46
CHANGING HOUSE STAFF-ATTENDING STAFF R E L A T I O N S* JOSEPH POST, M. D. Professor of Clinical Medicine New York University School of Medicine Attending Physician Lenox Hill Hospital New York, New York
DURING the past 20 years major changes have taken place in hospital practice. The free and relatively unassailable position the physician traditionally enjoyed has disappeared. One area which has undergone profound change is the house staff-attending staff relation, particularly in institutions where the attending staff is composed largely of physicians engaged in private practice. There has been an enormous expansion in the size of hospital house staffs disproportionate to the increase in patient population and to the numbers of medical school graduates. This has been associated with the greatly expanded residency-training programs for specialty board certification. The change in relation between house staff and attending staff with regard to patient care in some medical centers has made superfluous the role of the physician of record. In some institutions he is not permitted to write any orders: this is the sole prerogative of the house staff. Supervision is usually provided by attending physicians who are private practitioners or full-time institutionpaid physicians, assigned as visiting physicians to certain geographic areas for stated periods of time. They make rounds for prescribed periods and are charged with the overall surveillance of patient care for a particular geographic area. Their rounds usually consist of seeing problem patients, whose illnesses are difficult to define or to manage or of special interest. Inasmuch as their rounds have time limits, they cannot see every patient every day, nor can they have a detailed understanding of every patient on *Presented in a panel, Ethical Issues in Attending-Resident Relations, as part of the 1978 Annual Health Conference of the New York Academy of Medicine, The Hospital Reconsidered: A New Perspective, held May 1 and 2, 1978. Address for reprint requests: Lenox Hill Hospital, 77th Street and Park Avenue, New York, N.Y. 10021.
Bull. N.Y. Acad. Med.
CHANGING RELATIONS
47
CHANGING RELATIONS47
the floor. They depend upon the house staff for guidance and to direct their attention to specific patients. Let us examine some of the legal, ethical, and medical aspects of this system. LEGAL ASPECTS
When a patient enters the hospital the institution agrees to provide its services, i.e., its physical plant, food, heat, light, a bed, surgical suite, etc. in exchange for the patient's financial obligation. The patient makes another unwritten contract with the attending physician of record, namely, that he, the attending physician, will be responsible for the medical care. Special procedures, such as proctoscopy, liver biopsy, or surgical operation, must be formally agreed to by the patient with either the attending physician of record or a designated consultant. Payments are made to the attending physician of record. This establishes and recognizes a specific contractual relation. Nowhere in these understandings is the interposition of house staff control understood. Patient and attending physician recognize the house staff as surrogates of the latter but not as replacements. The Joint Commission on Accreditation of Hospitals has very specific comments in its manual for hospital practices: STANDARD III
The medical staff shall develop and adopt bylaws, rules and regulations to establish a framework of self-government and a means of accountability to the governing body. Interpretation: Where there is a medical staff policy that permits patient care orders to be written by the house staff, the policy must not be extended to prohibit orders from being written by the patient's private physician or dentist without his agreement. Further, the staff member's declination to participate in this practice shall not in itself be a basis for sanctions relating to staff membership or the holding of clinical privileges, or to the loss of other medical staff prerogatives. This principle should be made clear in the medical staff bylaws, rules and regulations. STANDARD XI
The governing body shall require that the medical staff establish controls that are designed to ensure the achievement and maintenance of high standards of professional ethical practices.
Interpretation:
Vol. 55, No. 1, January 1979
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J. POST
The governing body must establish policies to ensure that only a member of the medical staff shall admit a patient to the hospital and that only a licensed practitioner with clinical privileges shall be directly responsible for a patient's diagnosis and treatment within the area of his privileges, that each patient's general medical condition be the responsibility of a physician member of the medical staff, and that other direct medical care to patients is provided only by a member of the house staff or by other specified professional personnel or by allied health personnel acting under the supervision of a licensed practitioner with clinical privileges. When the organized medical staff concludes that its individual members may delegate the performance of certain practices related to medicine to specified professional personnel, the medical staff shall specify and the governing board shall ratify the responsibilities that may so be delegated.
