Cases & Commentaries

Do Not Disturb!

Spotlight Case
Commentary By F. Daniel Duffy, MD; Christine K. Cassel, MD

Case Objectives

  • Define professionalism.
  • Discuss behaviors associated with lack
    of professionalism.
  • Outline steps one should take if a
    significant breach of professionalism is witnessed.

Case & Commentary: Part 1

A 55-year-old obese woman with a history of
hypertension and severe obstructive sleep apnea requiring CPAP
(continuous positive airway pressure) is placed on morphine PCA
(patient-controlled anesthesia) pump for pain control following
cholecystectomy. At approximately 1:00 AM, 5 hours after starting
the morphine, the patient's respiratory rate decreased to 7 (while
on CPAP). Physical examination revealed an oxygen saturation level
of 98%, normal blood pressure, heart rate of 50, and pinpoint
pupils. The patient was noted to be lethargic, opening her eyes and
mumbling incoherently in response to vigorous shaking but quickly
falling asleep when the stimulus ceased. Concerned, the RN called
the attending physician. The physician seemed annoyed by the call,
barking, "What would you expect when you wake up a patient in the
middle of the night from deep sleep—an excellent level of
consciousness? Naturally, she would be drowsy!" He followed with,
"Wake me up only on life and death issues!"

Professionalism—Does It Mean Always
Being at the Top of the Game?

This case identifies intertwined failures in four
physician competencies that affect patient safety: professionalism,
patient care, communication and interpersonal skills, and
systems-based practice. How a physician responds when disturbed
from sleep to help a patient is arguably the best test of how well
professionalism has been incorporated into a physician's
personality. This case highlights how breaches in professionalism
are often associated with cognitive or emotional impairment on the
part of one member of the team, in this case the doctor, and
corrective action often requires teamwork to ensure safe
care.(1)

It is difficult to know whether this physician
has sufficient knowledge to recognize the seriousness of the
morphine overdose. Had there been no rude behavior, simple lack of
knowledge could explain the judgment error. However, his dressing
down of the RN suggests emotional impairment leading to cognitive
dysfunction. Whether this is a single lapse in professionalism, a
character trait, or acquired impairment can only be determined by
comparing this event with his behavior in similar situations.

The phenomenon of sleep inertia (2)
might be important in this case. Sleep inertia is confusion and
dysfunction that occurs upon awakening from sleep during deep
non-rapid eye movement (NREM) sleep. The disorientation may occur
after 30 minutes of sleep and may last from 10 minutes up to 2
hours after arousal. The disorientation may also include periods of
amnesia after awakening.

Most of us have experienced brief cognitive
impairment when sleep is suddenly interrupted. It takes a few
moments to awake sufficiently to process information after a call.
Our first response may be automatic, but with a little reflection,
we call back, ask for additional information, and revise our
decisions. If our initial reaction lacked emotional attunement and
was discourteous, we quickly apologize, admitting our lapse in
professionalism. Such self-assessment and self-correcting behavior
is central to competence in professionalism.

How Can We Predict Professionalism?

Screening applicants for medical school and
dismissing a few students each year weed out some of those with
character traits that are incompatible with medical
professionalism.(3)
However, once students enter their training, we are not very
successful in teaching medical professionalism or in identifying
and preventing burnout, which leads to acquired professional
incompetence.

Burnout is a syndrome of depersonalization in
relationships with coworkers and patients, emotional exhaustion,
cynicism, and ineffectiveness.(4) It
results when physicians are under constant pressure, have little
control over their schedules, and fail at self-care. Burnout is
associated with impaired job performance and poor health and may
contribute to alcoholism and drug addiction.(5) Three-quarters of the residents in one study were
burned out. They reported unprofessional behavior in discharging
patients early to make their work more manageable and admitted to
making medical errors, not fully discussing treatment options with
patients or answering their questions.(6)

Systems-Based Practice: On-Duty and On-Call
Systems

One defining aspect of medical professionalism is
responsibility for providing care throughout the course of a
patient's illness, including nights and weekends. Failing to ensure
that a competent physician is available in a timely manner is
professional abandonment.(7)
However, being available is not enough. The physician must be
cognitively alert and emotionally attuned to respond
compassionately to the needs of a caller or patient and motivated
to take appropriate action regardless of the hour or physician
sleepiness. In short, physicians must be at the top of their game
when they are responsible for patient care.

