FORUM emergency department, management, staffing, physician; education, resident, emergency medicine, coverage of

Attending Coverage

[Rosen P, Markovchick V: Attending coverage. Ann Emerg Med September 1985;14:897-899.]

I N T R O D U C T I O N For many years the question of attending coverage of residents did not

seem very important. As a house officer, one learned from the resident in the year ahead, and occasionally from the chief residents. Not infrequently, one even learned from a peer in the same year of the training program who al- ready had finished the rotation. Many programs did not have full-time fac- ulty, and many city-county hospitals had voluntary attending physicians with full-time private practices. Somehow the system worked; residents learned their specialties, and although there was often much second guessing and bloodshed at morbidity and mortality conferences, the true toll in egregious errors committed on unwitting patients probably will never be known.

The tree impetus for the development of full-time attending physicians almost certainly was economic rather than educational. The third-party pri- vate and public carriers demanded documentation that faculty had rendered care to the patients, and because residents could not be paid directly for services (as they were deemed in part to be students), it became necessary for faculty to be available and even present.

When emergency medicine programs commenced in the early 1970s, the scheme of supervision was not significantly different except that there were no attending physicians at all. (Occasionally a very reluctant and very junior faculty member was made responsible for the department, that is, a schedule had to be made out, and the responsibility fell to this faculty member.) The house staff, initially assigned for an educational experience, were supervised by the residents on call to the department, whose cooperation in the middle of the night can be imagined easily.

Workloads increased, and patients of increasing acuity began to arrive as prehospital care systems improved; if it wasn't obvious to anyone but the administrators who bore the brunt of the complaints, the unsupervised house staff were not delivering high-quality care. The plaintiff's attorneys entered the scene, and the complaints became not only embarrassing, but very expensive.

In an attempt to solve this crisis, emergency medicine programs were cre- ated as people concluded that the problem of the ED could never be solved unless there was a labor pool to draw on that actually desired to be present in the ED. The directorships became full-time, and faculties began to develop. Many institutions agreed to create new faculty slots on the strange grounds that house staff would make fewer mistakes if they were supervised by more experienced attending staffs.

Curiously even though many institutions were willing to recognize the need for attending supervision, it took many years before the university or city-county hospitals recognized the need for 24-hour coverage. That this recognition is not universal is attested to by the current lack of such cover- age in many teaching hospitals. The programs that began in the community hospitals started with full-time attending coverage; this occurred almost cer- tainly because it was the only way to insure the fee-for-service return on the private patient.

Peter Rosen, MD Vince Markovchick, MD Denver, Colorado

From the Department of Emergency Medical Services, Denver Department of Health and Hospitals, Denver, Colorado.

Received for publication May 10, 1985. Accepted for publication May 20, 1985.

Address for reprints: Peter Rosen, MD, Emergency Medical Services, Denver General Hospital, 777 Bannock Street, Denver, Colorado 80204.

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ATTENDING COVERAGE Rosen & Markovchick

Emergency medicine, as the youngest of the medical spe- cialties, has had an opportuni ty to learn from the experi- ences of the older fields. While it appeared ini t ial ly to play a leadership role in the education of house staff, i t unfortu- nately appears to be wil l ing to perpetuate the sys tem of nonsupervis ion on inconvenien t shifts (nights, weekends, and holidays).

ARGUMENTS AGAINST 24-HOUR COVERAGE

The usual arguments against providing 24-hour coverage are the following: 1) the need for autonomous responsibil i ty of the house staff; 2) the paucity of patients on the grave- yard shift; 3) the economic cost of supplying adequate num- bers of faculty; 4) the need for academic product ivi ty of the

"faculty; and 5) at least from a few honest souls, the greater convenience in the lifestyle that is somehow a compensa- t ion for the lesser income of an academic career.

1) Is i t not curious that the impor tant autonomous re- s p o n s i b i l i t y for the h o u s e s taff is never g iven on the dayt ime shift, during which there is easy access to fellows and attending physicians who are in the house? Moreover, while there are data to support the notion that unsuper- vised residents are more dangerous than either supervised residents or experienced a t tending physicians, TM we are aware of no data that show that residents who are fully su- pervised during residency are more dangerous than those who had this autonomy.

