. Mr. McDonough is now a hypertensive, diabetic male with stage one chronic kidney disease, history of MRSA bacteremia, and a recent liver transplant due to hepatitis C cirrhosis who is on prophylactic antibiotic, antifungal, and immunosuppressive medications.
I notice his new fever and somewhere between reviewing the paper chart, electronic records, and filling out several order forms for my routine fever workup, I do make time to appear by the bedside for a history and physical exam. With some suspicion for infectious etiology, comes the daunting task of choosing the appropriate broad-spectrum antibiotics. Not just one of them, but a combination. Not just the obsolete penicillin and ampicillin, but a myriad of classes of drugs. Further, I also keep a watchful eye on his renal function, history of drug-resistant bacteria, and potential interactions with his slew of current medications. I call my senior resident for advice who will then run the case by the infectious disease and/or the gastroenterology fellow on-call before getting back to me. Meanwhile, I log onto the computer to look up the most recent publications on the best course of management for Mr. McDonough's condition.
While perhaps no amount of medical knowledge or laboratory and imaging studies hold up as equivalent to findings on a bedside physical exam, they have and will continue to become exponentially intertwined with the way we practice medicine. And unarguably, the amount of time and effort expended by trainee physicians to learn and implement this new technology on more complex patients will increase. With that in mind, we often forget to acknowledge that today's intern and the intern of two decades ago have had the same amount of time to learn medicine's bulk of knowledge contemporary to their time. As a result, it is an unfortunate and yet inevitable fact that fewer hours are spent at the bedside to make time for learning and referring to new pharmacology, ever-growing medical literature, and novel imaging modalities. Witness to this claim is the fact that despite emergence of a formidable healthcare team consisting of nurses, phlebotomists, laboratory technicians, transporters, and therapists, today's intern work hours could only be reduced by mandates and by the force of law.
In the end, prolonged longevity and improved quality of life in the general patient population since the 1980's suggest an overall evolution in patient care and change in physician training for the better.
October 25, 2007
Absent Physician: Myth or Necessity?
I thank Dr. Robert James for sharing that wonderful quote of Dr. Michal Swash. Unfortunately, "... putting knowledge before wisdom, science before art and cleverness before common sense..." despite their potential harm to patients, are often the qualities that physicians are forced to use once their idealism has been tried and tempered by experience in the real world of medicine.
The sharpest example of this is what is known as "defensive medicine", that is, the ordering of unneccessary and expensive tests and consultations just to have a good defense in case a malpractice suit is filed. Once physicians leave the protected environment of the hospital they quickly learn how the "legal imperative", as I call it,coerces them into rationalizing that knowledge more than wisdom, cleverness more than common sense,and science more than art are necessary to keep the malpractice lawyers at bay.
My point is that, the current hostile litigious environment undermines and destroys the idealism and humanitarian values that all physicians start out with but few manage to hold on to.
Until there is serious and meaningful tort reform and doctors can practice medicine free from the threat of frivolous lawsuits, it will be difficult for most of them to live up to the idealism that Dr. James describes.
Michael J Rosenblum
Baystate Medical Center
October 30, 2007
The Changing Nature of Care: A Healthcare Team at the Bedside
"Say not thou: 'How was it that the former days were better than these?' for it is not out of wisdom that thou inquirest concerning this." --Ecclesiastes 7:10
It was during a night float shift that the nurse asked me to evaluate a febrile patient. Like all the patients on my unit, Mr. McDonough was my responsibility. I scanned my electronic handoff information (a legible list of problems, accurate medications, allergies, and anticipated complications) en route to his room.
Mr. McDonough looked ill--minimally responsive, diaphoretic with a weak, thready pulse. These findings led me toward a diagnosis of pneumonia and SIRS, but as an intern I was unsure, so I paged our in-house hospitalist, and called our 24-hour Rapid Response Team.
The IV therapist inserted a large bore IV, the respiratory therapist initiated CPAP and the ICU nurse monitored vitals while I started pressors. I contacted Mr. McDonough's family to discuss the ongoing events and to readdress code status. My attending and I discussed care, selected appropriate antibiotics and consulted our in-house intensivist. I had the time to learn from a supportive and experienced clinician at the bedside with immediate feedback.
To Err is Human and Crossing the Quality Chasm exposed the problems imbedded in the contemporary approach to healthcare delivery. As highly educated, trained and successful professionals physicians work exceptionally hard, but they can no longer do everything alone, nor should they. Teamwork and improved systems of care are the characteristics of highly functional healthcare organizations that maximize quality of care while reducing errors.