That said, it is unreasonable to expect one human
to be available 24 hours a day, 7 days a week, 365 days a year;
therefore, physicians participate in systems that ensure
availability of competent physicians as well as sufficient time off
to restore physical and emotional stamina. When demands for care
are nearly constant, limited "on-duty" shifts, with mandatory time
off between shifts, ensures alert physician availability. When
calls for service are infrequent, systems in which physicians are
"on-call" for telephone contact from home, returning to duty if
needed, are reasonable. Intermediate patient needs are provided by
longer on-duty shifts, during which naps of uninterrupted sleep can
be anticipated.

Systems, Teamwork, and Professionalism

Professionalism is an abstraction made concrete
through acts of undeserved kindness and trust, and honest admission
and correction of mistakes. Professionalism is challenged most when
patient needs conflict with personal needs.(8) Therefore, professionalism includes self-assessment of
one's own needs and self-care that ensures the physical and
emotional well being of the health care team.

Team members share the goal of quality care, have
specific roles, perform independent tasks, and adapt to
circumstances as they arise. Moreover, good teamwork mitigates the
risks of physician (or other staff) failures that disrupt team
function and lead to unsafe outcomes. Since physicians have
ultimate responsibility for diagnosis and treatment decisions,
other team members (the nurse in this case) have responsibility for
performance monitoring, backup, adaptability, and communication
that ensures that a message sent was received.(9)

The physical and mental condition of every team
member (including attending physicians) is important to a safe and
patient-centered health care system. Although important, physician
altruism is generally insufficient to overcome survival instincts
when humans exceed emotional or physical limits. High-reliability
health care systems must balance workload with time off to ensure
the physical and emotional well being of their workers, including
physicians.

The root cause for excessive sleep interruption
is complex. Physicians may take on more patient responsibility than
they can safely handle. There may be insufficient numbers of
physicians to handle the patient care needs in the specialty, or
the system may fail to design call or duty schedules that ensure
accurate night-time decision-making and sufficient time for sleep
and relaxation to rejuvenate emotional and cognitive
functioning.

Whatever their cause, difficulties with
professionalism, communication, and interpersonal skills identified
during training are related to difficulties later in life. One
study showed that disciplinary action by medical boards was
strongly associated with irresponsibility such as unreliable
attendance at clinic or failure to follow up on patient care
assignments and diminished ability to improve behavior during
medical school.(10)
The American Board of Internal Medicine (ABIM) identified a
relationship between low ratings by program directors of
professionalism during residency and sanctions imposed by medical
licensing boards years later (RS Lipner, PhD, oral communication,
May 2007). Additionally, Levinson and colleagues reported that
communication with patients that failed to express empathy created
a sense of uncaring and abandonment in patients and was associated
with increased malpractice claims.(11)

Case & Commentary: Part 2

Unsatisfied with this response, the RN, who
had already stopped the PCA, called the surgeon to express her
concern. The surgeon ordered naloxone (Narcan). The patient
immediately awoke, and the altered mental status and respiratory
depression were reversed.

Luckily, this case has a good outcome from
excellent teamwork. The RN mitigated the attending physician's
cognitive error. However, the impact of the attending physician's
unprofessional behavior on team trust and respect, as well as
system contributors to problems in professionalism, will be
explored below.

Emphasis on Professionalism in Medical
Education

The Accreditation Council on Graduate Medical
Education (ACGME) requires that residency programs teach and
evaluate six general physician competencies. One of these is
professionalism. This competency is defined as carrying out
professional responsibilities, adhering to ethical principles, and
showing respect, compassion, and integrity in clinical work with
patients and members of clinical teams.(12) Physicians' self-monitoring of their physical and
emotional state is also essential for professionalism, as is
self-care, which includes getting sufficient sleep to make good
decisions. The American Medical Association Council on Ethical and
Judicial Affairs considers physicians' attention to their own
health and wellness, as well as to the health of their colleagues,
an ethical imperative.(13)

