Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Bioethics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
Chest. 2012 May;141(5):1315-1320. doi: 10.1378/chest.11-1459.
There is an inherent tension between the training needs of inexperienced clinicians and the safety of the patients for whom they are responsible. Our society has accepted this tension as a necessary trade-off to maintain a competent workforce of physicians year after year. However, recent trends in medical education have diminished resident autonomy in favor of the safety of current patients. One dramatic example is the rapid increase in the number of academic ICUs that provide coverage by attending physicians at all hours. The potential benefits of this staffing model have strong face validity: improved quality and efficiency from the constant involvement of experienced intensivists, increased family and staff satisfaction from the immediate availability of attending physicians, and reduced burn-out among intensivists from reduced on-call responsibilities. Thus, many hospitals have moved toward 24-h coverage by attending intensivist physicians without evidence that these benefits actually accrue and perhaps without full consideration of possible unintended consequences. In this article, we discuss the potential benefits and risks of nocturnal intensivist staffing, considering the needs of current and future patients. Furthermore, we suggest that there remains sufficient uncertainty about these benefits and risks that it is both necessary and ethical to study the effects in earnest.
在经验不足的临床医生的培训需求与他们所负责的患者的安全之间，存在着固有的紧张关系。我们的社会已经接受了这种紧张关系，认为这是维持医生队伍每年都有能力的必要权衡。然而，最近医学教育的趋势削弱了住院医师的自主权，以维护当前患者的安全。一个引人注目的例子是，提供主治医生 24 小时覆盖的学术性 ICU 的数量迅速增加。这种人员配备模式的潜在好处具有很强的表面合理性：经验丰富的重症监护专家的持续参与提高了质量和效率，主治医生的即时可用性提高了家属和工作人员的满意度，减少了值班责任带来的重症监护专家倦怠。因此，许多医院已经转向由主治重症监护医师提供 24 小时覆盖，而没有证据表明这些好处确实存在，也许也没有充分考虑可能出现的意外后果。在本文中，我们考虑到当前和未来患者的需求，讨论了夜间重症监护人员配备的潜在好处和风险。此外，我们认为，关于这些好处和风险仍然存在足够的不确定性，因此认真研究这些影响是必要的，也是合乎道德的。
