In this study, we evaluated the clinical performance for inpatients between the single-attending-physician system and the multiple-attending-physicians system cross-sectionally and quantitatively at a rural hospital in Japan. Additionally, we qualitatively analyzed the physicians’ work burden under these two attending-physician systems to identify the advantages and disadvantages of the systems.
So far, only a few studies have reported the effects of the multiple-attending-physicians system, and most of them have emphasized the diagnostic accuracy regarding the interpretation of skin lesions or X-ray films [11–15]. In the present study, we obtained data on not only the working hours in the single and multiple-attending-physician systems but also the actual condition of medical care and the burden on physicians in Japan.
In the present study, the length of hospital stay was significantly lower in the multiple-attending-physicians group than the single-attending-physician group, and inpatient care cost was also lower in the multiple-attending-physicians group. However, we could not calculate significant differences because of the limitation in data collection. The following reasons can be assumed for the decrease in length of hospital stays and the seemingly lower medical costs. First, in the multiple-attending-physicians system, the sharing and discussion of patient information within the attending team may have reduced unnecessary tests and treatments and even facilitated early discharge from the hospital. As a result, unnecessary healthcare costs were reduced and the length of hospital stay was shortened, resulting in a decrease in inpatient care costs.
In this study, there were no significant differences in patients’ age, sex, and disease variations between the two attending-physician groups. Although the number of inpatients differed between the two attending-physician groups, the workload per actual working physician was hardly comparable for the following reasons: 1) each physician in both groups had many tasks other than inpatient care, such as participation in outpatient and branch clinics, endoscopy/other procedures and clinical internship (100 students per year), 2) since the multiple-attending-physicians group started their inpatient care in April 2017, the number of admitted patients was initially small.
Based on the VAS analysis, there was no significant difference in the indicator of working conditions or burdens between the two groups. However, it is possible that the multiple-attending-physicians group may have fewer working hours and less physical workload but may experience some difficulty regarding understanding the patients’ disease status, doctor-patient relationship, imbalances due to workload, and inter-professional relationships than the single-attending-physician group. Notably, the single-attending-physician system tended to be more physically stressful for the physicians. On the other hand, both the groups had similar scores on psychiatric burden. The multiple-attending-physician system may have less burden of overtime work than the single-attending-physician system, but there are more difficulties in understanding patients and cooperation among other professionals, which may have been offset and resulted in equal psychiatric burden.
The survey showed that the multiple-attending-physicians system has the advantages of 1) improving the physicians’ QOL, 2) lifelong learning effect, and 3) improving the quality of medical care. Its disadvantages include 1) the risk of miscommunication, 2) conflicting treatment policies among physicians, and 3) patients’ unfamiliarity with the multiple-attending-physician system. While improving the physicians’ QOL is the most important benefit, the effects on enhancing life-long learning, which is generally related to physicians’ burnout , suggests that the multiple-attending-physicians system may be a means to prevent physicians from dropping out in the long term. Furthermore, from the decision-making perspective, the involvement of multiple physicians can minimize sanctioning and reduce emotional distress among physicians .
On the other hand, there were ambivalent aspects regarding communication and the prevention of mistakes. Multiple rotations of physicians will inevitably increase the number of handovers between physicians, which could increase the risk of miscommunication, and the reduced duration of hospital stay per physician may cause communication troubles with patients and co-medical staff. At the same time, it is indicated that careful observation of patient management by multiple physicians can prevent mistakes and improve the level of overall medical care.
A cross-sectional study demonstrated that with more physicians, the accuracy in clinical practice under the team approach will improve . However, several studies indicate that the involvement of multiple professionals in a patient’s care could cause confusion and frustration among physicians, patients, and co-working staff in inpatient care, especially in ICU and end-of-life care [18–22]. Management of the end-of-life decision-making varied in relation to multiple and shifting attending responsibilities, and some patient’s families and clinicians were confused about who was making patient care decisions and with whom they should confer . Many patients were unable to name anyone when asked to identify an inpatient physician in charge of their care , and nearly 50% of responding attending physicians knew dying patients for less than 48 hours . According to the present study, this might be just a matter of traditional culture or depend on the severity and urgency of the situation, such as the ICU and acute care hospital. To tackle this problem, the standardization of the handoff process is important since only a few physicians engage in the appropriate handoff process .
The limitations of this study are, first, that the data were obtained from a single center with a small sample. Second, although the two attending-physician groups in this study worked in common practice areas, we did not collect data from patients and co-working staff. Regarding the pros and cons of the multiple-attending-physicians system, feelings and thoughts of patients as beneficiaries of care and co-working staff as counterparts of physicians’ work are also important. Third, in addition to the number discrepancy of inpatients between two groups, physicians from each group had different department background, which might affect the interpretation of the results to some degree. Despite the several research limitations, this is one of the few studies that identified the advantages and disadvantages of the two attending-physician systems. Further studies should include the two attending-physician systems in the same department or use a larger sample size in a multicenter setting and investigate the satisfaction of patients and healthcare professionals other than physicians in the case of the multiple-attending- physicians-system. Similarly, research should be conducted on the burden of physicians and the quality of care in outpatient settings in Japan.