Said on receiving an award:
I don't deserve this, but I have arthritis, and I don't deserve that either.
— Jack Benny (1894–1974)
Getting what we deserve and deserving what we get are not necessarily the same. The difference, if any, boils down to one's perspective, and sometimes to luck.1 Consider the following.
Because you have worked diligently at your job, you expect a raise in pay, but you don't get it. In your eyes, you didn't get what you deserved. Yet in the eyes of your boss—who had contemplated reducing your pay or even firing you—you got more than you deserved.
When I hire an individual or a company to do a job—fix my car, install new plumbing, or build a garage—inferior work and frequent delays are common. The persons responsible for these performances typically expect me to forgive, even condone, their deficiencies. Yet when these same individuals seek medical attention, they expect perfection—a perfect diagnosis and a perfect cure. When they receive anything less, they are more likely to sue than to forgive. They see physicians' shortcomings as malpractice and view their own faults as examples of human frailty.
What do patients say about their doctors and the medical care they receive? Many, of course, are satisfied and have no complaints. Others—and I believe most—harbor varying degrees of dissatisfaction, especially with their treatment as outpatients. According to discussions with my close friends and colleagues around the nation, these patients commonly say that it takes “forever” to get an appointment with the doctor. Even then, because of financial constraints, the appointment has to be with a doctor who is listed on the patient's insurance plan, not necessarily with one whom the patient really needs or prefers to see but cannot afford. In addition, time with the doctor rarely exceeds 10 to 15 minutes. After a few words with the patient, the doctor orders tests (some very expensive) and prescribes medications, some of which may also be expensive but not on the patient's restricted pharmacy plan. Moreover, explanations for the tests and medications, if given at all, are brief and full of medical terms that the patient does not understand. Most disturbing, the doctor never lays hands on the patient.
Once the tests are completed, the patient waits “forever” to get the results. Ultimately, the office nurse or physician assistant—not the doctor—reports and explains the test results to the patient. And on any given follow-up visit, the patient may be assigned to a different doctor, one whom he or she has never heard of and never expected to see. Thus, from their standpoint, these patients don't get the health care they deserve, and they don't deserve the type of care they get.
What about the physician's side of this story? External forces largely beyond our control clearly influence the way many of us practice medicine. Health maintenance organizations force us to care for the maximal number of patients in the minimal number of minutes, for the lowest number of dollars. Complicating the matter are Medicare's dwindling reimbursements, incessant duress from federally mandated regulations, revenue-oriented environments created by “for-profit-not-for-patient” hospital administrators, lawsuits lurking around every corner, and reams of required paperwork. Attending to these various demands and distractions cuts deeply into the time we could otherwise spend attending to our patients. We don't deserve the constraints we get, and we don't get the autonomy we deserve.
Does medical education enter this picture? Definitely—especially in relation to a mandate in 2003 from the Accreditation Council for Graduate Medical Education (ACGME). Acting to protect patient safety, the ACGME felt at the time that sleep deprivation and physical fatigue in physicians led to harmful medical errors. The mandate imposed rigorously enforced work-hour limits across all training programs, regardless of specialty. To date, however, the evidence suggests that the limit on duty hours has neither improved nor worsened patient outcomes.2,3
As a full-time medical educator for almost 60 years, I believe that these work-hour limits rob trainees of the opportunity to observe firsthand the natural history of acute disease. They interrupt the continuity of patient care. They discourage hard work, a requisite for excellence, and a basic element of the medical profession. They weaken the patient-doctor bond or prevent it from ever forming. And worst of all, they place emphasis on the doctor's well-being rather than on the well-being of the patient.
For these reasons and more, current house officers don't get the training they deserve, and many of them don't deserve the image of competency that their training certificates convey.4
For the multitude of ills enumerated here, all of us deserve remedies. But then, we don't always get what we deserve.
Herbert L. Fred, MD, MACP
Associate Editor, Texas Heart Institute Journal; and Professor, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston
References
- 1.Fred HL. We don't always get what we deserve. The Macon Telegraph. 1991 Jul 21;B5.
- 2.Volpp KG, Friedman W, Romano PS, Rosen A, Silber JH. Residency training at a crossroads: duty-hour standards 2010. Ann Intern Med 2010;153(12):826–8. [DOI] [PMC free article] [PubMed]
- 3.Reed DA, Fletcher KE, Arora VM. Systematic review: association of shift length, protected sleep time, and night float with patient care, residents' health, and education. Ann Intern Med 2010;153(12):829–42. [DOI] [PubMed]
- 4.Fred HL. Hyposkillia: deficiency of clinical skills. Tex Heart Inst J 2005;32(3):255–7. [PMC free article] [PubMed]