Cases & Commentaries
Do Not Disturb!
Approach to Improving SafetySafety TargetResource TypeSetting of CareTarget Audience
- 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
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: fourth edition. Ann Intern Med. 1998;128:576-594. [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 investigation. Acad Med. 2006;81(10 suppl):S74-S78. [go to PubMed]
19. Cohen JJ. Professionalism in medical education, an American perspective: from evidence to accountability. Med Educ. 2006;40:607-617. [go to PubMed]
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. Internet Resources Regarding Professional Well Being