2) While there is often a pauci ty of patients on the grave- yard shift in the less busy EDs, it is less true of the city- county hospitals. The problem is that one cannot schedule the arrival of the sickest patients. If there is at any t ime a need for the experience, expertise, and supervision of an at- tending physician, then there is that same need at all t imes. The mere fact that the difficult case comes in only occa- sionally on the night shift can hardly mit igate the need for the supervision of that case, part icularly when the resources of the hospital are min imized and the difficulties of arrang- ing adequate care are maximized . Moreover there is no more ideal t ime for teaching. With few patients in the de- partment, one can afford to spend much t ime wi th a single resident and observe that individual 's abil i ty to acquire his- torical or physical diagnostic data or perform a t ime-con- suming technical procedure. There is also an incomparable opportunity to associate wi th the nonmedical character of the resident.

3) There is no doubt that i t costs more money to pur- chase a faculty member than a resident. There is also no doubt that many city-county and universi ty hospitals see more than their share of indigent patients, who make it dif- ficult to generate the amount of money required to staff fully. Nevertheless if one is to factor in the costs of failing to provide adequate coverage if wi th no other paremeter than avoidable damage claims, then i t becomes obvious that the economic argument is not one of great validity. Moreover many public inst i tut ions have hopeless financial offices that do not even begin to capture the funds that can be generated, even from indigent populations, that would more than suffice to meet the salary requirements of a full- t ime faculty.

Finally, a moral issue is being evaded by calling on this argument. That is, there is better care to be provided, and if the inst i tut ion cannot provide that care wi th adequate qual- ity, ostensibly on the basis of lack of funds, should the in-

s t i tut ion be in the business in the first place? While it is comfortable to argue that a l i t t le is better than none, there are always places where dollars can be found in large in- stitutions. (At the t ime of our last budget cut, while we were losing monies for a t tending staff coverage, approx- imate ly $400,000 worth of administrators were added. Phy- sician salaries are always enticing targets to administrators who invariably overlook the fact that patients come to the hospital for medical care, not administration.)

4) It is interesting that in inst i tut ions that provide 24- hour coverage, there is just as much academic product ivi ty of faculty as in those that do not. One can certainly point to the research, books, and papers produced by the programs that provide 24-hour coverage, and it certainly does not ap- pear that this output has been lessened by the service com- mi tme n t of these programs. It is not unusual to find an at- tending physician on a quiet night shift working on a draft of a paper or catching up on his or her reading.

5) It is nei ther a personal nor an isolated observation that people choose their careers for many different reasons and that often the least serious consideration is the amount of money made. 5 Clearly one needs to be able to support one's family, but there is l i t t le evidence that academic salaries are starvation-level wages. In fact, the discrepancy between aca- demic salaries and private practice is much lower than it once was, 6 so it is doubtful that money alone prevents someone from choosing an academic career.

The sad truth is that too many people have chosen emer- gency medicine because they thought i t provided an oppor- tuni ty to have a "nice lifestyle." Does working nights pro- duce hardship? In many ways it does take both a menta l and a physical to l l / , s There is, moreover, a social price ex- acted on the family. Unfortunately patients do not cooper- ate and become acutely ill only at convenient hours. Unless one is will ing to make the argument that academic produc- t ivi ty is dependent on having no service commitment , then there can be no meri t to this position.

Our specialty has a price tag just as do all others; while one can schedule the bad shifts, and thus know beforehand when they will occur, the reali ty is that there are many more bad shifts than most people th ink when they choose the field. The responsibil i ty for round-the-clock service can- not be and shou ld no t be evaded s imp ly because one chooses to be an academic physician. The reason for choos- ing academics is not because i t makes one bet ter than someone in private practice, nor because i t wi l l excuse someone from the service responsibilit ies of the private sec- tor, but s imply because one needs the rewards of teaching and research. If a person cannot feel the satisfaction of those opportunities, then by no means should that person be in academics. 9 It is as easy and as hard as that.

6) The only reason a good program will collapse is if it loses all support from its insti tution. The only reason that the 24-hour coverage is not provided in many inst i tut ions is that the directors have not asked for adequate numbers to cover or have failed to provide 24-hour coverage when they already have adequate numbers. The experience of the Liai- son Residency Endorsement Commi t tee (the forerunner of the current Residency Review Commit tee) was that the fastest way to get a program to provide a new faculty mem- ber that they could "in no way afford" was a negative en- dorsement. On at least one occasion, the program had found funds for the new posi t ion even before receiving publ ic notice of the negative opinion. Not one program closed its

120/898 Annals of Emergency Medicine 14:9 September 1985

doors because it was forced to produce visible support for the residency by virtue of a demand for increased faculty.