The State Board of Regents defines "unprofessional conduct" as follows: Chapter I-Board of Regents-Rules and Regulations (Part 29 Education Law, 66506) 29.1 11) performing professional services which have not been duly authorized by the patient or client or his or her legal representative. 29.2 6) failing to exercise appropriate supervision over persons who are authorized to practice only under the supervision of the licensed professional.
New developments whereby house staff controls patient management have changed the concept of the role of a house officer from that of a postgraduate student to a responsible hospital physician employee. Indeed, some labor agreements between house staff and hospital have defined house staff physicians as employees. The ruling by the National Labor Relations Board [(223) NLRB No. 57 in 1976 in relation to the.Cedars-Sinai Hospital case] was that interns and residents were students and not employees, a ruling sustained by the Supreme Court of the United States. Currently two bills [HR 2222 and S1884] are under consideration by the Congress to change that status so that interns and residents may be covered by the 1974 health-care amendments to the National Labor Relations Board Act. Should these become law, postgraduate medical training will require review and redefinition. Should the physician of record continue to be held responsible for the patient's care even though he lacks authority? What happens when something goes wrong in the course of the treatment or investigational studies and legal action is taken against the physician of record? How is his position defensible when he may have surrendered control of the care of the patient? Bull. N.Y. Acad. Med.
CHANGING RELATIONS
CHANGING RELATIONS
49
49
ETHICAL ASPECTS We have specific rules laid down by the state education law and by the Joint Commission on Accreditation of Hospitals. Are these to be changed? Should the patient be told before entering the hospital that he will not be cared for by his personal physician? Should he know that he will be treated by the house staff, with guidance from an unknown attending physician, who is on service at the particular time and who may or may not visit daily? Should he be told that a member of the house staff will perform the surgical operation with his surgeon of choice in attendance? If the patient is to continue to exercise free choice of his physician when he is outside a hospital, is he to give up this freedom of choice when he enters a hospital? Admission to hospital is usually for serious illness and a time of unusual stress for the patient and the family, when the reassurance of familiar, supportive figures can be a major factor in the patient's response to illness. On the other hand, should he be offered the opportunity to choose his house staff doctors and the visiting physician? Are all patients, rich or poor, treated alike in this teaching setting, or can one assure oneself of a choice of physician by electing to be in a private room? Should the physician of record be paid for professional services rendered to the patient if he is not in authority? Should the house staff or the temporarily designated visiting physician be paid for such services? Should the physician of record be paid for special services offered by house staff at his request such as liver biopsy, sigmoidoscopy, or thoracentesis? How do third-party payers deal with this? MEDICAL ASPECTS
The major arguments for giving authority to house staff for patient care is that it is necessary for their adequate training, and a corollary to this is that the best medical care is rendered in such a teaching setting. The wide exposure of the patient to the medical talent and equipment available in such an institution has the potential for the best medical diagnosis and therapy. But this often involves more expensive work-ups and longer hospital stays, and sometimes elaborate tests are performed of value for the most complete patient care, but sometimes they are done to satisfy curiosity, as part of the teaching experience. Are we to have one standard of hospital utilization review for "teaching" patients and one for others? The medical problems seen in the hospital, where the major training is Vol. 55, No. 1, January 1979
50 50
J. POST
J POS
