EDITORIAL
New Professionalism, Nostalgic Professionalism, Pejoratives, and Evidence-Based Persuasion Scott Corlew, MD, MPH, and William Lineaweaver, MD
S
ince 2003, a series of regulations have placed restrictions on resident physician work hours, limiting total work hours and continuous work hours in hospitals. More recently, studies and discussions have raised the issue of placing limits on elective surgery by surgeons following nights when they have been on call. The basis for these varieties of regulations is the assumption that work hour restrictions will decrease clinical errors related to physician fatigue. A number of studies have shown that regulation and limitation of resident work hours, however, have failed to produce any clear benefits to patient safety. Decreased resident clinical experience, however, as well as increased demands on attending physicians and ancillary staff, are consequences of resident work hour restrictions and these consequences may have careers of their own as complex manpower issues.1 Proposals for restricting elective surgery by surgeons coming off call nights suffer from lack of any clear problem to solve. Studies of procedures done after call nights by cardiothoracic surgeons, general surgeons, obstetricians-gynecologists, and trauma surgeons fail to show any increase in complications compared to procedures done when surgeons operate on days unburdened by a previous night’s call.1Y3 One commentary, using highly contrived interpretations of one of the abovementioned studies, sensationally declared an ‘‘83% increase’’ in complications done by a subset of surgeons who slept less than 6 hours while on call, but this startling claim evaporates with scrutiny. The original study noted that on call surgeons with less than 6 hours of ‘‘sleep opportunity’’ had a complication rate of 6.2%, whereas surgeons with 6 or more hours of ‘‘sleep opportunity’’ had a complication rate of 3.4%. The ‘‘83% increase’’seems to be based on a misleading manipulation of this data subset: 6.2 j 3.4 = 2.8 3.4 100 = 82%. Neither of these groups, however, had complication rates significantly different than the 4.9% complication rate achieved by surgeons operating on days with no preceding night call.4 From available evidence, there seem to be grounds to reconsider the issue of resident work hour restrictions. Instead of simplistic, quantitative guidelines that are now being implemented, a more f lexible set of formulae should be considered, one that takes some account of educational priorities, care continuity, graduated responsibility, and collateral issues such as moonlighting, as well as patient safety and resident fatigue. Also, from available evidence, there seems to be no ground for general restriction on elective procedures done by surgeons after a night on call. The previously mentioned paragraph could serve as an evidence-based summary of these issues. The issues, however, have been subjected to another level of analysis exemplified by a recent essay by Arora and coauthors.5 These commentators proceed to a normative argument uncluttered by any data. They assign a categorical affirmative value to the term ‘‘new professionalism.’’ This term embraces ‘‘the current system of medical training.’’ This professionalism ‘‘must fully adopt a team based care model in which patient ownership is not relegated to an individual, but shared among a group of team members.’’ Regulated shifts will ‘‘I(help) residents recognize their limits as humans, emphasizing the importance of physicians’ health and alertness.’’ Behavior deviating from this categorical affirmative (such as interns ‘‘staying past shift limits’’) is categorically excluded from affirmative valuation by assigning the term ‘‘nostalgic professionalism’’ to such behavior and developing the term as a pejorative, a ‘‘depreciatory, contemptuous’’ word.6 Nostalgic professionalism is defined as ‘‘consistently placing a patient’s or profession’s needs above one’s own personal needs.’’ Although these characteristics were once (and occasionally may still be) laudable, ‘‘at times these behaviors directly conf lict with the current system of medical training.’’ Demonstrating the dynamics of pejoratives, the authors categorically link nostalgic professionalism to other ‘‘depreciatory, contemptuous’’ behavior, including risks of transmitting illness, generalized and situational lying, and indulgence in ‘‘preconceived notionsIof what constitutes professional behavior.’’ Can this sort of analysis be considered legitimate as a meaningful contribution to the debate of these issues? First of all, the analysis fails the definition of argument, that is, a ‘‘statement of the pros and cons of a proposition.’’6 The normative assignments of good and bad to ‘‘new professionalism’’ and ‘‘nostalgic professionalism,’’ respectively, are nothing more than an exercise in labeling. Received December 16, 2013, and accepted for publication, after revision, December 16, 2013. From the 1850 Chadwick Drive, Suite 1427, North Tower, 4 West Jackson, MS 39204. Conflicts of interest and sources of funding: none declared. Reprints: William Lineaweaver, MD 1850 Chadwick Drive, Suite 1427, North Tower, 4 West Jackson, MS 39204. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7203-0263 DOI: 10.1097/SAP.0000000000000138