ARGUMENTS FAVORING 24-HOUR COVERAGE

Positive arguments for providing complete coverage fall basically into three categories: patient service, administra- tion, and education.

We already have alluded to our position that patient care is benefited by having the wisdom of experience available to help both in the decision making and the technical tasks necessary to care for all, not just critical, patients. That does not mean that the resident cannot be given major re- sponsibility for patient care; that is a function of how busy the department is. When the department is busy, there is a need for more than one experienced physician, and the resi- dent is forced to act as the attending physician, but with the advantage of a backup. The argument that the attending physician can be asleep or is only a phone call away is just not valid. When we tell people to "call me if you're in trou- ble," we are also telling them "good residents don' t need to call." This double message always will argue against calling. The patients who present at night have different problems and at t i tudes toward heal th care than pat ients in the daytime; therefore the requirement for attending experience is great.

There are many arguments and conflicts that occur in the middle of the night that cannot be resolved on a resident level. To solve them on the spot will prevent many hours of subsequent cleanup. Moreover one will never truly know how the department and the hospital as a whole function at night unless physically present. The aversion to work is maximal in the middle of the night, and it often takes the authority of the attending physician to accomplish what are otherwise routine tasks in the daytime.

We have already alluded to the enormous opportunity for education that exists on the night shift. But one responsibil- ity that has not been addressed is that of role model. If the resident never sees an attending physician at night, he con- cludes that this is not an important part of emergency med- icine and that he will not be abligated to this responsibility after completing training. Because most groups load the younger members with the night shifts, it is no wonder that this attitude becomes even more reinforced and leads to the practice of hiring moonlighters, some of whom have been nonemergency medicine specialists, to cover the undesir- able shifts or leads hospitals to think that they are ade- quately covered by unsupervised house staff. It also conveys the double message that there is something unique about emergency medicine as evidenced by the residency pro- gram, but that physicians from other specialties are ade- quately trained to supervise residents at night. At present all primary supervision of emergency medicine residents in the ED should come from emergency medicine specialists.

Since we began to provide 24-hour coverage, we have had

a much greater understanding of the capacity of our indi- vidual residents and have used the night shifts profitably to shore up weak areas. When one is the only attending physi- cian in the hospital, there is often an interface possible with other departmental house staff that will not occur when their own attending physicians are available on daylight shifts. The cooperation between the services thus becomes enhanced, and this can only improve all aspects of the de- partment's function.

C O N C L U S I O N There is no easy way to practice or teach emergency med-

icine. It is a round-the-clock responsibility, and the only way to discharge it is to accept the reality of the responsibil- ity and share it equally. If the attending staff is to provide full-time 24-hour attending coverage, it is imperative that all staff, including the director, share equally in night cover- age. This will be a vital factor in the acceptance of such a burden on the part of the attending staff and will serve as a lifelong role model for residents.

Failure to provide attending coverage means either that attending coverage is never necessary or that it has deliber- ately not been chosen, no matter what rationalization is given, and this represents an evasion of responsibility both the educational program and to the quality of patient ser- vice. Emergency medicine has had an unparalleled oppor- tunity to provide a new kind of education and patient ser- vice. The rewards for high quality are great. Let us not sacrifice our opportunity for leadership for convenience of lifestyle.

REFERENCES 1. Eisenhauer ED, Derveloy RJ, Hastings PR: Prospective evalua- tion of central venous pressure (CVP) catheters in a large city- county hospital. Ann Surg 1982;196:560-564. 2. Borja AR: Current status of infraclavicular subclavian vein catheterization. Ann Thorac Surg 1972;13:615.

3. Herbst CA: Indications, management and complications of percutaneous subclavian catheters. Arch Surg 1978;1421.

4. Bo-Linn GW, Anderson DJ, Anderson KC, et al: Percutaneous central venous catheterization performed by medical house of- ficers: A prospective study. Cathet Cardiovasc Diagn 1982;8: 23-29.

5. Herzberg F: One more time: How do you motivate employees? in Harvard Business Review: On Human Relations. New York, Harper & Row, 1979, p 361.

6. Petersdorf RG: Sounding board: Academic medicine: No long- er threadbare of genteel. N Engl ] Med 1981;304:841-843.

7. Olson CM: Shift work. Journal of Emergency Medicine 1984;2:37.

8. Rosen P: Night shift and the emergency physician (editorial). Journal of Emergency Medicine 1984;2:27. 9. Petersdorf RG: Sounding board: Is the establishment defensi- ble? N Engl ] Med 1983;309:1053-1057.

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