done, are but the tips of the icebergs of illness. They are catastrophic medical events in patients' lives. It is long-term observation out of hospital that encompasses the basic care of the sick. The house officer sees none of this. Clinic service in hospitals provides relatively poor medical care. House staff physicians usually do not spend much time in this area and none in home care. The intensive and coronary care units and the operating rooms are places of excitement and great decision-making, yet these represent the smallest parts of patient-care involvement. If we are concerned with this truncated education, why not with the other kind? For the most part we provide little opportunity for students and house staff to learn about the long-term care of patients. I mention this not to expand the scope of my discussion needlessly, but to observe that in the care of specific patients the discontinuity in care that we encourage by excluding the physician of record is not in the patient's best interest. Elimination of the physician of record from the hospital raises some serious questions other than those already mentioned or the matter of his bruised ego. House staff works three or four nights each week, and when a resident or intern leaves his patients at 5 P.M. a much smaller night crew takes over. It is impossible for them to know all the patients. From 5 P.M. to 9 A.M. many things can and do happen to patients. During this period many emergency episodes around the hospital occupy the night crew. Priorities must be observed. An intern or resident may not be able to deal adequately with a specific patient because of his lack of familiarity, but the patient's own doctor can. Once we eliminate him from the care of his patient we may be denying the patient invaluable assistance. How do we justify this in the name of teaching and all the benefits to the patient of the teaching setting? Long weekends come more often these days. How do we provide for such lapses? If there is one thing we fail to instill in our teaching programs it is that medical care in or out of the hospital is a continuum of 24 hours a day, 365 days a year. When the responsible physician goes away he has a trusted colleague look after his practice and his records are available. There should be no lapses in medical care. Unless we are prepared to provide this type of coverage in the hospital, we are deficient in our service. If the trend to giving total authority to house staff continues and extends throughout our hospital system we shall have backed into a two-tier medical practice system, similar to the one in Britain. One group of hospital-based physicians will supervise house staff and medical student Bull. N.Y. Acad. Med.
CHANGING REAIOS5 RELATIONS
~~~~~~CAGN
51
activities and another group will work in their offices. If this is our ultimate goal, we should define it as such. It is always easier to raise questions than to answer them. Until now we have acted as though these problems did not exist. But it is essential that we deal with them because if we do not, others less qualified will lay down simplistic rules which may aggravate the difficulties and create new ones.
Vol. 55, No. 1, January 1979
CHANGING HOUSE STAFF-ATTENDING STAFF R E L A T I O N S* JOSEPH POST, M. D. Professor of Clinical Medicine New York University School of Medicine Attending Physician Lenox Hill Hospital New York, New York
DURING the past 20 years major changes have taken place in hospital practice. The free and relatively unassailable position the physician traditionally enjoyed has disappeared. One area which has undergone profound change is the house staff-attending staff relation, particularly in institutions where the attending staff is composed largely of physicians engaged in private practice. There has been an enormous expansion in the size of hospital house staffs disproportionate to the increase in patient population and to the numbers of medical school graduates. This has been associated with the greatly expanded residency-training programs for specialty board certification. The change in relation between house staff and attending staff with regard to patient care in some medical centers has made superfluous the role of the physician of record. In some institutions he is not permitted to write any orders: this is the sole prerogative of the house staff. Supervision is usually provided by attending physicians who are private practitioners or full-time institutionpaid physicians, assigned as visiting physicians to certain geographic areas for stated periods of time. They make rounds for prescribed periods and are charged with the overall surveillance of patient care for a particular geographic area. Their rounds usually consist of seeing problem patients, whose illnesses are difficult to define or to manage or of special interest. Inasmuch as their rounds have time limits, they cannot see every patient every day, nor can they have a detailed understanding of every patient on *Presented in a panel, Ethical Issues in Attending-Resident Relations, as part of the 1978 Annual Health Conference of the New York Academy of Medicine, The Hospital Reconsidered: A New Perspective, held May 1 and 2, 1978. Address for reprint requests: Lenox Hill Hospital, 77th Street and Park Avenue, New York, N.Y. 10021.
Bull. N.Y. Acad. Med.