Annals of Plastic Surgery
& Volume 72, Number 3, March 2014
www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
263
Annals of Plastic Surgery
Editorial
Second, the analysis fails the ethical imperative of what Shaw and Elger7 call ‘‘evidence based persuasion.’’ These authors have formulated rules for ethical persuasion in doctor-patient exchanges, but we propose that these rules can be applied to any responsible promotion of a proposition or choice. The rules include the following: 1. remove biases; 2. provide honest, impartial evidence-based information; 3. provide rational interpretations of this information; 4. use reason rather than emotion; and 5. avoid creating new biases. The categorical endorsement of new professionalism and the stigmatization of ‘‘nostalgic professionalism’’ fail all of the stipulations of evidence-based persuasion. Most obviously, the endorsementpejorative assignments simply serve to create a new bias. Available evidence indicates that resident work hour regulation deserves comprehensive reevaluation. No evidence available at this time justifies restriction of elective procedures by surgeons coming off night call. Further considerations of these issues can only be constructively advanced by continued accumulation and rational analysis of credible data. Moving beyond evidence-based persuasion will not clarify these issues nor optimally benefit the professionals
264
www.annalsplasticsurgery.com
& Volume 72, Number 3, March 2014
and patients who will have to live with evolving regulations of health care delivery. The endorsement of new professionalism and the stigmatization of nostalgic professionalism are premature and misleading conclusions applied to complex, evolving issues that deserve more intelligent treatment. REFERENCES 1. Sharpe JP, Weinberg JA, Magnolti LJ, et al. Outcomes of operations performed by attending surgeons after overnight trauma shifts. J Am Coll Surg. 2013; 216:791Y799. 2. Viden C, Nash DM, Rangre J, et al. Complications of daytime elective laparoscopic cholecystectomies performed by surgeons who operated the night before. JAMA. 2013;310:1837Y1841. 3. Zinner M, Fresichlag JA. Surgeons, sleep, and patient safety. JAMA. 2013;310: 1807Y1808. 4. Lineaweaver W. Sleepy surgeons and patient safety. Ann Plast Surg. 2011;67: 203Y204. 5. Arora VM, Farnan JM, Humphrey HJ. Professionalism in the era of duty hours. JAMA. 2012;308:2195Y2196. 6. Brown L, ed. The New Shorter Oxford English Dictionary. Oxford: Clarendon Press; 1993:2141, 112. 7. Shaw D, Elger B. Evidence-based persuasion. JAMA. 2013;309:1689Y1690.
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
New Professionalism, Nostalgic Professionalism, Pejoratives, and Evidence-Based Persuasion Scott Corlew, MD, MPH, and William Lineaweaver, MD
S
ince 2003, a series of regulations have placed restrictions on resident physician work hours, limiting total work hours and continuous work hours in hospitals. More recently, studies and discussions have raised the issue of placing limits on elective surgery by surgeons following nights when they have been on call. The basis for these varieties of regulations is the assumption that work hour restrictions will decrease clinical errors related to physician fatigue. A number of studies have shown that regulation and limitation of resident work hours, however, have failed to produce any clear benefits to patient safety. Decreased resident clinical experience, however, as well as increased demands on attending physicians and ancillary staff, are consequences of resident work hour restrictions and these consequences may have careers of their own as complex manpower issues.1 Proposals for restricting elective surgery by surgeons coming off call nights suffer from lack of any clear problem to solve. Studies of procedures done after call nights by cardiothoracic surgeons, general surgeons, obstetricians-gynecologists, and trauma surgeons fail to show any increase in complications compared to procedures done when surgeons operate on days unburdened by a previous night’s call.1Y3 One commentary, using highly contrived interpretations of one of the abovementioned studies, sensationally declared an ‘‘83% increase’’ in complications done by a subset of surgeons who slept less than 6 hours while on call, but this startling claim evaporates with scrutiny. The original study noted that on call surgeons with less than 6 hours of ‘‘sleep opportunity’’ had a complication rate of 6.2%, whereas surgeons with 6 or more hours of ‘‘sleep opportunity’’ had a complication rate of 3.4%. The ‘‘83% increase’’seems to be based on a misleading manipulation of this data subset: 6.2 j 3.4 = 2.8 3.4 100 = 82%. Neither of these groups, however, had complication rates significantly different than the 4.9% complication rate achieved by surgeons operating on days with no preceding night call.4 From available evidence, there seem to be grounds to reconsider the issue of resident work hour restrictions. Instead of simplistic, quantitative guidelines that are now being implemented, a more f lexible set of formulae should be considered, one that takes some account of educational priorities, care continuity, graduated responsibility, and collateral issues such as moonlighting, as well as patient safety and resident fatigue. Also, from available evidence, there seems to be no ground for general restriction on elective procedures done by surgeons after a night on call. The previously mentioned paragraph could serve as an evidence-based summary of these issues. The issues, however, have been subjected to another level of analysis exemplified by a recent essay by Arora and coauthors.5 These commentators proceed to a normative argument uncluttered by any data. They assign a categorical affirmative value to the term ‘‘new professionalism.’’ This term embraces ‘‘the current system of medical training.’’ This professionalism ‘‘must fully adopt a team based care model in which patient ownership is not relegated to an individual, but shared among a group of team members.’’ Regulated shifts will ‘‘I(help) residents recognize their limits as humans, emphasizing the importance of physicians’ health and alertness.’’ Behavior deviating from this categorical affirmative (such as interns ‘‘staying past shift limits’’) is categorically excluded from affirmative valuation by assigning the term ‘‘nostalgic professionalism’’ to such behavior and developing the term as a pejorative, a ‘‘depreciatory, contemptuous’’ word.6 Nostalgic professionalism is defined as ‘‘consistently placing a patient’s or profession’s needs above one’s own personal needs.’’ Although these characteristics were once (and occasionally may still be) laudable, ‘‘at times these behaviors directly conf lict with the current system of medical training.’’ Demonstrating the dynamics of pejoratives, the authors categorically link nostalgic professionalism to other ‘‘depreciatory, contemptuous’’ behavior, including risks of transmitting illness, generalized and situational lying, and indulgence in ‘‘preconceived notionsIof what constitutes professional behavior.’’ Can this sort of analysis be considered legitimate as a meaningful contribution to the debate of these issues? First of all, the analysis fails the definition of argument, that is, a ‘‘statement of the pros and cons of a proposition.’’6 The normative assignments of good and bad to ‘‘new professionalism’’ and ‘‘nostalgic professionalism,’’ respectively, are nothing more than an exercise in labeling. Received December 16, 2013, and accepted for publication, after revision, December 16, 2013. From the 1850 Chadwick Drive, Suite 1427, North Tower, 4 West Jackson, MS 39204. Conflicts of interest and sources of funding: none declared. Reprints: William Lineaweaver, MD 1850 Chadwick Drive, Suite 1427, North Tower, 4 West Jackson, MS 39204. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7203-0263 DOI: 10.1097/SAP.0000000000000138
Annals of Plastic Surgery
& Volume 72, Number 3, March 2014
www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
263
Annals of Plastic Surgery
Editorial
Second, the analysis fails the ethical imperative of what Shaw and Elger7 call ‘‘evidence based persuasion.’’ These authors have formulated rules for ethical persuasion in doctor-patient exchanges, but we propose that these rules can be applied to any responsible promotion of a proposition or choice. The rules include the following: 1. remove biases; 2. provide honest, impartial evidence-based information; 3. provide rational interpretations of this information; 4. use reason rather than emotion; and 5. avoid creating new biases. The categorical endorsement of new professionalism and the stigmatization of ‘‘nostalgic professionalism’’ fail all of the stipulations of evidence-based persuasion. Most obviously, the endorsementpejorative assignments simply serve to create a new bias. Available evidence indicates that resident work hour regulation deserves comprehensive reevaluation. No evidence available at this time justifies restriction of elective procedures by surgeons coming off night call. Further considerations of these issues can only be constructively advanced by continued accumulation and rational analysis of credible data. Moving beyond evidence-based persuasion will not clarify these issues nor optimally benefit the professionals
264
www.annalsplasticsurgery.com
& Volume 72, Number 3, March 2014
and patients who will have to live with evolving regulations of health care delivery. The endorsement of new professionalism and the stigmatization of nostalgic professionalism are premature and misleading conclusions applied to complex, evolving issues that deserve more intelligent treatment. REFERENCES 1. Sharpe JP, Weinberg JA, Magnolti LJ, et al. Outcomes of operations performed by attending surgeons after overnight trauma shifts. J Am Coll Surg. 2013; 216:791Y799. 2. Viden C, Nash DM, Rangre J, et al. Complications of daytime elective laparoscopic cholecystectomies performed by surgeons who operated the night before. JAMA. 2013;310:1837Y1841. 3. Zinner M, Fresichlag JA. Surgeons, sleep, and patient safety. JAMA. 2013;310: 1807Y1808. 4. Lineaweaver W. Sleepy surgeons and patient safety. Ann Plast Surg. 2011;67: 203Y204. 5. Arora VM, Farnan JM, Humphrey HJ. Professionalism in the era of duty hours. JAMA. 2012;308:2195Y2196. 6. Brown L, ed. The New Shorter Oxford English Dictionary. Oxford: Clarendon Press; 1993:2141, 112. 7. Shaw D, Elger B. Evidence-based persuasion. JAMA. 2013;309:1689Y1690.
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