In addition to personal professionalism, health
care organizations should reform work practices and change
attitudes toward physician work. Fatigue and physical or emotional
exhaustion should be unacceptable risks to safe care, rather than
signs of dedication. Recognizing the deleterious effects of fatigue
leading to resident burnout and patient safety problems, the ACGME
requires all training programs to "educate faculty and
residents...to recognize the signs of fatigue...and adopt and apply
policies to prevent and counteract the potential negative effects."
These policies include specialty-specific duty hour limitations for
residents and fellows of 80 hours per week, 30 hours of continuous
duty without a break, and at least 1 day in 7 free of clinical
duties.(14)

Some physician educators express concern that
emphasizing physician self-care and adopting a "shift-work
mentality" may interfere with the physician–patient
relationship and destroy medical professionalism. These concerns
ignore the larger problem of fatigue-related burnout, depression,
and emotional defensiveness expressed as cynicism or resentment
resulting in detachment and a lack of compassion for patients.
These are more serious risks to quality patient care than failing
to provide continuous care to patients by a single physician, as
demonstrated by self-reported studies of burned-out residents and
absence of serious quality problems following the introduction of
housestaff hours limitations.(15)

Assessing Professionalism Among
Trainees

Identifying and tracking critical incidents of
unprofessional behavior, as occurred in this case, is an essential
method for tracking professionalism.(16) Another evaluation method used for medical students
and residents is obtaining ratings of professional behavior from
peers, nurses, telephone operators, and other team members; for
example, the National Board of Medical Examiners is testing a
survey for use in medical schools.(17) A
Professionalism Mini-CEX is a checklist of important behaviors that
faculty use to rate performance and provide feedback to students
and residents about professional relationships observed during
patient encounters.(18)
Objective Standardized Clinical Evaluations are examinations in
which standardized patients rate a student's or resident's
communication and interpersonal skills related to humanism and
ethical discussions with patients.(19)
Teaching and formative evaluation of professionalism can be
conducted at the student or practicing team level through critical
incident root cause analysis and reflection on action, which
involves guided analysis of the events, their causes and outcomes,
the emotional effect on the participants, and how the experience
might shape decisions for future action.(20)

What Steps Should Any Health Care Professional
Take in This Situation?

In this case, the RN should report the error in
judgment and professionalism through the quality improvement
process, recommending an assessment of the attending physician for
burnout. The report can document unprofessional behavior on several
levels: (i) failure to respect the judgment and concern of a team
member, (ii) failure at self-assessment of cognitive impairment
induced by sleep or other problems, and (iii) failure to
responsibly backup a fellow team member. In a high-functioning
team, a team meeting on quality of care following this incident
could provide an opportunity to design a system that ensures
professional competence in all of the members of the team.

The personal care of the unprofessional physician
should be managed through a medical professional wellness
program.(21) In
a high-functioning team, unprofessional behavior can be addressed
as a routine aspect of improving teamwork and instilling trust
among the members. Unfortunately, there is some evidence that the
physicians with the greatest risk for incompetent professionalism
seek solo and nonteamwork practice situations (FR Lewis, Jr., MD,
oral communication, 2007).

In medical situations, the power differential
between physicians and other members of the team may impede
handling unprofessional behavior in a collegial way. This leads to
ignoring important instances of unprofessional behavior and
reporting physicians to medical staffs, licensing boards, or others
more interested in action than in remediation. Although there
always is a need to protect patients, and some cases of
unprofessional behavior are so egregious that this type of
disciplinary approach is appropriate, the downside to this pathway
is that it often leads to secrecy, confrontation, and even
litigation. Approaching issues of professionalism first as
potential systems problems that can be remediated with changes in
the system and education in professionalism often lead to the
desired outcomes of safe, high-quality care and collegial work
relationships. The culture of "no blame," and system responsibility
for potential or actual safety issues, can permit a conversation
about the root causes of unprofessional behavior.

Although we cannot be sure about the root cause
of the unprofessional behavior in this case, we can be fairly
certain that burnout was an important contributing factor.
Preventing burnout is the responsibility of all physicians and of
the health care organization in which they work. (For resources,
see Table.) Promoting physician well-being is a new aspect
of systems-based practice and professionalism that is beginning to
be implemented in the earliest years of training. The new
professionalism calls on physicians "to cultivate methods of
personal renewal, emotional self-awareness, connection with social
support systems, and a sense of mastery and meaning in their
work."(5) An
investment in education in professionalism and in physician
self-care can help prevent a lifetime of subsequent problems in
some cases.