The equilibrium of supervision and autonomy is the key to developing physicians of the future. In 1986, Dr. Green may have successfully treated Mr. McDonough alone in the middle of the night, but unsupervised care of patients with septic shock, although a great learning experience, is no longer acceptable medical practice. In light of the fact that patients in 2007 are older and sicker, a lone resident doing all the "scut" will no longer suffice. Despite the increased complexity, our care is improving, with the mortality rate for pneumonia falling from 7.5% in 1993 to 4% in 2005. (1) Examination at the bedside remains a key factor for all members of the team and communication is paramount. However, the days of the lone physician who does it all are gone forever--to the benefit of our patients.
References: 1. Agency for Healthcare Research and Quality. HCUPnet, Healthcare Cost and Utilization Project. 2007. Available at http://hcupnet.ahrq.gov/. Accessed October 29, 2007.
Jonathan M Green
Washington University School of Medicien
November 28, 2007
In reply to the many letters....
To all who wrote, either directly to me or posted on this site, thank you for taking the time to both read my article and share your thoughts. I have received over 50 emails and letters sent directly to me commenting on the article. Never did I think it would generate such a response.
The vast majority of responses were in agreement with my sentiments, and not surprisingly, these were almost uniformly from physicians of my generation or older (I hate to think of myself as being an old curmudgeon already"¦). There were some responses from younger physicians that took some issue with my musings. To those (very) few that seem to be offended, I apologize, my intent was not to accuse you of being lazy or uncaring physicians. Even when I trained, my attending physicians always referred to the "days of the giants" when things were really tough.
Much of the change has been thrust upon us as Dr's and trainees, incrementally, some intentionally some not, some due to technology, some due to public concern over real or perceived problems with care. As one person whom wrote to me said, doctors are much more information managers now. I agree wholeheartedly with this. The wealth of data, at least which is in written form, has increased exponentially. Unfortunately, the un-written data, that which comes from direct observation of the patient has been lost, buried in the mounds of paperwork.
I believe that the source of much of the discontent voiced by patients with medicine has its roots in the disconnection of the physician from his or her patient. Trust between individuals is established through direct, personal encounters. Trust is at the heart of the doctor patient relationship. Trust can only be established at the bedside.
Jonathan M. Green, MD
Steven M Hegedus
Memphis Health Loop
December 1, 2007
Remaining at the Bedside
In the recent letter, "The Changed Nature of Scut,: An Absence at the Bedside," Dr. Green highlights concern for the changing face of medical education. Though life as a resident has evolved, I disagree that technology has worsened the process of medical education.
In his account, Dr. Green recalls a patient with deteriorating course. I would argue that did not examine the patient merely to draw blood, evaluate sputum, and collect urine, but instead because he cared for the patient and recognized the value of the physical assessment; in short, he chose at that moment to be a doctor. In this era of evidence based medicine, we recognize that such a patient with progressing septic shock should be started on broad spectrum antibiotics, not based on exhaustive point of care body fluid assessment, but because of the bedside attention of an attentive intern.
In addition, the changing face of medicine and medical training has not eased the workload of trainees, and proclamations of an idealistic past are non-constructive at best. In modern teaching hospitals, residents are faced with increased demand for patient throughput, greater medical complexity, and the care of sicker patients than ever before. Still, hospital wards echo of the "good old days," when residents worked tirelessly without work hours restrictions or ancillary assistance. Overworked and undervalued by mentors longing for the past, it is no wonder students and residents turn away from general medicine in favor of more hopeful pursuits.
Medical education has changed dramatically in recent years, however the essence of medicine has remained the same. Tonight countless interns juggling numerous clinical responsibilities will turn away from their computers to examine struggling patients at the bedside. As mentors, let us help them to recognize the weight and privilege of their responsibility, so that in twenty years they too will recall the patients whom they serve.
Bohdan A. Oryshkevich
February 23, 2009
Better and Worse
I sympathize with both generations of physicians.
On one side the presence of scut was laborious but it certainly kept me at the bedside. I remember a patient going into severe shaking rigors while suffering necrotizing pyelonephritis and an unmeasurably high temperature. The resident came with buckets of ice cubes. Witnessing physiological processes in the presence of a patient was education. Old scut was a necessary evil.
Today, there is technological scut. One has to follow up on data that is often redundant and unnecessary. I am amazed at how doctors today feel uncomfortable about physical findings and feel that they must be confirmed by some test. X-rays, CT scans, and MRIs are not memorable. Patients are. Clinical care requires common sense and conservation of energy and personal resources to be able to take care of patients. Technology can distract the physician away from taking care of the patient. But it can help too.
Today, however one can look up almost anything at the bedside. I remember having to call security in the middle of the night as a resident to open up the medical library so that I could check how many cafe-au-lait spots made a diagnosis of neurofibromatosis. The patient did have neurofibromatosis. Today one just has to google it.
The process is the same. Yesterday and today nothing keeps the resident from the patient. If you spend less time looking things up or ordering them today because of computers, you can spend more time with the patient.
The question is whether sitting is too comfortable or the blackberry is too distracting.
Physical exhaustion from running around vs mind numbing clerical work. These are the alternatives.
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