In JAMA: Abraham Verghese and I discuss the changing world of ward attendings

Senior attendings like to quip that the medical students seem to be getting younger every year. They’re not.

But the attendings on the wards of American teaching hospitals actually have gotten younger. At UCSF Medical Center, for example, about 90% of our ward attending-months are now staffed by hospitalists, about half of them physicians in their first six to seven years on faculty. When I was a resident in the mid-1980s, the vast majority of my attendings were senior faculty, mostly subspecialists.

Not only has the cast of characters changed, but the nature of being a ward attending has also been transformed by a series of forces, including resident duty-hours regulations, increased supervisory expectations, sicker patients, and electronic health records. Because everyone is so busy and the stakes so high, my sense is that all of those on the wards are a bit uneasy, searching desperately for a new normal. We’re actors in a play and have just been handed a new script.

Several months ago, I was chatting with my friend Abraham Verghese, the acclaimed author and a professor at Stanford, about how much more challenging being a ward attending is these days, and we got a bit nostalgic. Not that the old days were so great, mind you – residents were exhausted, the degree of autonomy that trainees enjoyed was probably unethical, the pressures to improve quality and safety were largely nonexistent, and writing notes and orders in indecipherable chicken-scratch on dead trees was ludicrous. But at least everyone understood the way things worked, and that lent a certain comfort and calmness to the enterprise.

Abraham and I decided to write an article about our observations, and it is published in JAMA. I won’t say much more about it here, in the hopes that you’ll read the article itself. But here is one key paragraph, which I hope will whet your appetite:

    … opportunities for misunderstanding abound. Given time constraints, should the team sit in a conference room, discussing the virtual construct of the patient in the computer – the iPatient – or should they be rounding and seeing patients together? If the senior resident prioritizes “getting the work done” over attending teaching rounds, is that an acceptable tradeoff? All of these questions have made clear how fragile the old attending-trainee ecosystem was and how much of the daily work (and harmony) rested on a bedrock of unspoken assumptions and powerful traditions. The magnitude and rapidity of today’s changes have left all the species groping for a new and more stable habitat.

The article is accompanied by a podcast of an interview that JAMA’s editor, Howard Bauchner, conducted with Abraham and me.

In writing this piece, our goal was not to bring back the Days of the Giants (truth be told, I think the quality of care is better today; as for the educational experience, I’m not so sure) but to start a conversation among leaders, attendings, trainees, and patients about what needs to be done to improve the ward experience for everyone involved. I’d welcome your comments.

Robert Wachter, MD blogs regularly at Wachter’s World.