F. Daniel Duffy, MD
Senior Advisor to the President of ABIM
Director, Community Health Track, University of Oklahoma, Tulsa

Christine K. Cassel, MD
President and CEO of the American Board of Internal Medicine
President and CEO of the ABIM Foundation

References

1. Katz JN, Kessler CL, O'Connell A, et al.
Professionalism and evolving concepts of quality. J Gen Intern Med.
2007;22:137-139.
[go to PubMed]

2. Wertz AT, Ronda JM, Czeisler CA, Wright KP Jr.
Effects of sleep inertia on cognition. JAMA. 2006;295:163-164.

[go to PubMed]

3. Wagoner NE. Admission to medical school:
selecting applicants with the potential for professionalism. In:
Stern DT, ed. Measuring Medical Professionalism. New York, NY:
Oxford University Press; 2006.

4. Maslach C, Schaufeli WB, Leiter MP. Job
burnout. Annu Rev Psychol. 2001;52:397-422.
[go to PubMed]

5. Spickard A Jr, Gabbe SG, Christensen JF.
Mid-career burnout in generalist and specialist physicians. JAMA.
2002;288:1447-1450.
[go to PubMed]

6. Shanafelt TD, Bradley KA, Wipf JE, et al.
Burnout and self-reported patient care in an internal medicine
residency program. Ann Intern Med. 2002;136:358-367.
[go to PubMed]

7. American College of Physicians. Ethics manual:
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[go to PubMed]

8. ABIM Foundation, ACP-ASIM Foundation, and
European Federation of Internal Medicine. Medical professionalism
in the new millennium: a physician charter. Ann Intern Med.
2002;136:243-246.
[go to PubMed]

9. Baker DP, Salas E, King H, et al. The role of
teamwork in professional education of physicians: current status
and assessment of recommendations. Jt Comm J Qual Patient Saf.
2005;31:185-202.
[go to PubMed]

10. Papadakis MA, Teherani A, Banach MA, et al.
Disciplinary action by medical boards and prior behavior in medical
school. N Engl J Med. 2005;353:2673-2682.
[go to PubMed]

11. Levinson W, Roter DL, Mullooly JP, et al.
Physician-patient communication: the relationship with malpractice
claims among primary care physicians and surgeons. JAMA.
1997;277:553-559.
[go to PubMed]

12. Accreditation Council for Graduate Medical
Education Outcomes Project Web site. Available at: http://www.acgme.org/outcome/. Accessed September 27,
2007.

13. Physician Health and Wellness. American
Medical Association Web site. Available at: http://www.ama-assn.org/ama/pub/category/15466.html.
Accessed October 17, 2007.

14. Accreditation Council for Graduate Medical
Education. Duty Hours Language. Available at: http://www.acgme.org/acWebsite/dutyHours/dh_Lang703.pdf.
Accessed September 27, 2007.

15. Horowitz LI, Kosiborod M, Lin Z, Krumholz HM.
Changes in outcomes for internal medicine inpatients after
work-hour regulations. Ann Intern Med. 2007;147:97-103.
[go to PubMed]

16. Sullivan W. Work and Integrity: The Crisis
and Promise of Professionalism in America. 2nd ed. San Francisco,
CA: Jossey-Bass; 2005.

17. National Board of Medical Examiners.
Assessment of Professional Behaviors. Available at: http://professionalbehaviors.nbme.org/index.html.
Accessed September 27, 2007.

18. Cruess R, McIlroy JH, Cruess S, et al. The
professionalism mini-evaluation exercise: a preliminary
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[go to PubMed]

19. Cohen JJ. Professionalism in medical
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accountability. Med Educ. 2006;40:607-617.
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20. Epstein RM, Hundert EM. Defining and
assessing professional competence. JAMA. 2002;287:226-235.

[go to PubMed]

21. Federation of State Physician Health Programs
Web site. Available at: http://www.fsphp.org/. Accessed September 27,
2007.

Table

Table. Internet Resources Regarding
Professional Well Being

Physician's Guide to the Internet: Physician's Health and
Well Being
The Center for Professional
Well Being
The Vanderbilt Center for Professional Health