CHANGING RELATIONS
47
CHANGING RELATIONS47
the floor. They depend upon the house staff for guidance and to direct their attention to specific patients. Let us examine some of the legal, ethical, and medical aspects of this system. LEGAL ASPECTS
When a patient enters the hospital the institution agrees to provide its services, i.e., its physical plant, food, heat, light, a bed, surgical suite, etc. in exchange for the patient's financial obligation. The patient makes another unwritten contract with the attending physician of record, namely, that he, the attending physician, will be responsible for the medical care. Special procedures, such as proctoscopy, liver biopsy, or surgical operation, must be formally agreed to by the patient with either the attending physician of record or a designated consultant. Payments are made to the attending physician of record. This establishes and recognizes a specific contractual relation. Nowhere in these understandings is the interposition of house staff control understood. Patient and attending physician recognize the house staff as surrogates of the latter but not as replacements. The Joint Commission on Accreditation of Hospitals has very specific comments in its manual for hospital practices: STANDARD III
The medical staff shall develop and adopt bylaws, rules and regulations to establish a framework of self-government and a means of accountability to the governing body. Interpretation: Where there is a medical staff policy that permits patient care orders to be written by the house staff, the policy must not be extended to prohibit orders from being written by the patient's private physician or dentist without his agreement. Further, the staff member's declination to participate in this practice shall not in itself be a basis for sanctions relating to staff membership or the holding of clinical privileges, or to the loss of other medical staff prerogatives. This principle should be made clear in the medical staff bylaws, rules and regulations. STANDARD XI
The governing body shall require that the medical staff establish controls that are designed to ensure the achievement and maintenance of high standards of professional ethical practices.
Interpretation:
Vol. 55, No. 1, January 1979
48 48
J. POST
The governing body must establish policies to ensure that only a member of the medical staff shall admit a patient to the hospital and that only a licensed practitioner with clinical privileges shall be directly responsible for a patient's diagnosis and treatment within the area of his privileges, that each patient's general medical condition be the responsibility of a physician member of the medical staff, and that other direct medical care to patients is provided only by a member of the house staff or by other specified professional personnel or by allied health personnel acting under the supervision of a licensed practitioner with clinical privileges. When the organized medical staff concludes that its individual members may delegate the performance of certain practices related to medicine to specified professional personnel, the medical staff shall specify and the governing board shall ratify the responsibilities that may so be delegated.
The State Board of Regents defines "unprofessional conduct" as follows: Chapter I-Board of Regents-Rules and Regulations (Part 29 Education Law, 66506) 29.1 11) performing professional services which have not been duly authorized by the patient or client or his or her legal representative. 29.2 6) failing to exercise appropriate supervision over persons who are authorized to practice only under the supervision of the licensed professional.
New developments whereby house staff controls patient management have changed the concept of the role of a house officer from that of a postgraduate student to a responsible hospital physician employee. Indeed, some labor agreements between house staff and hospital have defined house staff physicians as employees. The ruling by the National Labor Relations Board [(223) NLRB No. 57 in 1976 in relation to the.Cedars-Sinai Hospital case] was that interns and residents were students and not employees, a ruling sustained by the Supreme Court of the United States. Currently two bills [HR 2222 and S1884] are under consideration by the Congress to change that status so that interns and residents may be covered by the 1974 health-care amendments to the National Labor Relations Board Act. Should these become law, postgraduate medical training will require review and redefinition. Should the physician of record continue to be held responsible for the patient's care even though he lacks authority? What happens when something goes wrong in the course of the treatment or investigational studies and legal action is taken against the physician of record? How is his position defensible when he may have surrendered control of the care of the patient? Bull. N.Y. Acad. Med.
CHANGING RELATIONS
CHANGING RELATIONS
49
49
ETHICAL ASPECTS We have specific rules laid down by the state education law and by the Joint Commission on Accreditation of Hospitals. Are these to be changed? Should the patient be told before entering the hospital that he will not be cared for by his personal physician? Should he know that he will be treated by the house staff, with guidance from an unknown attending physician, who is on service at the particular time and who may or may not visit daily? Should he be told that a member of the house staff will perform the surgical operation with his surgeon of choice in attendance? If the patient is to continue to exercise free choice of his physician when he is outside a hospital, is he to give up this freedom of choice when he enters a hospital? Admission to hospital is usually for serious illness and a time of unusual stress for the patient and the family, when the reassurance of familiar, supportive figures can be a major factor in the patient's response to illness. On the other hand, should he be offered the opportunity to choose his house staff doctors and the visiting physician? Are all patients, rich or poor, treated alike in this teaching setting, or can one assure oneself of a choice of physician by electing to be in a private room? Should the physician of record be paid for professional services rendered to the patient if he is not in authority? Should the house staff or the temporarily designated visiting physician be paid for such services? Should the physician of record be paid for special services offered by house staff at his request such as liver biopsy, sigmoidoscopy, or thoracentesis? How do third-party payers deal with this? MEDICAL ASPECTS
The major arguments for giving authority to house staff for patient care is that it is necessary for their adequate training, and a corollary to this is that the best medical care is rendered in such a teaching setting. The wide exposure of the patient to the medical talent and equipment available in such an institution has the potential for the best medical diagnosis and therapy. But this often involves more expensive work-ups and longer hospital stays, and sometimes elaborate tests are performed of value for the most complete patient care, but sometimes they are done to satisfy curiosity, as part of the teaching experience. Are we to have one standard of hospital utilization review for "teaching" patients and one for others? The medical problems seen in the hospital, where the major training is Vol. 55, No. 1, January 1979
50 50
J. POST
J POS
done, are but the tips of the icebergs of illness. They are catastrophic medical events in patients' lives. It is long-term observation out of hospital that encompasses the basic care of the sick. The house officer sees none of this. Clinic service in hospitals provides relatively poor medical care. House staff physicians usually do not spend much time in this area and none in home care. The intensive and coronary care units and the operating rooms are places of excitement and great decision-making, yet these represent the smallest parts of patient-care involvement. If we are concerned with this truncated education, why not with the other kind? For the most part we provide little opportunity for students and house staff to learn about the long-term care of patients. I mention this not to expand the scope of my discussion needlessly, but to observe that in the care of specific patients the discontinuity in care that we encourage by excluding the physician of record is not in the patient's best interest. Elimination of the physician of record from the hospital raises some serious questions other than those already mentioned or the matter of his bruised ego. House staff works three or four nights each week, and when a resident or intern leaves his patients at 5 P.M. a much smaller night crew takes over. It is impossible for them to know all the patients. From 5 P.M. to 9 A.M. many things can and do happen to patients. During this period many emergency episodes around the hospital occupy the night crew. Priorities must be observed. An intern or resident may not be able to deal adequately with a specific patient because of his lack of familiarity, but the patient's own doctor can. Once we eliminate him from the care of his patient we may be denying the patient invaluable assistance. How do we justify this in the name of teaching and all the benefits to the patient of the teaching setting? Long weekends come more often these days. How do we provide for such lapses? If there is one thing we fail to instill in our teaching programs it is that medical care in or out of the hospital is a continuum of 24 hours a day, 365 days a year. When the responsible physician goes away he has a trusted colleague look after his practice and his records are available. There should be no lapses in medical care. Unless we are prepared to provide this type of coverage in the hospital, we are deficient in our service. If the trend to giving total authority to house staff continues and extends throughout our hospital system we shall have backed into a two-tier medical practice system, similar to the one in Britain. One group of hospital-based physicians will supervise house staff and medical student Bull. N.Y. Acad. Med.
CHANGING REAIOS5 RELATIONS
~~~~~~CAGN
51
activities and another group will work in their offices. If this is our ultimate goal, we should define it as such. It is always easier to raise questions than to answer them. Until now we have acted as though these problems did not exist. But it is essential that we deal with them because if we do not, others less qualified will lay down simplistic rules which may aggravate the difficulties and create new ones.
Vol. 55, No. 1, January 1979
